Physical Therapist's Guide to Ulnar Collateral Ligament Injury
Ulnar collateral ligament (UCL) injuries generally occur when repetitive stress damages the inside of the elbow, compromising stability. UCL injuries are most common in athletes who play "overhead" sports, such as volleyball and baseball, which require using the arms in an overhead position. These injuries are occurring in greater frequency with the rise of sport specialization. They are often referred to as "Tommy John" injuries, named after the famous baseball pitcher who underwent the first surgery for a UCL injury in 1974. A physical therapist can help improve your arm's strength and range of motion, and your body's overall stability and balance following a UCL injury.
What is Ulnar Collateral Ligament (UCL) Injuries?
The ulnar collateral ligament is a band of tissue that connects the inside of your upper arm (humerus) to the inside of your forearm (ulna). This ligament helps to support and stabilize your arm when you perform a motion, such as throwing a ball. A UCL injury may at first cause pain and tightness in the area. However, over time and with repetitive stress or trauma, the UCL can become stretched and even tear. Surgery is not always necessary to heal a UCL injury, but it may be performed if pain persists or the elbow feels unstable upon a return to sport or other activities.
Signs and Symptoms
With a UCL injury, you may experience:
- Soreness or tightness along the inside of your elbow
- Minor swelling and possible bruising along the inside of your arm
- Possible numbness and tingling in your arm
- Instability at your elbow joint (a feeling like your elbow might “give out” when you move it through certain motions)
- Pain when using your arm in an overhead position (eg, throwing/pitching a ball, swinging a racquet)
- Difficulty warming up for a sport, or needing a longer time to warm up
- Poorer performance (eg, a decrease in pitching speed)
How Is It Diagnosed?
Your physical therapist will conduct a thorough evaluation that includes taking your health and activity history. Your physical therapist may ask you questions including:
- When and how did this injury occur? (Sudden or gradual?)
- How long have you had pain?
- Have you had any numbness and tingling in your arm?
- Did you feel a "pop" near your elbow when throwing or performing an overhead activity?
- Have you experienced any instability (eg, a feeling of your arm “giving out”) when performing an overhead activity?
- Have you experienced a decrease in job or sport performance?
- What other sports or activities do you participate in?
- Have you had to stop playing your sport, or performing your job, because of the injury to your elbow?
Your physical therapist may gently touch the area around your elbow joint to locate the specific area of pain. Your physical therapist may slightly bend your arm while applying pressure along the outside of your elbow joint, or ask you to mimic a throwing motion as the therapist resists against it.
To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic surgeon. The surgeon may order further tests, such as magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA), to confirm the diagnosis and to rule out other possible damage.
How Can a Physical Therapist Help?
Your physical therapist can help improve your arm's strength and range of motion following a UCL injury, and help restore your shoulder and core stability, coordination, and balance. Your therapist also will work with you before and after any necessary surgery, and can help identify other issues that may have contributed to your injury, such as range of motion and strength deficits, or improper throwing mechanics. Your physical therapist will help you:
Boost your healing process. Decreasing stress across the injured area is the best way to promote healing of a UCL injury. Your physical therapist will likely tell you to take some time off from your sport or other activity. Your therapist may educate you on the RICE (rest, ice, compression, elevation) principle and may implement "cross-friction massage" to help the body supply nutrients to the injured ligament.
Strengthen your muscles. After your injury your arm may feel weaker. Strengthening the muscles of your shoulder, upper back, and shoulder blades in addition to those of the forearm will help decrease the stress at the elbow joint. Addressing lower-body balance or any weakness through your hips and trunk also may help decrease stress across your elbow.
Improve your range of motion. After your injury you may notice more difficulty straightening or bending your arm. Your physical therapist will work with you to improve your arm's range of motion, including possibly stretching your shoulder to help decrease stress on your elbow when performing overhead movements.
Correct your movements. While every sport requires different arm positions, certain positions may put an athlete at greater risk for injury to the elbow. Examining and modifying the movements you perform may help you safely return to your sport. Your physical therapist will help design a specific program to allow a gradual full return to activity.
Prepare to return to sport. An important component of preparing for a return to sports after an UCL injury is preparing the arm to properly withstand the stress placed on it during throwing or other overhead motions. Your physical therapist will work with you to establish and implement a progressive program to prepare you for a return to practice and competition.
If Surgery Is Required
If surgery is necessary, your physical therapist may measure your arm strength and range of motion prior to surgery to define a baseline goal to achieve following the procedure.
Immediately following surgery, your arm will likely be placed in a splint, brace, or sling to protect your elbow. Physical therapy will begin within the first week to 10 days following surgery. Your physical therapist will:
- Provide appropriate guidance. You will receive an individualized treatment program of gradual rehabilitation that will ensure you heal in the safest and most effective way possible.
- Protect the graft/repair site in the early postoperative period. You will be provided a brace that will likely need to be worn for 5 to 6 weeks, depending on your surgeon’s preference. Your physical therapist will show you how to ensure you don’t bend your arm too much or rotate your shoulder too far during this time.
- Improve how far you can move your shoulder and elbow. When you are ready, your physical therapist will help you gently bend and straighten your arm through different exercises and stretching techniques. Your therapist also will gently stretch your shoulder to help decrease stress across the elbow.
- Improve the strength of your arm. Through a series of exercises, your physical therapist will work with you to improve your arm strength. Your hand grip and forearm strength will likely be the first things you will work on following surgery. As you progress, the exercises will begin to focus more on your shoulder blade and upper back muscles.
- Improve muscle strength and coordination. As you begin to heal and progress, your exercises will become more specific to your sport or other activity.
Resuming sport-specific activities. An athlete who has experienced a UCL injury can begin to return to throwing at approximately 6 months after surgery. The return is based on the surgeon and physical therapist providing clearance to do so.
Returning to full competition. An athlete generally can be cleared to return to game competition approximately 12 to 14 months after surgery.
Can this Injury or Condition be Prevented?
Certain factors may increase a person’s chances of injuring the UCL. For example, shoulder and elbow range of motion imbalances may play a role in creating too much stress at the elbow. Balance and coordination deficits also can lead to improper movement during sporting or other activities. Your physical therapist will design an individualized treatment program to address and correct these deficits.
Current evidence suggests the biggest factors for athletes developing this injury are pitch velocity, and the overall volume of throwing and other overhead activities performed in a specific sport. Throwing with high velocity (>83 mph), pitching too many pitches, pitching on short rest, pitching while fatigued, and introducing new pitches in excess are all factors related to exposing the UCL to force that it may not be able to withstand. Other factors such as age, type of sport, and position played also may affect overall arm fitness and health. It is important to keep up with regular arm care and exercises in order to reduce the likelihood of injury.
Real Life Experiences
Jason is an 18-year-old college baseball player who is also on the Dean’s List at school. Last week, he “pulled an all-nighter” studying for an important test, and pitched an important game on exam day.
Jason pitched a great first inning, but noticed his right elbow began to feel tight in the second inning; he lost some control over his pitches in the third. By the fourth inning, he was pushing through pain and tightness because he didn’t want to let his team down. When throwing a fast ball to the second batter in the fifth inning, he felt a “pop” and a sharp pain in his right elbow. He then felt numbness and tingling on the inside of his right forearm and was unable to continue pitching.
The school’s athletic trainer examined Jason, applied ice to the arm, and put it in a sling. He referred Jason to an orthopedic surgeon who specialized in baseball injuries. The surgeon diagnosed a severe UCL injury. After talking with the surgeon and his family, Jason decided to have surgery to reconstruct the UCL on his right elbow.
Immediately after surgery, Jason was placed in a custom splint that held his elbow at a 90° angle with a sling around his shoulder to support his arm. He began his physical therapy 10 days after his surgery.
Jason’s physical therapist gently removed his splint and helped him begin to move his right elbow and shoulder. He gave Jason a series of exercises to perform at home, to work on his posture, shoulder blade strength, and the overall range of motion of his elbow and shoulder.
Over the next few weeks, Jason teamed with his physical therapist to work on his shoulder and elbow range of motion, single-leg balance exercises, core strengthening, and posture and shoulder-blade exercises. As he regained strength and motion, Jason learned new exercises to strengthen the muscles of his shoulder. His physical therapist measured his range of motion to ensure he was on track, and introduced more intense exercises at the shoulder and elbow.
Jason then began a throwing program that gradually increased the stresses across his elbow as he moved from shorter- to longer-distance throws. His physical therapist and pitching coach instructed him to focus on his mechanics and be aware of the position of his arm, trunk, and legs when he threw.
When the new baseball season began, Jason was able to return to the starting lineup! With careful attention to the instructions of his physical therapist on adequate warm ups, safe throwing motions, maintaining shoulder and arm strength and overall balance, and not throwing too much, he was able to pitch a complete season.
Jason called his physical therapist after his last postseason game, proud to report that he had set a personal record for number of wins and earned run average!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
Although all physical therapists are prepared through education and experience to treat UCL injuries, you may want to consider:
- A physical therapist who is experienced in treating people with UCL injuries. Some physical therapists have a specialized practice with a focus on sports and orthopedics, and more specifically, the upper extremity.
- A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in sports or orthopaedic physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool developed by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist:
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have UCL injuries.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of UCL injuries. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Whiteside D, Martini DN, Lepley AS, Zernicke RF, Goulet GC. Predictors of ulnar collateral ligament reconstruction in Major League Baseball pitchers. Am J Sports Med. 2016;44(9):2202–2209. Article Summary in PubMed.
Bruce JR, Andrews JR. Ulnar collateral ligament injuries in the throwing athlete. J Am Acad Orthop Surg. 2014;22(5):315–325. Article Summary in PubMed.
Garrison JC, Cole MA, Conway JE, et al. Shoulder range of motion deficits in baseball players with an ulnar collateral ligament tear. Am J Sports Med. 2012;40(11):2597–2603. Article Summary on PubMed.
Shanley E, Rauh MJ, Michener LA, et al. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011;39(9):1997–2006. Article Summary on PubMed.
Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329–335. Article Summary on PubMed.
Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective study. Am J Sports Med. 2011;39(2):253–257. Article Summary on PubMed.
Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29(4):619–644. Article Summary on PubMed.
Lin YC, Thompson A, Kung JT, et al. Functional isokinetic strength ratios in baseball players with injured elbows. J Sport Rehabil. 2010;19(1):21–29. Article Summary on PubMed.
Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Am J Sports Med. 2009;37(3):566–570. Article Summary on PubMed.
Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523–527. Article Summary on PubMed.
Kibler WB, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. Am J Sports Med. 2008;36(9):1789–1798. Article Summary on PubMed.
Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players. Am J Sports Med.2004;32(5):1158–1164. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by David Colvin, PT. Authored by Craig Garrison, PT, PhD, ATC, and Joseph Hannon, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.
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