Rehab and Prevention of - PowerPoint Presentation

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Rehab and Prevention of Ulnar Collateral Ligament Injuries

Lucas C. Smith PT, DPT, CSCSSlide2

Anatomy of the Ulnar Collateral Ligament (UCL)

UCL, Also known as the medial collateral ligament is composed of 3 bundles.

Anterior Bundle (most commonly injured)

Posterior BundleTransverse LigamentThe UCL connects the Humerus to the Ulna, and prevents elbow valgus and distraction.

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Mechanism of Injury to the UCL

Most common is repetitive

valgus

force at the elbow.Common in overhead sportsBaseballVolleyballThe average valgus stress at the elbow for an adult pitcher is 64 N.m.The UCL provides 54% of resistance to this stress therefore 34 N.m per pitch!

Acute trauma providing a strong valgus stress to the elbow.

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Common Signs and Symptoms

Pain when using your arm in an overhead position.

85% of cases will report pain with the acceleration phase of throwing.

If injury is acute reports of hearing a “pop”.Pitchers may report decreased accuracy, velocity, control, stamina, and strength.Reports of soreness and swelling along the medial elbow.Possible numbness and tingling in the forearm.Instability of the elbow “It feels like my elbow is going to give out when I throw”.4Slide5

Physical Therapy Evaluation

Start with a detailed history

Is the injury Acute or Chronic? Did you have have surgery?

What sport or activity contributed to the issues?How long have you had the pain?Did you hear a pop? Do you have any numbness or tingling?How long have you been playing your sport, and how often do you play?Are you currently playing?

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Physical Therapy Evaluation

Palpate along the medial elbow and look for areas of pain.

Apply pressure to the UCL,

Ulnar nerve, and Common flexor tendon.Assess ROM of the elbow and shoulderRecent studies have shown that a decrease in Total Shoulder ROM is associated with UCL injuries in baseball players.Professional baseball pitchers have been shown to lack 3-5 degrees of elbow extension at baseline.If post op follow the ROM restrictions at the elbow per protocol.

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Physical Therapy Evaluation

If Patient has not had surgery perform manual muscle tests (MMT).

Wrist, Elbow, Shoulder,

Scap/upper back, CoreRemember to Include the Pronator Teres and wrist flexors primarily the Flexor Carpi Ulnaris because they are the primary protectors of the UCL.Test balance with single leg stance or Y balance test.

Poor mechanics and movement patterns due to decreased balance and core strength can cause increased risk for injury.

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Physical Therapy Evaluation

If non operative perform Special Tests.

Valgus

stress test Have the patient sit with their elbow flexed at 20-30 degrees and provide a valgus force to the elbow.A positive test will be pain and/or laxity.Moving Valgus stress testHave the patient sit with their shoulder in the 90/90 position. Apply and maintain a constant moderate

valgus torque to the fully flexed elbow and then quickly extends the elbow. A positive test is medial elbow pain reproduced

between 120 degrees and 70 degrees.

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Non Operative Rehab for the UCL

Pain and Inflammation Reduction.

Soft tissue mobility to break up scar tissue, remove fluid build up and increase tissue extensibility.

Deep Tissue MassageCross Friction MassageGrastonUse of modalities to control inflammation and pain.If acute use Cryotherapy and Electrical Stimulation.If chronic Heat and Ultrasound.

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Non Operative Rehab for the UCL

Improve and Maintain ROM

Perform ROM in all planes of the elbow and wrist.

The main goal of ROM activities prevent and eliminate any elbow flexion contractures.Perform active assistive and passive ROM to the elbow and wrist.Also utilize joint mobility performing posterior glides of both the Humeroulnar joint to help with elbow extension, and the Glenohumeral joint to help with shoulder rotation mobility.

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Non Operative Rehab for the UCL

Improve and Maintain ROM

If the patient has an extension contracture use a low-load long-duration stretch.

Lay the patient supine on a table with their arm out stretched with a towel under the upper arm.The shoulder should be internally rotated with the forearm pronated.Apply light resistance with a band or weight.Pt should hold the stretch for 10-15 min

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Non Operative Rehab for the UCL

Early Strengthening activities

When patient has achieved full ROM and minimal pain and tenderness start isotonic strengthening exercise.

Elbow and wrist Flexion/Extension, Forearm Pronation/Supination.Start with basic exercises with a t-band or dumbbell.Glenohumeral and Scapulothoracic strengtheningFocus on shoulder ER and periscapular

musculature.Exercise can be performed with t-band or dumbbells

Great exercises at this point are the throwers 10 exercises

Core strengthening and stability.

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Throwers 10 Exercise

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Non Operative Rehab for the UCL

As strength improves start advanced strengthening activities.

Increase Resistance

Rhythmic stabilization exerciseChange speeds with exercisePlyometric exerciseHigh Level balance activitiesTo begin these exercises the patient should have full non painful ROM, no pain or tenderness with palpation, and strength of effected arm should be 70% of contralateral arm.

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Non Operative Rehab for the UCL

Increase Resistance

Start to incorporate exercise in the gym with free weights and machines.

Start with chest press, seated rows, lat pull downs, and triceps extensionStart increased resistance biceps muscle eccentric exercise.This is important because the biceps is a very important stabilizer in the follow through phase of throwing.

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Non Operative Rehab for the UCL

Rhythmic stabilization exercise

Start with supine rhythmic stabilization exercise with arm at 90 deg flex, and then incorporate PNF patterns.

Add manual resistance with exercise and rhythmic stabilizations at end range.This can be done with any of the throwers 10 exercises.

Closed Chain rhythmic stabilization.Ball on wall exercise.

Prone with hands on ball and perform rhythmic stabilizations.

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Non Operative Rehab for the UCL

Change Speed with Exercise

Perform with a

t-band of varying resistance.Seated and or standing wrist flexion and extension alternating reps of fast and slow sets.Perform the same technique with elbow flex and extension, shoulder IR and ER, and shoulder extension.Start to incorporate sustained holds with exercise.Hold for 5-10 seconds at the end of the concentric contraction.

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Non Operative Rehab for the UCL

Plyometric

Exercise

Start in a push up/plank position and perform UE step ups, progressing to UE jump ups.Forward, lateral, in, and diagonal patternsPlyometrics are also performed with a medicine ball.Start with 2 handed activities.Chest pass, side to side throw, and overhead soccer throws.

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Non Operative Rehab for the UCL

Progress 2 handed

plyometrics

to 1 handed with medicine ballPerform wrist flexion and extension flips.Shoulder internal and external rotation throws. Perform at 0 degrees and 90 degrees.Prone shoulder 90/90 external rotation throws.Eccentric shoulder ER catching with a concentric return.Both great for posterior rotator cuff strengthening.Overhead wall dribbles for endurance.

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Non Operative Rehab for the UCL

High Level Balance Activities

This is where you simply get creative.

Perform many of the previous exercise on one leg or on a stability ball.All IR and ER exercise including plyometrics on one leg.Progress to unstable surface.Throwers 10 exercises sitting or laying on a swiss

ball.Chest and overhead passes from a BOSU

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Non Operative Rehab for the UCL

Return to activity and sport

When the patient has full strength, ROM, and is pain free start a progressive return to activity program.

For example a interval throwing program.Return to golf program.When the patient has finished the interval program pain free, has no pain or tenderness, passes all isokinetic testing they should return to the MD for a release back to full activity.21Slide22

Post Operative Rehab for the UCL

Always follow the surgeons protocol if they have one and if they do not, get approval of the protocol you wish to use before proceeding.

In my experience the UCL reconstructions I have seen are those using the

autogenous palmaris longus graft.I prefer to use the Andrews Protocol developed by Dr. Andrews.All protocols including the Andrews protocol will incorporate the same ROM activities and exercise described in the non operative sections they are just introduced at different times and ROM progresses differently.

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Prevention of UCL Injuries

The first line of prevention of UCL injuries is education.

Research has shown that the amount of pitching is directly linked to UCL injuries

Therefore we need to educate patients and coaches on the importance of limiting pitch counts, varying speeds of pitches, and avoid playing year round.A great line from the American Sports Medicine Institute (ASMI)“To become a successful adult pitcher, the youth should not strive to be a “youth pitcher” but instead a young athlete that is a good pitcher.”

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Prevention of UCL Injuries

Maintain good shoulder ROM

Decreased total shoulder ROM has been directly linked to UCL injuries therefore it is important to regularly stretch the shoulder musculature and capsule.

Maintain strong scapular musculature and condition all of the muscle in the kinetic chain of throwing.Work from the ground up.Make the throwers 10 exercise part of you normal routine.Both traditional and with balance modifications.CORE strength is key to stability and throwing mechanics therefore don’t forget.Include the primary muscles that protect the UCL, the Pronator

Teres and Flexor Carpi Ulnaris.Full body conditioning with cross training.

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Prevention of UCL Injuries

Rest and Proper Nutrition

Vital to all athletes and often forgotten is the importance of rest and proper nutrition.

Both are required to allow the body to recover and rebuild after activity and necessary to obtain peek performance. 25Slide26

THANK YOU

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References

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