Revision Ulnar Collateral Ligament Reconstruction

Jeremy R. Bruce, MD; Neal S. ElAttrache, MD; James R. Andrews, MD


J Am Acad Orthop Surg. 2018;26(11):377-385. 

In This Article

Patient History and Physical Examination

In the patient with a suspected UCL injury, a thorough history should be obtained, including information on the timing of the season, position played, level of competition, training regimen, number of pitches/innings at the time of the injury, and symptoms at onset, including any ulnar nerve symptoms and their duration. Some patients report feeling a pop at the time of injury. Others report feeling vague pain that affects pitching accuracy and/or velocity. A history of shoulder or kinetic chain injuries before or after the index procedure should also be noted.

Details about prior UCL reconstruction should also be obtained, including surgical technique and graft used, flexor-pronator repair/débridement, olecranon osteophyte resection, and/or other concomitant procedures. Information about ulnar nerve decompression and/or transposition associated with the primary procedure is critical, as is the type of transposition. The rehabilitation course after such an injury should be well documented, including the amount of time that pitching was discontinued, the physical therapy/training regimen, and other nonsurgical measures undertaken.

The physical examination should include a detailed evaluation of the injured elbow. Pain is the most common reason for revision reconstruction.[4] However, other symptoms include ulnar nerve symptoms and stiffness. Palpation of the proximal and distal sites of the UCL can provide information on the location of the tear or injury.[4] Elbow motion should be compared with motion on the contralateral side. For thorough nerve examination, which includes the Tinel test, and assessment of nerve stability throughout elbow motion, information about the initial procedure (eg, whether the ulnar nerve was transposed) is important. The flexor/pronator muscle group is a secondary stabilizer to valgus stress at the elbow. Flexor/pronator muscle group strength testing and palpation of its origin at the medial epicondyle should be assessed.

The same special tests apply to an athlete with medial elbow pain with and without previous UCL reconstruction. For pain and/or instability, the valgus stress test, milking maneuver, moving valgus stress test, and posteromedial overload maneuver should be performed.[2]

The physical examination should also include a detailed evaluation of the entire upper extremity and kinetic chain. The range of motion of the shoulders should be compared for deficits. Special attention should be paid to ipsilateral scapular dyskinesis, asymmetric rotator cuff weakness, and glenohumeral internal rotation deficiency. Core stability and lumbopelvic control should be part of the overall kinetic chain assessment.