What is a Ulnar Collateral Ligament (UCL) sprain?
- An ulnar collateral ligament (UCL) sprain in the elbow refers to an injury to the UCL, which is a key stabilizer of the medial elbow, particularly during activities that involve overhead throwing.
- The UCL is composed of three bundles: anterior, posterior, and transverse, with the anterior bundle being the primary restraint to valgus stress.
- UCL sprains are common in athletes who participate in overhead sports, such as baseball pitchers, due to the repetitive valgus stress placed on the elbow during the throwing motion. This repetitive stress can lead tomicrotears, partial tears, or complete ruptures of the ligament [Gehrman & Grandizio, 2022; Hariri & Safran, 2010; Carr et al, 2020].
How is a Ulnar Collateral Ligament (UCL) sprain diagnosed?
The diagnosis of an ulnar collateral ligament (UCL) sprain in the elbow involves a combination of clinical evaluation and imaging studies.
- History and Physical Examination:
- Patients
with a UCL sprain typically present with medial elbow pain, which may
be exacerbated by throwing or other activities that place stress on the
elbow.
- Patients may also experience a decrease in throwing velocity and accuracy.
- Physical examination findings often include tenderness over the medial
elbow and positive valgus stress tests, such as the moving valgus stress
test and the milking maneuver [Hariri & Safran, 2010; Safran et al, 2005].
- Imaging Studies: The diagnosis of a UCL sprain is primarily clinical, supported by imaging studies.
- Magnetic Resonance Imaging (MRI):
MRI is considered the gold standard for diagnosing UCL injuries. It
provides detailed visualization of the ligament, showing signs of
laxity, irregularity, and increased signal intensity, which indicate
injury. MRI has a sensitivity and specificity ranging from 57% to 100%
and 89% to 100%, respectively [Mirowitz & London, 1992; Campbell et al, 2020].
- Ultrasound (US):
Conventional and stress ultrasound are valuable, especially for dynamic
assessment. Conventional US has a sensitivity of 79% and specificity of
98% for full-thickness tears, while stress US has a sensitivity of 96%
and specificity of 81%. Stress US can measure joint gapping under valgus
stress, correlating with the severity of UCL injury [Ciccotti & Ciccotti, 2020; Thomas et al, 2022; Park et al, 2020].
What are the treatments for a Ulnar Collateral Ligament (UCL) sprain?
Non-surgical treatment options for an ulnar collateral ligament (UCL) sprain in the elbow include several approaches aimed at reducing pain, promoting healing, and restoring function. These options are particularly effective for low- to medium-grade partial tears (grade I or II).
- Rest and Activity Modification: Initial management involves rest from aggravating activities, particularly throwing, to allow the ligament to heal. Activity modification is crucial to prevent further injury [Hariri & Safran, 2010; Carr et al, 2020].
- Physical Therapy: A structured rehabilitation program focusing on strengthening the flexor-pronator muscles, improving range of motion, and gradually progressing to sport-specific activities is essential. Physical therapy alone has shown a return to sport (RTS) rate of approximately 79.7% [Gopinatth et al, 2023].
- Bracing: The use of a hinged elbow brace can provide support and limit valgus stress on the elbow during the healing process, particularly in younger athletes [Savoie & O'Brien, 2020].
- Platelet-Rich Plasma (PRP) Injections: PRP injections have been used to promote healing of partial UCL tears. Studies have shown that PRP, combined with physical therapy, can be effective, with RTS rates similar to those achieved with physical therapy alone [Gopinatth et al, 2023; Chauhan et al, 2019; Podesta et al, 2013].
- A case series by Podesta et al. evaluated 34 athletes with partial UCL tears who received a single type 1A PRP injection under ultrasound guidance. At an average follow-up of 70 weeks, 88% of athletes returned to the same level of play without complaints. Significant improvements were noted in the Kerlan-Jobe Orthopaedic Clinic (KJOC) score (from 46 to 93) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score (from 21 to 1) [Podesta et al, 2013].
- A systematic review by Fucaloro et al. analyzed eight studies involving 278 partial-thickness and 44 full-thickness UCL tears. The return to sport (RTS) rates ranged from 46% to 100%, with higher success rates observed in studies with longer rehabilitation programs (12-14 weeks) and those using leukocyte-poor PRP. The RTS rates for partial-thickness tears ranged from 59% to 100% [Fucaloro et al, 2024].
- Chauhan et al. conducted a comparative study on professional baseball players, showing that PRP did not significantly improve return to play (RTP) outcomes compared to non-PRP treatment. However, variability in PRP preparations and rehabilitation protocols may have influenced these results [Chauhan et al, 2019].
- A systematic review and meta-analysis by Gopinatth et al. found no significant difference in RTS rates between athletes treated with PRP and those who did not receive PRP. The overall RTS rate for nonoperative management, including PRP, was 79.7% [Gopinatth et al, 2023].
Surgical
Surgical approaches for ulnar collateral ligament (UCL) sprains in the elbow
primarily include UCL reconstruction (UCLR) and UCL repair with suture
augmentation.
- UCL Reconstruction (UCLR): Different techniques have been described, including the Modified Jobe Technique with a return to play (RTP) rate of approximately 80-90% [Pezzulo et al, 2024; Vitale & Ahmad, 2008; Carr et al, 2020] and a Docking Technique that has shown a 90% RTP rate at 12 to 18 months. The docking technique is associated with fewer complications, particularly ulnar neuropathy, compared to the modified Jobe technique [Pezzulo et al, 2024; Vitale & Ahmad, 2008; Watson et al, 2014; Looney et al, 2021].
- UCL Repair with Suture Augmentation: This approach is typically used for acute injuries, minimal ligamentous
degeneration, or isolated proximal or distal avulsions [Pezzulo et al, 2024; Dugas et al, 2025; Spears et al, 2024] and RTP rates ranging from 92% to 96% and a shorter time to return to play (approximately 6 months) compared to UCLR [Dugas et al, 2025; Spears et al, 2024].
What is the average recovery time post-surgery for UCL sprains?
The average recovery time post-surgery for ulnar collateral ligament (UCL) sprains in the elbow varies depending on the surgical approach used.
- For UCL reconstruction (UCLR): The Modified Jobe Technique has an average time to return to full competition is 12 to 15 months, with professional pitchers often requiring 15 to 18 months to return to their previous level of competition [Carr et al, 2020]. The Docking Technique typically results in a return to play (RTP) at around 12 to 18 months post-surgery, with a high success rate of approximately 90% [Pezzulo et al, 2024].
- For UCL repair with suture augmentation: This approach has shown a shorter recovery time, with athletes generally returning to sport in approximately 6 to 9 months. The RTP rate is high, ranging from 92% to 96% [Dugas et al, 2025; Spears et al, 2024].
What are the potential complications following UCL surgery in the elbow?
Common complications following ulnar collateral ligament (UCL) surgery in the elbow, considering both UCL reconstruction and UCL repair with suture augmentation, include:
- Ulnar Neuropathy: This is the most frequently reported complication. The incidence of postoperative ulnar neuropathy varies, with rates reported as high as 12% overall for UCL reconstruction. Ulnar nerve transposition, particularly submuscular transposition, is associated with higher rates of ulnar neuropathy [Looney et al, 2021; Clain et al, 2019].
- Revision Surgery: UCL repair with suture augmentation has been associated with a higher risk of revision surgery compared to UCL reconstruction. The estimated 2-year revision-free survival was 99.5% for UCL reconstruction compared to 97.9% for UCL repair [Varady et al, 2024].
- Persistent Ulnar Nerve Symptoms: Persistent ulnar nerve symptoms post-surgery are reported in a small percentage of patients, particularly those who underwent concomitant ulnar nerve transposition [Hones et al, 2024].
- Infection and Wound Complications: Although less common, infection and wound complications can occur postoperatively. These are generally managed with appropriate medical or surgical interventions.
- Graft Failure: Graft failure, although rare, can occur and may necessitate revision surgery. The choice of graft (autograft vs. allograft) can influence the risk of graft failure, with allografts associated with a higher revision rate [Hones et al, 2024].
- Other Nerve-Related Complications: Other nerve-related complications, such as transient paresthesia, can occur, particularly in athletes involved in high-stress activities like gymnastics and javelin throwing [Jones et al, 2014].
