Elbow Subluxation

with UCL and

Triceps Tear

Thomas Gibson
 Anatomy of the Elbow

Elbow is essentially a hinge joint, with slight

rotation, and gliding motions at the radius.
The elbow joint is made up of three bones
Humerus
Radius
Ulna
Held together by
ligaments such as
UCL, RCL, and
annular ligament.
 Anatomy of the UCL

The ulnar collateral ligament (UCL) is a thick

band of ligamentous tissue that forms a
triangular shape at the medial elbow.
anterior bundle
posterior bundle
transverse ligament
Primary stabilizer of the elbow.
Originates at the posterior distal aspect of
medial epicondyle and inserts to the base
of the coronoid process.
 MOI and Predisposing factors
MOI: applied valgus force at the elbow joint, signs
would include pain over the medial aspect of the
elbow, and limited ROM due to pain and instability.
Positive Stress Tests: Valgus Stress Test, Moving Valgus
Sign, and Milking Sign.
Risk increases with:
Contact sports where falling on outstretched
arm leads to elbow dislocation
Throwing and overhead sports
Poor physical condition
Improper throwing mechanics
 UCL TX: Conservative

At first, many of the symptoms may be

treated with rest or significantly decreasing
the amount of activity.
Correcting an athlete's posture, strength
and release of the ball.
Analgesics and anti inflammatory drugs
can be used to reduce pain and
inflammation.
Main goal is to regain ROM and promote
UCL healing.
Brace is optional.
 UCL TX: Surgery

Many different approaches to UCL repair.

Direct repairs can arthroscopically be done
in situations if the UCL was acutely damaged
due to a fall on the outstretched arm.
If the ligament has been pulled off the bone
it can be reattached via sutures through the
bone.
If the ligament is damaged due to an
overuse injury, the ligament must be
replaced.
 UCL Rehabilitation

In nonsurgical cases, strengthening and stretching

for the muscles of the forearm are the main focus.
Many times in rehab on UCL repair, a lot of the
focus is on shoulder strengthening exercises.
Immediately after surgery ROM exercises to begin
to work to regain full range of motion.
Once ROM is restored rehab process is started and
progressed, including a gradual throwing process.
Can take 1 to 3 months with the most basic
surgery.
Other methods can take up to a year.
 Other TX for UCL

Surgery to repair UCL is called Tommy John surgery.

Limited blood supply so ligament is replaced by a
graft.
Torn ligament is replaced by either Palmaris Longus
tendon or Gracilis tendon. (autograft)
Surgery is used on athletes whose symptoms do not
improve over time.
Athletes who put repetitive stress on UCL will often
opt for surgery.
Throwers or overhead sports.
Full recovery approx. 12 months.
Anatomy of Triceps
- normal triceps brachii
muscle (right side,
posterior view)
- Long Head
- origin: infraglenoid
tubercle of the scapula
- insertion: olecranon
process of ulna
- Short Head
- origin: posterior humerus
- insertion: olecranon
process of the ulna
- Radial nerve innervates
the triceps
- vascular supply comes
from the profunda
brachii artery
 - typically there is a rapid eccentric load against

Predisposing Factors
a contracting triceps while extending elbow
- direct trauma to the flexed elbow followed by
forced elbow extension is the other typical
injury mechanism
-accidents or sudden unexpected acute loading of the
arm during sports
MOI

- participating in power events

Predisposing Factors
MOI and

- heavy weight training

- use of anabolic steroids
- local steroid injections
- having chronic olecranon bursitis
- triceps olecranon spurring
- systemic diseases: can compromise tendon insertion
and result in rupture
- diabetes mellitus
- renal osteodystrophy
- hyperthyroidism
 Triceps Research and Facts

- average age of occurrence: 30 to 50 years old

- male to female ratio is 3:2
- thought to be because more males tend have more
predisposing factors (the sports they do, steroid
usage, etc)
- Article: Triceps Tears in Athletes: Different Injury
Patterns and Surgical Treatment
- looked at 1,014 tendon ruptures in 781 patients
- only found 8 triceps ruptures (0.8%)
- most often occur in the tendon insertion site
 Triceps TX: Conservative

- partial triceps tears can be successfully

treated with rest and extension splinting.

- recovery of strength is approx. 3 to 6 months

- depending on the degree of the tear

- tears of 50% or less can be treated

nonoperatively
 Triceps TX: Conservative
Bracing

different types of braces that allow the

joint to be locked in different degrees of
flexion/extension
 Triceps TX: Surgical
- complete acute ruptures
usually happen at the
olecranon and can be
repaired with heavy sutures
through bone tunnels
- complete chronic ruptures
need to be addressed
through surgical repair using above: achilles allograft placed over the ulna
an autograft or allograft below: achilles allograft patched over the
- usually autografts of the triceps muscle
semitendinosus, gracilis, or
palmaris tendons have been less
successful due to the size
mismatch
- achilles allograft works the best
because the shape and size.
 Other TX for Triceps
Like mentioned before Platelet rich plasma (PRP) is an emerging
non-surgical treatment for partial tricep tears
A case report:
Patient with partially torn distal triceps tendon
Tried PRP injection after failed physical therapy interventions
Outcome: The PRP injection along with a specific rehab strategy
helped the athlete to return to light weight training and
coaching activity after 15 visits over a 3 month period
One month after discharge patient reported pain free daily
living and return to previous activity
Still plenty of research to be done on PRP
 Case Study

21yr old male

Football athlete
7/28/16
R elbow subluxation
UCL tear
Triceps tear
 MAPPSS

Swelling present esp medially

Cont p! and swelling limited movement.
Lack full ext ttp ucl, post olecranon/triceps insertion
+ opening w/ valgus strain
x-ray elbow likely old avulsion fx triceps/post olecranon.
+ bone fleck at posterior olecranon
+fluid discrete triceps tear
Medially +fluid ucl difficult visualize
8/17 lacks 5-10 degree full ext, has full flex/sup/pro
+ucl laxity
 TX

No Surgery
RICE
NSAIDS
Elbow Brace for all activity
Rehab
Strengthening and ROM
Graston
 Rehab
wrist extension and tricep ext w/ band
flexion push ups
ulnar deviation con/ecc tricep manual
radial deviation resistance
wrist bosu pushup
pronation/supination tricep extension
elbow ext on table lateral box shuffle
isometrics 130, 90, 45 pushup
3X eccentrics 100+
oscillations
Biodex Test 8/24
Biodex Test 8/24
Biodex Test 9/21
 Comparison of different TX:
UCL
Surgical vs. conservative
either approach can be taken in this situation
Treatment method can be sport/activity specific
Non-throwing athletes and low demand patients
often take conservative route
In this case, athlete is a soccer player which
allowed for more options
Retrospect review: In the NFL over a 4 year span
showed 18/18 players with UCL injuries were
successfully treated non-operatively.
mean time lost was 0.64 games
 Comparison of TX: UCL
Surgery is the route most often taken by throwing
sport athletes.
Baseball/Softball
UCL tear is often a result of an overuse injury
Goal of surgery is to get the athlete back to
throwing at the level/speed reached before injury
Tommy John surgery; approx 12 month recovery
The most widely accepted success rate for Tommy
John surgery is around 80%
% of players in MLB who return to throw at least
one pitch at the big league level.
 Comparison of Tx: Triceps
Surgery vs. conservative
Conservative
tears of 50% or less.
Study done on NFL players showed 6 of 9 athletes with
tricep tears who did not have surgery returned
without loss of strength, without pain, and without loss
of function.
Other 3 players later needed surgery.
Surgical
Usually the treatment of choice for athletes with
complete tears
Favored if done within three weeks
Research is inconclusive on the best method of treating a
partial tear to the triceps. Case by case basis
 Conclusion
A couple different options exist in terms of treating
a UCL and Triceps tear.
The non-surgical route was taken in the case study
we observed.
This type of injury, like many, is important to be
researched and observed because the treatment
method is not always going to be the same
Likewise, early detection of these injuries can lead
to a more clean healing process.
 Citations
Cheatham, Scott W., et al. "Rehabilitation Of A Partially Torn Distal Triceps Tendon After Platelet
Rich Plasma Injection: A Case Report." International Journal Of Sports Physical Therapy8.3
(2013): 290-299. SPORTDiscus with Full Text. Web. 6 Dec. 2016.

Foulk, David M., and Marc T. Galloway. Partial Triceps Disruption: A Case Report. Sports Health 3.2
(2011): 175178. PMC. Web. 6 Dec. 2016.

Koh, Jason Lee, et al. "Ulnar collateral ligament reconstruction in elite throwing athletes."
Arthroscopy: The Journal of Arthroscopic & Related Surgery 22.11 (2006): 1187-1191.

Langer, P, P Fadale, and M Hulstyn. Evolution of the Treatment Options of Ulnar Collateral Ligament
Injuries of the Elbow. British Journal of Sports Medicine 40.6 (2006): 499506. PMC. Web. 6
Dec. 2016.

Petty, Damon H., et al. "Ulnar collateral ligament reconstruction in high school baseball players
clinical results and injury risk factors." The American journal of sports medicine 32.5 (2004):
1158-1164.