Medial Elbow Instability & Ulnar Collateral Ligament Reconstruction in a Collegiate Baseball Player.

Transcription

1 Medial Elbow Instability & Ulnar Collateral Ligament Reconstruction in a Collegiate Baseball Player

2 PLAN for the day: Brief introduction Review of elbow anatomy Ulnar Collateral Ligament Pathology Assessment Treatment Surgical procedure Case specifics Rehabilitation Useful Conclusions

3 So What is medial elbow instability? Gradual wearing out of the Ulnar collateral ligament, which provides most of the support to the medial side of the elbow Generally caused by repetitive throwing/pitching Complete UCL ruptures would be felt with a single pitch Majority of athletes with UCL instability are baseball pitchers

4 UCL Tears Sprains are graded I, II, or III, depending on the severity of the sprain: grade I: pain with minimal damage to the ligament grade II: more ligament damage and mild looseness of the joint grade III: complete tearing of the ligament and the joint is very loose or unstable. Because the MOI is gradual, many UCL injuries progress though the first two stages, and the athlete will finally seek treatment at stage II or III

5 The Elbow: Joint of Mystery? no! The primary function of the elbow is to allow for positioning of the hand The elbow is a hinge joint that is created by the humerus, the radius (lateral), and the ulna (medial) The hinge is created by the articulation of the humerus & ulna. The radius is just along for the ride.

6 Actions of the Elbow The actions of the elbow include flexion, extension, and rotation (pronation and supination)

7 Humerus Medial and lateral epicondyles Capitellum Radial fossa Olecranon fossa

8 Radius & Ulna Radius Radial head articulates with the capitellum of the humerus Ulna Articulates with the trochlea and the olecranon fossa of the humerus Provides most of the bony stability of the elbow joint

9 1 elbow = 3 joints The elbow joint is actually three joints enclosed in one joint capsule! Ulnohumeral (flexion/extension) Radiohumeral (pivoting and rotation for pronation and supination) Radioulnar (pivot/glide motions)

10 Ligaments of the Elbow Ulnar collateral (medial) 3 portions Anterior: controls most of the valgus stress Posterior: secondary stabilizer Transverse: thickening of capsule - minimal joint stability Radial collateral (lateral) Connects epicondyle to annular ligament Annular: circles the head of the radius Interosseus: connects the medial borders of the radius and ulna

11 Ligaments (cont.)

12 Elbow Stabilizers Valgus Forces UCL (medial) Joint Capsule Bone Articulation Distraction UCL (medial) RCL (lateral) Joint Capsule 90 Flexion 54% 10% 33% 78% 10% 8% Extension 31% 38% 31% 6% 5% 85%

13 Innervations Ulnar nerve Cubital tunnel Median nerve Radial nerve

14 Blood Supply Brachial Artery Splits into the ulnar artery and radial artery at the elbow joint

15 Muscles at the Elbow Elbow flexion Biceps Brachialis Brachioradialis Pronator Teres Elbow extension Triceps Anconeus

16 Muscles (cont.) Wrist extensors (lateral epicondyle) Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris Wrist flexors (medial epicondyle) Flexor carpi radilais longis Flexor carpi ulnaris Palmaris longus

17 Muscles (cont.) Pronators Pronator teres Pronator quadratus Supinators Biceps brachii Supinator

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19 Chronic UCL laxity

20 Mechanism of injury Sports commonly associated with UCL injury Baseball Golf Javelin Repetitive movements: overhand throwing, swinging a bat, or swinging a golf club Motions involved in an overhand throw/pitch: Wind up Early cocking Late cocking Acceleration Follow through

21 Throw that ball!

22 Signs and symptoms Loss of control Increasing pain with activity Pain at the medial aspect of the elbow Possible tingling/numbness due to ulnar nerve involvement because of its location at the cubital tunnel Feeling of a loose elbow

23 Assessment History Generally of overhead throwing Involves description of pain, and any prior injuries Inspection Palpation ROM AROM, PROM, RROM Special tests Valgus stress test at 30º Flexion

24 Differentiation of assessment ROM is extremely helpful in determining if there is any limitation from joint pathology Capsular limitations (joint effusion) will generally affect both flexion and extension equally Non-capsular limitations (loose bodies) will generally limit one motion more than the other publications/wc/images/f19-20.gif

25 Diagnostic Imaging If the valgus stress test is positive, further testing may be necessary to determine the severity of the UCL injury A study done on the efficacy of different imaging techniques found: Magnetic Resonance Imaging (MRI) showed 100% full tears, 14% partial tears Computed Tomography Arthrography Showed 100% full tears, 71% partial tears

26 Non-surgical treatment Specific Protocol May vary, but generally follows two phases: Phase I Rest 2-3 months NSAIDS Ice daily 2-4 times, for minutes Splint to reduce pain, and decrease ROM if needed AROM & PROM exercises for flexors and pronators Phase II (if pain free) Discontinue splint/brace Upper extremity strengthening Throwing progression starting at 3 months Hyperextension brace may be used

27 To cut or not to cut? When are you a candidate for surgery?? Determining factors: Prior injuries Time in season Player potential Non-operative treatment often recommended first to avoid the long recovery associated with surgery

28 Surgery Decision Usually happens after non-operative treatment has failed The necessity of surgery may be determined immediately based on the situation There needs to be a large commitment on the athlete s behalf because of the extensive rehab involved after surgery

29 Surgery Decision (cont.) An important note: This decision hinges on whether or not the athlete desires to continue playing competitive or professional baseball Avoiding surgery has no negative effect on general lifestyle activities of daily living If the athlete desires to compete in recreational sports, it will be necessary to wear a brace to protect from nerve injury because of instability in the elbow joint.

30 Who gets this surgery? James Andrews (Birmingham, AL) is one of the most renowned UCL reconstruction surgeons Of his patients 20% are Major League Players 20-25% are Minor League Players The rest (roughly 60%) are college or high school athletes reds.enquirer.com

31 History of UCL surgery This surgery was invented by Dr. Frank Jobe for pitcher Tommy John in 1974 John told his LA Dodgers team surgeon to make something up Previously, a UCL injury was career-ending to pitchers When the UCL is weakened and stretched, it is considered a dead arm because they cannot throw at high velocities Dr. Jobe told John that he could do nothing and never pitch again to try an untested surgery and still never pitch again.

32 Tommy john surgery - original technique Harvest Tendon Usually the palmaris longus Transverse incision across the wrist, another incision proximal on the forearm Tendon is pulled to determine that it is the correct tendon Tendon is removed, cleaned, and placed in saline If the gracilis tendon is used, it would be harvested from the leg that is not the plant foot for pitching

33 Procedure (cont.) Elbow is exposed through a (roughly) 6 inch incision Flexor bundle is detached Ulnar nerve is recognized, lifted out, and moved to provide greater access to the joint (this may cause scarring) Damaged ligament is located and scraped out

34 Procedure (cont.) Holes drilled: 2 in the humerus, aimed at ulna I in ulna, perpendicular to the humerus Tendon is threaded through the holes in a figure-8 pattern, and sutured to itself

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36 Advances in the procedure Objective: doing as little damage as possible to the surrounding tissue Muscle Splitting technique: Instead of detaching the entire flexor bundle, the muscle splitting technique transects the flexor bundle from the medial epicondyle to 1 cm distal to the sublime tubercle of the ulna

37 Advances (cont.) No nerve transposition: The muscle splitting technique does not require that the ulnar nerve be moved (but it still must be identified before cutting!)

38 Advances (cont.) Bone anchor method Instead of drilling through the bone, troughs are created at the UCL attachment sites, and anchors are placed on either side. The tendon graft is threaded through the anchors and attached back to itself

39 Advances (cont.) Docking procedure Tunnel in humerus is drilled to intersect with two smaller, perpendicular tunnels. The surgeon is able to adjust the tension of the tendon graft better than using the old tunnel technique.

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41 Outcomes of surgery Over time, the tendon graft ligamentizes (learns to become a ligament) The new ligament gets blood supply from the flexor bundle and the marrow in the drill-holes There have not been any biopsies done to see exactly how the tissue has changed Follow-up MRI s show that the new tissue is functioning as a ligament should General opinion that pitchers are able to make a full return to play, and even throw harder than they did before their injury

42 Pros and Cons There are still some faults in the procedure, but it has helped the sport of baseball tremendously - 1 in 9 pitchers would not be playing without it The outcomes are getting better and better, and clubs are getting less wary of the surgery The Yankees signed Jon Lieber to a 2-year contract with 3.5 million guaranteed when he was less than 5 months into his rehabilitation from surgery!)

43 How much is too much??? Knife happy? As the success rate increases, so do the number of surgeries. 10 years ago, doctors were more likely to recommend rest for a partial tear now, the numbers favor surgery Food for thought The non surgical success rate is lower than thought initially: it is about a 50/50 chance it will heal with conservative treatment Commonly, players can be hampered with problems for years that intermittently come and go.

44 Rehabilitation procedure VERY strict procedure Requires a full year of rehabilitation, plus another year of pitching to get back into form The body must have time to convert the tendon into a ligament (change from connecting tendon-bone, to bone-bone) The graft is very weak right after surgery, and rebuilding must be gradual The player may feel good by 7 or 8 months, but at that time, the graft is not ready to withstand the force generated in throwing Also important to strengthen the shoulder

45 Case study 19 year of collegiate male baseball pitcher Right hand dominant Injury history: Asthma, resolved tibia fracture Fall 2004 (senior year in high school) Experienced general elbow pain and decreased throwing speed, felt worn out (fall ball college) Elbow felt tight and pain with every pitch Assessed by an athletic trainer, clinical impression: 2 nd degree UCL sprain

46 Case Study Assessment by Doctor #1 Mild UCL sprain no throwing Assessment by Doctor #2 UCL sprain due to chronic valgus overload MRI results unremarkable, safe to begin rehabilitation Athlete assessed again by an athletic trainer, main complaint being a decrease in overall strength and endurance Plan to continue strengthening program

47 Case Study Assessment by Doctor #3 Stress x-rays showed a tear in UCL Tommy John surgery to reconstruct UCL Used Gracilis tendon for the graft in elbow Athlete began his rehabilitation plan

48 Case Study month post-op assessment by athletic training student No tenderness with palpation Some tingling in right hand with elbow extension ROM graph Active Flexion Active Extension Passive Flexion Passive Extension *Right 110º -20º 110º -20º Left 145 º 0 º 145 º 0 º

49 Rehabilitation Program Phase 1 Week 1 Posterior splint at 90º elbow flexion Wrist AROM flexion/extension Elbow compression Exercises Gripping Wrist ROM Shoulder Isometrics Biceps isometrics Cryotherapy

50 Rehabilitation Phase 1 Goals: protect healing tissue, decrease pain/inflammation, retard muscular atrophy, protect graft site Week 2 Functional brace: 30º - 100º flexion Wrist isometrics Elbow flexion/extension isometrics Continue week 1 exercises Scar tissue massage Begin Cardiovascular conditioning Week 3 Advance brace to 15º - 110º flexion (increase ROM 5º extension and 10º flexion every week)

51 Rehabilitation Phase 2 Weeks 4-8 Criteria to progress to phase 2: minimal pain and tenderness Goals: gradual increase in ROM, promote healing, begin to improve muscular strength Activities Begin 1 lb resistance exercises for arm: wrist curls, wrist extensions, wrist pronation/supination, elbow flexion/extension (progress through weeks 4-8) Rotator cuff strengthening (no external rotation until week 6) gradually progress through weeks 4-8

52 Rehabilitation Phase 3 Weeks 9-13 Criteria to progress to phase 3: full non-painful ROM, no pain or tenderness Goals: increase strength, power, and endurance, maintain full ROM, prepare to return to functional activities Activities: Continue shoulder strengthening program and forearm/wrist isometric program Begin eccentric elbow flexion/extension Begin manual resistance diagonal programs Begin plyometric exercises with plyoball and mini tramp Week 11: begin isokinetics

53 Rehabilitation Phase 4 Weeks Criteria to progress to phase 4: full, non-painful ROM, 2 weeks of pain-free plyometrics, physician assessment and approval Goals: continue to increase strength, power and endurance of upper extremity, prepare for fully functional return Activities Continue strengthening program, plyometrics, and isokinetics Week 22-24: initiate throwing program (see chart) Month 11-12: possible return to competitive throwing

54 Current status Athlete began throwing program at 17 weeks post-op, but is taking the throwing program slowly His elbow never hurts when throwing, but is sore for 1-2 days after throwing Short-term goals are to continue with the rehabilitation and throwing programs consistently and pain-free The long-term goal is to play baseball in the spring

55 Conclusions from the case Was surgery really necessary? Depends who you ask: the athlete would say YES! Would it have healed with conservative treatment? Maybe/maybe not Determining factors An athlete who was willing to go through the long rehabilitation entire college baseball eligibility to use Personal fulfillment aspect

56 Whew! Review Introduction Review of elbow anatomy Ulnar Collateral Ligament Pathology Assessment Treatment Surgical procedure Case specifics Rehabilitation Useful Conclusions

57 References Starky, C., Ryan, J. Evaluation of Orthopedic and Athletic Injuries, 2 nd ed. Philadelphia, PA: F. A. Davis Company, Prentice, W. Arnheim s Principles of Athletic Training. Boston, MA: McGraw Hill, Ellenbecker TS, Mattalino AJ. The Elbow in Sport. Champaign, IL: HumanKinetics Publishing, University of Michigan Health System Ulnar Collateral Ligament Reconstruction In Baseball Pitchers Altchek, DW, Hyman J, Williams R, Levinson M, Allen AA, Palletta Jr. GA, Dines DM, and Botts JD. Management of MCL Injuries of the Elbow in Throwers. Techniques in Shoulder and Elbow Surgery1:73-81, Azar FM, Andrews JR, Wilke, and Groh D. Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes. The American Journal of Sports Medicine28:16-23, Tommy John surgery: Pitcher's best friend Mirowitz, S.A., London, S.L. Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation. Radiology, Vol 185, , Post-operative rehabilitation protocol following ulnar collateral lignament reconstruction using autogenous gracilis graft (for ASMOC)