Ulnar Collateral Ligament Evaluation and Diagnostics

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Key points

  • 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

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.

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