UCL INjuries in quarterbacks
If sports fans or fantasy owners were to look through the injury headlines, the injury to the Buffalo Bills Josh Allen is dominating headlines. He is the current number one quarterback in regards to fantasy points. There are a lot of questions in regards to his injury and most recent reports are calling his injury an “elbow sprain.”
We will provide some insight to his UCL injury and evaluate potential options and prognosis. He did have a prior ulnar collateral ligament in 2018 and missed 4 games due to this injury. The injury occurred on November 6, 2022 in the final quarter. He was throwing the football and a defender went for the ball and caused his elbow to hyperflex with a valgus load.
The first description of a tear of the ulnar collateral ligament (UCL) appeared in a 1946 report by Waris that focused on elbow injuries in javelin throwers. However, it was not until 1974 that the first UCL reconstruction (UCLR) was performed by Dr. Frank Jobe on Los Angeles Dodgers pitcher Tommy John .
The UCL of the elbow is composed of three bundles. The anterior oblique ligament (AOL) or bundle, posterior oblique ligament (POL) or bundle, and the transverse ligament (which unites the AOL and POL). The AOL is the strongest elbow collateral ligament with an average failure load of 260 N .
There are also differences between the football throwing motion and baseball throwing motion. Baseball pitchers generate higher rotational and angular velocities in the shoulder, elbow and trunk when compared to football players [3,4]. During the deceleration phase of throwing, baseball pitchers generate higher compressive forces and torques at the shoulder and elbow comparatively . Moreover, the position of the body and arm differs between the two throwing motions. Quarterbacks tend to stand more upright, have shorter strides, and “lead with the elbow” during arm cocking and ball release. All of these likely factor in on why injuries in quarterbacks may differ from the injuries and recovery of pitchers of javelin throwers.
Ciccotti et al. used ultrasonography to demonstrate that the UCL undergoes hypertrophy with use, reporting that the mean thickness of the UCL was significantly greater in the throwing arm than in the non-throwing arm. The hypertrophy of the ligament was accompanied by increased laxity, with ultrasonography demonstrating a mean medial gap of 4.56 mm in the throwing elbow as compared with 3.7 mm in the non-throwing elbow. The laxity and gapping are likely adaptive, providing strength to tolerate high valgus stress while allowing the generation of higher pitching velocities .
The initial evaluation of an athlete with medial elbow pain begins with a thorough history, though with quarterbacks there is usually trauma involved. Video may also be available to evaluate the mechanism of injury and may be a part of the history. There is usually pain over the medial elbow and there may be a sense of instability. The athlete may have felt an acute pop in the elbow. Ulnar nerve symptoms such as numbness and/or tingling in the small finger and the ulnar side of the ring finger must be discussed.
A thorough examination of the medial elbow structures is imperative. Palpation of the elbow structures and medial elbow can help localize the pain and differentiate between the UCL and medial epicondyle. The examiner should check to see whether the patient has a palmaris longus on either arm by having the patient flex his or her wrist and oppose the thumb and small finger. Evaluation of bilateral shoulder rotational range of motion for glenohumeral internal rotation deficit (GIRD) is a critical part of the examination. A variety of specialized tests for the UCL have been developed and should also be performed.
When discussing UCL injury, understanding severity is important for sports medicine providers to be aware of the nomenclature and treatment recommendations based upon severity. One categorization includes grade 1 as an intact ligament with or without edema, grade 2a is a partial tear and grade 2b is a chronic healed injury, and grade 3 is a complete tear . There also is a newer sixstage UCL grading scheme. The stages are based on location of tear (proximal/humeral, midsubstance, or distal/ulnar) and if the UCL injury was a partial tear or complete tear . Both of these grading schemes use MRI imaging and are likely less relevant in quarterbacks when compared to baseball pitchers.
MRI can also help a surgeon determine whether the os trigonum has a fibrous, fibrocartilaginous, or cartilaginous attachment to the talus and can detect FHL tenosynovitis or chondral injury. MRI or ultrasonography can be used to assess for FHL tenosynovitis, which can present with fluid in the tendon sheath or nodules. Ultrasound can also be used for dynamic evaluation of the ankle. Dynamic ultrasound assessment of the ankle in active or passive plantar flexion may reveal impingement of the os trigonum between the posterior tibia and calcaneus.
Published data on UCL injuries in quarterbacks is limited, likely due to the relative infrequency when compared to baseball pitchers. The largest series to date on UCL injuries in professional quarterbacks was published by Dodson and colleagues . They documented ten UCL injuries in quarterbacks from 1994 to 2008. Most injuries occurred as the result of being tackled with only two resulting from the throwing motion. The high prevalence of trauma-related UCL injury is also supported by a small series from Kenter and colleagues .
Nine of the ten UCL injuries in Dodson’s series  were managed nonoperatively, including three athletes who had complete tears or grade 3 injuries. Quarterbacks with a grade I–II injury returned around 7 days, whereas grade III injuries had a mean of 67 days to return to play. There is extremely limited data on UCL reconstruction in the professional quarterback, with most case series consisting of only one or two athletes [10-11].
Research into the usage of orthobiologics for UCL injuries has increased in the past few years. There are multiple studies using platelet-rich plasma (PRP), suggesting possible advantages to combining PRP with physical therapy after sprains or partial tears [12-15]. It is possible that a professional medical team would use PRP or possibly stem cells in an injury like this depending on the grade of injury. These would augment the physical therapy that will be done for rehabilitation. It is unlikely a quarterback will need any type of bracing for a grade I or grade II injury and will likely be too restrictive to play with.
Surgery will be reserved for grade III injuries or complete tears. There is some other professional opinions stating that most quarterbacks can likely recover without surgery, although all cases will be unique and other factors may influence the decisions made. More recently, Ben Roethlisberger did have a UCL injury and underwent a UCL reconstruction.
In summary, ulnar collateral ligament injuries in quarterbacks are less common than baseball players. Most of them occur with trauma and contact and it is rare to occur with simplay the throwing motion, which is much more common in pitchers and javelin throwers. Grade I and II injuries seem to recover well and fairly quickly with nonoperative treatment. Grade III injuries may undergo operative and nonoperative treatment.
- Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986 Oct;68(8):1158-63.
- Regan WD, Korinek SL, Morrey BF, An KN. Biomechanical study of ligaments around the elbow joint. Clin. Orthop. Relat. Res. 1991; 271:170–9. 5. Dugas JR, Walters BL, Beason DP, et al. Biomechanical comparison.
- Fleisig GSER, Andrews JR, Matsuo T, Sattenwhite Y, Barrentin SW. Kinematic and kinetic comparison between baseball pitching and football passing. J Appl Biomech. 1996;12(2):207–224. doi: 10.1123/jab.12.2.207.
- Wick HDC, Werner S. A kinematic comparison between baseball pitching and football passing. Sports Med Update. 1991;6:13–16.
- Ciccotti MG, Atanda A Jr, Nazarian LN, Dodson CC, Holmes L, Cohen SB. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med. 2014 Mar;42(3):544-51. Epub 2014 Jan 28.
- Ford GM, Genuario J, Kinkartz J, et al. Return-to-play outcomes in professional baseball players after medial ulnar collateral ligament injuries: comparison of operative versus nonoperative treatment based on magnetic resonance imaging findings. Am. J. Sports Med. 2016; 44:723–8.
- Ramkumar PN, Frangiamore SJ, Navarro SM, et al. Interobserver and intraobserver reliability of an MRI-based classification system for injuries to the ulnar collateral ligament. Am. J. Sports Med. 2018; 46:2755–60.
- Dodson CC, Slenker N, Cohen SB, Ciccotti MG, DeLuca P. Ulnar collateral ligament injuries of the elbow in professional football quarterbacks. J Shoulder Elb Surg. 2010;19(8):1276–1280. doi: 10.1016/j.jse.2010.05.028
- Kenter K, Behr CT, Warren RF, O’Brien SJ, Barnes R. Acute elbow injuries in the National Football League. J Shoulder Elb Surg. 2000;9(1):1–5. doi: 10.1016/S1058-2746(00)80023-3
- Dodson CC, Thomas A, Dines JS, Nho SJ, Williams RJ, 3rd, Altchek DW. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med. 2006;34(12):1926–1932. doi: 10.1177/0363546506290988.
- Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elb Surg. 2001;10(2):152–157. doi: 10.1067/mse.2001.112881.
- Clark NJ, Desai VS, Dines JD, Morrey ME, Camp CL. Nonreconstruction options for treating medial ulnar collateral ligament injuries of the elbow in overhead athletes. Curr. Rev. Musculoskelet. Med. 2018; 11:48–54.
- McCrum CL, Costello J, Onishi K, et al. Return to play after PRP and rehabilitation of 3 elite ice hockey players with ulnar collateral ligament injuries of the elbow. Orthop. J. Sports Med. 2018; 6:2325967118790760.
- Podesta L, Crow SA, Volkmer D, et al. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am. J. Sports Med. 2013; 41:1689–94.
- Deal JB, Smith E, Heard W, et al. Platelet-rich plasma for primary treatment of partial ulnar collateral ligament tears: MRI correlation with results. Orthop. J. Sports Med. 2017; 5:2325967117738238.
- Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes. Sports Health. 2015 Nov-Dec;7(6):511-7. doi: 10.1177/1941738115607208. Epub 2015 Sep 22. PMID: 26502444; PMCID: PMC4622381.
- Total Pro Sports. https://www.totalprosports.com/nfl/buffalo-bills-josh-allen-elbow-injury-video-jets/