- •
The overhead throwing motion results in a predictable pattern of stresses across the elbow joint (tension medially, compression laterally, and shear posteriorly), which may overwhelm the static and dynamic stabilizers and result in injury.
- •
In particular, the medial tensile stresses can exceed the tensile strength of the ulnar collateral ligament (UCL) and result in acute or chronic injury.
- •
History of UCL injury typically is acute or insidious decreased throwing effectiveness with symptoms
Ulnar Collateral Ligament Evaluation and Diagnostics
Section snippets
Key points
Anatomy and biomechanics
Proper diagnosis and treatment of elbow pathology in the throwing athlete require a firm understanding of the anatomy and biomechanics of the joint. The elbow joint is composed of 3 articulations: the proximal radioulnar joint, the ulnohumeral joint both anteromedially and posteriorly, and the radiocapitellar joint laterally. These articulations allow for both flexion/extension of the elbow and pronosupination of the forearm to occur and each may be a site of pathology in the overhead thrower.
History
The evaluation of an overhead throwing athlete with concern for UCL injury begins with a thorough history. That history should incorporate questions that are unique to throwers in order to confirm the presumptive diagnosis and rule out alternative or concomitant injuries. A majority of UCL injuries represent some combination of acute and chronic injury. These athletes describe preexisting or prior episodes of medial elbow pain that has worsened with a more recent event. A minority of athletes
Physical examination
With concern for UCL injury, physical examination of the throwing athlete should not be limited to the elbow alone. The athlete should be looked at holistically. A thorough and comprehensive examination should be undertaken, with the standard inclusion of inspection, palpation, range of motion, strength and sensation testing, and special provocative maneuvers. The entirety of the kinetic chain should be evaluated, including the lower extremities and core to identify any deficiencies, which may
Imaging of the throwing elbow
Some diagnoses in the thrower may be made based on a thorough history and comprehensive physical examination; however, diagnostic imaging often is valuable to confirm the diagnosis and rule out concomitant pathology. As in most musculoskeletal complaints, plain radiography typically is the initial imaging study obtained. As in other joints, plain radiographs of the elbow can provide the clinician with significant information regarding loss of joint space, osteophyte formation, loose bodies,
Differential diagnosis
The differential diagnosis for medial elbow symptoms in a throwing athlete for whom UCL injury is suspected covers several alternative diagnoses (Table 1), some of which may occur concomitantly with UCL injury. The clinician’s thorough history and comprehensive physical examination in addition to the judicious use of imaging studies should be aimed at ruling out these alternative diagnoses. Although the history, physical examination, and imaging may encourage a clinician to focus on the elbow
Summary
The overhead throwing motion subjects the elbow to a predictable pattern of forces, including medial tension, lateral compression, and posterior shear that in turn results in a predictable pattern of injury. This pattern serves as the principle differential diagnosis for clinicians caring for an overhead throwing athlete with medial elbow symptoms. Amongst this differential, careful history, physical examination, and diagnostic imaging allow the clinician to correctly identify UCL injury.
Disclosure
The authors have nothing to disclose.
References (73)
- et al.
Shoulder rehabilitation strategies, guidelines, and practice
Orthop Clin North Am
(2001) - et al.
Fundamental principles of shoulder rehabilitation: conservative to postoperative management
Arthroscopy
(2002) - et al.
Kinetic chain contributions to elbow function and dysfunction in sports
Clin Sports Med
(2004) - et al.
Mechanics and pathomechanics in the overhead athlete
Clin Sports Med
(2013) - et al.
The kinetic chain revisited: new concepts on throwing mechanics and injury
PM R
(2016) - et al.
The Thrower’s elbow
Orthop Clin North Am
(2014) - et al.
Multimodality imaging of the painful elbow: current imaging concepts and image-guided treatments for the injured thrower's elbow
Radiol Clin North Am
(2016) Valgus extension overload: diagnosis and treatment
Clin Sports Med
(2010)- et al.
How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players with UCL injuries
J Shoulder Elbow Surg
(2014) - et al.
Magnetic resonance imaging of the elbow: update on current techniques and indications
J Hand Surg
(2006)
MR imaging of ligament injuries to the elbow
Radiol Clin North Am
Magnetic resonance imaging of injury to the medial collateral ligament of the elbow: a cadaver model
J Shoulder Elbow Surg
MR imaging of the elbow. An update
Radiol Clin North Am
Magnetic resonance imaging–based classification for ulnar collateral ligament injuries of the elbow
J Shoulder Elbow Surg
Magnetic resonance imaging of the elbow in athletes
Clin Sports Med
Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment
Arthroscopy
Detection of loose bodies in joints
Radiol Clin North Am
MR imaging of entrapment neuropathies at the elbow
Magn Reson Imaging Clin N Am
Ulnar collateral ligament injury in the overhead athlete
Clin Sports Med
Valgus extension overload syndrome and stress injury of the olecranon
Clin Sports Med
Oblique stress fracture of the olecranon in baseball pitchers
J Shoulder Elbow Surg
Valgus stability of the elbow: a definition of primary and secondary constraints
Clin Orthop
The ulnar collateral ligament injury: evaluation and treatment
J Bone Joint Surg Am
Stress ultrasound evaluation of medial elbow instability in a cadaveric model
Am J Sports Med
Dynamic contributions of the flexor-pronator mass to elbow valgus stability
J Bone Joint Surg Am
Biomechanics of pitching with emphasis upon shoulder kinematics
J Orthop Sports Phys Ther
Kinetics of baseball pitching with implications about injury mechanisms
Am J Sports Med
Biomechanics of baseball pitching: a preliminary report
Am J Sports Med
Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers
Am J Sports Med
Study of the carrying angle of the human elbow joint in full extension: a morphometric analysis
Surg Radiol Anat
Sonographic incidence of ulnar nerve (sub)luxation and its associated clinical and electrodiagnostic characteristics
Muscle Nerve
The “moving valgus stress test” for medial collateral ligament tears of the elbow
Am J Sports Med
Valgus extension overload and plica
The elbow flexion test: a clinical test for the cubital tunnel syndrome
Clin Orthop
Elbow injuries in throwing athletes: a current concepts review
Am J Sports Med
Cited by (12)
Reinjury Following Return to Play
2024, Seminars in Musculoskeletal RadiologyLens exposure during computed tomography for elbow injuries in baseball players: a phantom study
2023, Gazzetta Medica Italiana Archivio per le Scienze MedicheDual Bracing for Ulnar Collateral Ligament Injuries Restores Native Valgus Laxity and Native Medial Joint Gapping of the Elbow
2023, Orthopaedic Journal of Sports MedicineArthroscopic rod technique compared to stress ultrasound in the dynamic evaluation of lateral ligament instabilities of the elbow
2023, Archives of Orthopaedic and Trauma SurgerySystematic Assessment of the Quality and Comprehensibility of YouTube Content on Ulnar Collateral Ligament Injury and Management
2023, Orthopaedic Journal of Sports MedicineThe Role of Ultrasound in the Evaluation of Elbow Medial Ulnar Collateral Ligament Injuries in Throwing Athletes
2022, Current Reviews in Musculoskeletal Medicine