DEFINITION

The ulnar collateral ligament (UCL) is a primary stabilizer of the medial side of the elbow. A tear in this ligament can cause pain and disability, primarily in an overhead athlete. When reconstruction is performed, the anterior band of the ligament is reconstructed.

 

 

ANATOMY

 

The UCL originates from the inferior aspect of the medial epicondyle and inserts onto the sublime tubercle of the ulna.

 

There is an anterior band, a posterior band, and a transverse band (FIG 1).

 

The anterior band provides the primary resistance to valgus stresses between 20 and 120 degrees and is further divided into anterior and posterior bundles that tighten in a reciprocal fashion as the elbow is flexed and extended.

 

PATHOGENESIS

 

Injury to the UCL occurs with a valgus force applied to the elbow. This can occur from trauma such as a fall on an outstretched hand. Injury is most commonly seen in the overhead athlete who applies a significant and repetitive valgus force to the elbow during sports.

 

Injury is most common in baseball, javelin, and volleyball but can be seen in numerous other sports such as football, wrestling, and tennis.

 

 

 

FIG 1 • Anatomy of the medial aspect of the elbow. (Reprinted with permission from Leversedge FJ, Goldfarb CA, Boyer MI. Pocketbook Manual of Hand and Upper Extremity Anatomy: Primus Manus. Philadelphia: Lippincott Williams & Wilkins, 2010.)

 

NATURAL HISTORY

 

Injury to the UCL can occur in one instance with immediate onset of pain or can be progressive over a period of time.

 

Patients who do not repeatedly expose the injured ligament to continued stress have a high rate of success with nonsurgical treatment if gross elbow instability is not present.

 

Athletes participating in sports that place a valgus stress on the elbow and who wish to continue to participate will usually require surgical reconstruction to resume participation.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients will complain of pain on the medial side of the elbow. There may be associated complaints of numbness and/or tingling if there is concurrent irritation to the ulnar nerve.

 

Patients may describe feeling a pop in the elbow with one incident of a valgus force, such as a baseball pitch or javelin throw. Conversely, there may be a history of several days or weeks of progressive, worsening medial elbow discomfort, tightness, or trouble with activity involving valgus force to the elbow.

 

Patients with isolated UCL injury will rarely complain of instability. Unless concurrent flexor-pronator mass (FPM) or ulnar nerve injury is present, patients will rarely complain of weakness.

 

In addition to a thorough basic elbow examination as described previously, provocative tests to diagnose UCL tears

 

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include the moving valgus stress test and the milking test. Pain along the UCL elicited with these tests is

indicative of a UCL tear.

 

The milking test is performed by pulling or “milking” the thumb of the involved elbow while placing a valgus force on the elbow. The involved shoulder is held in an abducted and externally rotated position while the test is performed.

 

The moving valgus stress test is performed in a similar position, but the involved elbow is moved from 30 to 120 degrees while valgus stress is applied to the elbow.

 

Direct valgus stress testing may also cause pain. However, the examiner will rarely appreciate laxity with this test. This test should be performed in approximately 30 to 60 degrees of elbow flexion.

 

Palpation of the posteromedial olecranon may elicit pain in chronic situations of valgus extension overload.

 

Chronic microlaxity may also result in lateral-sided compression, causing overload of the radiocapitellar joint. Palpation of this area should be performed for pain or crepitans.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Initial plain radiographs are helpful especially in younger individuals. These may reveal bony avulsion of the ligament, growth plate fracture, posteromedial olecranon osteophytes, or osteochondritis dissecans (OCD) of the capitellum. Plain radiographs in more mature throwing athletes often show calcifications and or osteophytes. Stress radiographs may be helpful in cases of significant instability.

 

The imaging of choice is an elbow magnetic resonance imaging (MRI) with or without intra-articular contrast.

 

The T-sign is a finding often seen on an MRI and is suggestive of injury to the UCL (FIG 2). In cases where an MRI cannot be attained, a computed tomography (CT) arthrogram can be used to diagnose injury to the UCL.

 

Stress ultrasound has more recently been proposed to compliment MRI/magnetic resonance angiography (MRA) particularly in athletes with a clinically subtle injury, partial injury on MRI/MRA, failed nonoperative

treatment, or recurrent injury after previous UCL reconstruction2 (FIG 3).

 

 

 

FIG 2 • MRI of the elbow showing the T-sign (arrow).

 

 

 

FIG 3 • Ultrasound of the UCL.

 

DIFFERENTIAL DIAGNOSIS

FPM injury/medial epicondylitis Medial epicondyle fracture Ulnar neuritis

Ulnar stress fracture

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative treatment consists of rest, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and rehabilitation focused on shoulder and scapular strengthening along with evaluation of the specific mechanics involved in each athlete's sport.

 

Athletes who are not involved in overhead sports may return when symptoms allow and may participate with a hinged elbow brace.

 

Athletes involved in overhead sports often require a 3-to 6-week period of rest, during which time a coordinated rehabilitation program including leg, core, and shoulder strengthening and flexibility is carried out. Once preinjury range of motion (ROM) and strength are restored without pain, then a progressive throwing program is initiated. This program includes tossing at increasing distance up to ˜180 to 200 feet; pitchers then begin a mound program throwing fastballs first with increasing effort, followed by off-speed pitches. This thorough nonoperative program may require 8 to 12 weeks before return to sport.

 

Certain overhead-throwing athletes have high success with nonoperative measures. Dodson et al6 noted that

professional football players, specifically quarterbacks, have a high rate of return with nonoperative treatment.

 

 

Podesta and associates12 reported an 88% return to competition for athletes with partial tears of the UCL treated with platelet-rich plasma (PRP) in short-term follow-up.

 

SURGICAL MANAGEMENT

 

Surgical management is considered for all athletes who fail nonoperative treatment.

 

 

Surgical management consists of reconstruction of the anterior band of the UCL. Most commonly, a palmaris longus autograft is used if available. Alternatives include contralateral hamstring, plantaris, or medial strip of Achilles

 

tendon autograft. Allograft reconstruction has also been described recently with good results.14

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Preoperative Planning

 

Preoperative planning should include evaluating if the patient has an available palmaris longus tendon. If not, alternative graft options should be discussed with the patient. The palmaris longus tendon has been identified in 85% of the population.

 

Patients with ulnar nerve symptoms should be evaluated for possible ulnar nerve decompression or transposition performed at the time of UCL reconstruction. A subluxing ulnar nerve should also be identified and considered for surgical treatment.

 

Concurrent intra-articular pathology such as loose bodies can be managed with arthroscopy at the time of reconstruction.

 

Patients with acute injuries should be evaluated for return of full elbow motion prior to undergoing surgery.

 

Positioning

 

The patient is placed in the supine position with a hand table. If elbow arthroscopy is to be performed, the patient should be positioned for this in the desired position first and then switched to the supine position.

 

Either a sterile or nonsterile tourniquet can be used.

 

If a hamstring, plantaris, or medial Achilles strip autograft is to be taken, the contralateral leg should also be draped out and a nonsterile tourniquet should be used.

 

 

 

FIG 4 • Incision centered over the medial epicondyle.

 

Approach

 

The approach consists of a standard medial incision centered over the medial epicondyle (FIG 4). The initial surgery described by Jobe et al11 consisted of a takedown of the FPM and ulnar nerve transposition.

 

 

More recent modifications describe an FPM split and ulnar nerve transposition only if indicated.15 Commonly used techniques include the Jobe figure-of-eight technique and the docking technique.

Biomechanical evaluation of both techniques has revealed valgus stability comparable to the native ligament.3

 

TECHNIQUES

• Figure-of-Eight Reconstruction—Jobe Technique

An extensile medial incision is used centered over the medial epicondyle.

Care should be taken to identify and protect the branches of the medial antebrachial cutaneous nerves (TECH FIG 1A).

The medial epicondyle, ulnar nerve, and the fascia overlying the FPM should be identified. The sublime tubercle can often be palpated 2 to 3 cm distal to the medial epicondyle.

The raphe between the middle and posterior thirds of the FPM should be identified and split from the medial epicondyle distally in line with the fibers, past the sublime tubercle (TECH FIG 1B).

Blunt dissection using a periosteal elevator will bring the ligament into visualization (TECH FIG 1C).

Once the ligament is identified from the inferior border of the medial epicondyle to the sublime tubercle, it should be incised in line with its fibers. This will expose the joint. An assessment of ligament integrity can be performed at this point by applying valgus stress and noting any joint gapping (TECH FIG 1D).

 

 

The origin of the ligament at the inferior aspect of the epicondyle as well as the anterior and medial aspect of the epicondyle are exposed for drilling of the tunnels.

 

The anterior and posterior aspects of the sublime tubercle are exposed using sharp dissection (TECH FIG 1E). Enough area must be exposed to allow for a sufficient bone bridge between the tunnels to prevent fracture. Ideally, one should have at least 8 to 10 mm between the ulnar tunnels.

 

Once the exposure has been performed and ligament laxity has been confirmed, the holes may be drilled or the graft can be obtained.

 

Using a 3.5-mm drill bit, the ulnar tunnels are drilled anterior and posterior to the sublime tubercle at ˜5 to 7 mm from the articular margin and with a 10-mm bone bridge. These tunnels should converge at a point within the ulna below the sublime tubercle (TECH FIG 1F). Fracture of the bone bridge between the tunnels is a pitfall that should be avoided.

 

Once the tunnels are drilled, a curette should be used to assure connection of beneath the sublime tubercle. Inadequate preparation of this tunnel will result in difficulty with graft passage.

 

A curved suture passer should be used to pass a suture through this tunnel. This will be used for graft passage. The loop should be passed from posterior to anterior. This can also be used to identify the isometric point of the humeral tunnel (TECH FIG 1G).

 

The humeral tunnel is drilled using a 4.5-mm drill bit in a retrograde direction starting at the origin of the ligament midway between the base and tip of the epicondyle (TECH FIG 1H). This tunnel is drilled to a depth of approximately 10 to 15 mm. Care should be taken not to fracture the epicondyle or to drill out the back wall into the cubital tunnel.

 

The FPM is then split at the junction of the anterior and middle thirds, exposing the superior surface of the medial epicondyle. Two smaller tunnels are then drilled with a 3.5-mm drill bit in an anterograde direction starting on the anterior and medial aspects of the epicondyle converging onto the larger, 4.5-mm tunnel (TECH FIG 1I).

 

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TECH FIG 1 • A. (Left, right) Jobe technique and docking technique for UCL reconstruction. B. Incision with identification of the medial antebrachial cutaneous nerve. C. Split in the FPM. D. Blunt dissection exposing the UCL. E. Exposure of the sublime tubercle for drilling. F. Drilling of the ulnar tunnels. The drill is prepared for the anterior tunnel and the forceps is in the posterior tunnel. G. Suture in the ulnar tunnels and pointing toward the humeral starting point. H. Drilling of the 4.5-mm humeral tunnel. I. Split of the FPM exposes the superior surface of the medial epicondyle for drilling. J. Measuring for the palmaris longus harvest. K. Harvesting of the palmaris longus graft. L. Prepared graft. M. Graft has been passed and is ready to be secured. N. Suturing of the graft to itself and to the native ligament. O. Ulnar nerve transposition with fascial sling.

 

 

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A curette should be used to assure connection of these tunnels. Vicryl sutures should be passed in opposite directions such that a looped end is present at the origin of the ligament on the humerus and one looped end is located at the opening of the anterior tunnel.

 

At this point, three sutures should be in the tunnels for passage of the graft.

 

The palmaris longus graft is harvested using three transverse incisions approximately 1 cm in length starting distally at the wrist crease. Once the tendon is identified distally just beneath the skin, a hemostat is placed under the tendon and used to pull the tendon distally. This will allow for easy visualization of the subcutaneous position of the tendon.

 

A second incision is made approximately 6 to 8 cm proximal to the initial incision. Once the tendon is identified here, the process is repeated and a hemostat is placed under the tendon to allow for traction to be applied. The third incision is placed approximately 15 cm from the wrist crease at the muscle tendon junction of the palmaris (TECH FIG 1J).

 

Once all three incisions are created and the tendon is identified, the tendon can be cut distally and pulled out through each incision sequentially until the tendon is entirely located external to the most proximal incision (TECH FIG 1K). The entire tendon length should be at least 15 cm.

 

Once this is confirmed, the tendon is transected as proximal as possible. Any muscle fibers should be removed.

 

The tendon ends should be tagged using a no. 2 suture to aid in passage of the graft. Care should be taken not to make the end too bulbous (TECH FIG 1L).

 

The graft is then passed in a retrograde fashion through the 4.5-mm distal humeral tunnel and out through the 3.5-mm superomedial humeral tunnel. The graft is then passed through the adjacent 3.5-mm anterior humeral tunnel and back out through the 4.5-mm distal humeral tunnel to create the proximal loop of the figure-of-eight.

 

The posterior limb of the graft that is exiting the humerus should be brought over the top and into the anterior ulnar tunnel. This will then exit out the posterior ulnar tunnel to complete the figure-of-eight (TECH FIG 1M).

 

Both limbs are then pulled to tension the graft. The elbow should be placed in approximately 45 to 60 degrees of flexion. An assistant should maintain a varus force on the elbow for the rest of the procedure.

 

Prior to suturing the graft, the palmaris longus graft incisions should be closed.

 

The graft is then tied to itself using a nonabsorbable suture. Multiple points of fixation should be used.

 

The native ligament can then be closed over the top of the reconstruction to add more collagen tissue to the reconstruction (TECH FIG 1N).

 

The ulnar nerve is usually not visualized during the procedure. If a transposition is performed, the nerve can be identified and dissected out at the onset of the procedure.

 

The most common transposition performed in this setting is an anterior subcutaneous transposition, which avoids takedown of the FPM. The nerve is freed proximally and distally to the motor branch of the flexor carpi ulnaris. It is then brought anterior to the epicondyle and secured there loosely in a subcutaneous pocket or fascial sling with absorbable sutures (TECH FIG 1O).

 

Closure of the FPM fascial splits can be performed using absorbable suture.

 

The subcutaneous layer and the skin are closed using absorbable suture and a static splint is applied with the elbow at 90 degrees of flexion, the forearm in neutral rotation including the wrist.

• Docking Technique

   

  Several other techniques have been described that use the same exposure but different modes of graft passage and fixation.

   

  The docking technique uses the same ulnar tunnel but only one proximal humeral tunnel for the graft. It is a common technique used.

   

  After drilling the ulnar and the central humeral tunnel in a retrograde fashion, two smaller holes are drilled

  in an anterograde fashion from the superior and anterior aspect of the medial epicondyle through the anterior FPM split. These tunnels are made with a 2.0-mm drill bit sufficient for passage of sutures. This bridge should be at least 8 to 10 mm in size.

   

  The two smaller proximal holes will also converge on the central humeral tunnel. Sutures or wire should be passed through each smaller tunnel in an anterograde fashion exiting the distal humeral tunnel. These should be kept separate so as to avoid crossing the sutures. The looped end of both sutures should come out the distal end of the tunnel.

   

  The graft is prepared in a slightly different fashion than the figure-of-eight technique. A nonabsorbable no. 2 suture is placed in a Krackow pattern on one end. The other end can be tagged with a temporary stitch.

   

  The graft is first passed through the ulna (TECH FIG 2A). The end with the nonabsorbable suture is passed first and is brought into the humeral tunnel so as to sit flush in the tunnel. The sutures should exit out one of the smaller drill holes in the humerus.

   

  The graft should be tensioned and then the other limb of the graft is sized for the appropriate length. The graft is then cut to fit into the humeral tunnel without any laxity. This tunnel should be 10 to 15 mm in length.

   

  A second nonabsorbable 2.0 suture is then placed using a Krackow stitch pattern along approximately 1 cm of the exposed end of the graft. The ends of this suture are passed through the humeral tunnel and out the other 2.0-mm drill hole docking the graft into the humerus. It is then tensioned, and the sutures coming out through each of the smaller humeral drill holes are tied together over the bone bridge.

   

  The graft is essentially one loop from the humerus into the ulna and back (TECH FIG 2B). After the graft is tied, the two limbs can also be sutured together to provide additional tension. All this should be done with a varus force applied to the elbow.

   

  The closure is as previously described.

   

   

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  TECH FIG 2 • A. Graft passed through the ulnar tunnel. B. Graft in place for docking technique.

• Other Techniques

 

Other techniques have been described using interference screws or suture implants. One such technique, the DANE technique, uses an interference screw on the ulna and the docking technique on

the humerus. This technique has also resulted in good outcomes.5

PEARLS AND PITFALLS

Difficulty in ▪ The tunnels should be meticulously cleaned of any fragments or ridges of bone

passing that may prevent passage. In addition, the end of the graft should not be too large the graft and suture should be used judiciously on each end to prevent enlarging the graft.

Mineral oil can be applied to the graft to aid in passage.

Fracture of ▪ A backup option should be available during surgery. Care should be taken to avoid

the bone this, but if it occurs, interference screw or EndoButton fixation can be successful in bridge salvaging the reconstruction.

between the tunnels

Hamstring

autograft is used.

• Unlike the palmaris longus graft, the hamstring is much thicker and should be

thinned sufficiently to facilitate passage.

Neurologic ▪ Care should be taken to identify the medial antebrachial cutaneous nerve during

awareness exposure and protect it throughout the surgery and during closure to prevent a neuroma in continuity.

• One should also remain vigilant of the close proximity to the ulnar nerve during drilling of the posterior ulnar tunnel to prevent postoperative neurologic symptoms.

 

 

POSTOPERATIVE CARE

 

The patient is placed in a posterior splint at the time of surgery for 7 to 10 days.

 

After that, the patient is placed in a hinged elbow brace with progressive advancement of elbow flexion and extension weekly until full ROM is achieved at 4 to 6 weeks.

 

Gentle strengthening is initiated between weeks 6 and 12. Special attention is directed toward optimizing leg, core, and shoulder strength and flexibility.

 

Swinging a bat, golf club, or racquet may begin at 3 months after surgery. A throwing program is begun at 4 months. Progressive tossing proceeds from ˜30 feet to ˜180 to 200 feet. Pitchers begin to throw from the mound at 6 to 8 months.

 

Full recovery in overhead athletes that place a repetitive valgus load on the elbow will take 12 to 18 months.

 

Other athletes can return to full activity by 8 to 12 months.

OUTCOMES

Most outcome studies after reconstruction have been performed in baseball players.

The original article by Jobe et al11 showed a 63% return to participation. A second article published by Conway et al 4 showed a 68% return to previous level of competition with reconstruction.

More recent articles have evaluated the modified Jobe technique, which incorporates a muscle-splitting

 

 

approach and

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ulnar nerve transposition only if needed. Thompson and associates15 reported 93% excellent outcomes with this technique.

Cain and associates1 reviewed 743 athletes with a minimum 2-year follow-up and found that 83% return to the same or higher level of competition.

Rohrbough and associates13 and Dodson et al7 evaluated outcomes of the docking technique and reported 90% to 92% return to the same or higher level of play.

Savoie14 reported his series of UCL reconstructions using allograft and noted an 83% return to the same or higher level of athletic participation.

Vitale and Ahmad16 performed a systematic review of published studies evaluating outcomes of patients following UCL reconstruction. They found that 83% of patients had an excellent outcome with an overall 10% complication rate.

Factors related to better outcomes included use of the muscle-splitting approach in lieu of the FPM takedown. Also, series in which patients only had an ulnar nerve transposition if needed resulted in better

outcomes.16

Research done on professional baseball pitchers reveals a rate of return of 82% to 83%8,9 and no significant loss of pitching velocity.10

Athletes not participating in repetitive overhead activity with large valgus force have a high rate of return to the prior level of competition with nonsurgical management.

Concurrent injury to the FPM, ulnar nerve, or intra-articular structures can decrease the chances of returning to the preinjury level of competition.

 

 

COMPLICATIONS

Elbow stiffness is a complication that can occur with any elbow surgery. Progressive advancement of elbow ROM in the first 4 weeks postoperatively should be initiated. In cases where ROM is lacking, an NSAID can be beneficial in decreasing inflammation and can aid in achieving full ROM. In more difficult cases, dynamic splinting can be used.

Injury to the ulnar nerve can occur during surgery. When retracting around the sublime tubercle, care should be taken to avoid excessive pressure on the nerve. If the nerve is already irritated preoperatively, this may increase the possibility of postoperative nerve symptoms.

Injury to the medial antebrachial cutaneous nerve can occur. Neuroma in continuity can give medial elbow pain that may cause persistent symptoms in the overhead athlete.

Undiagnosed intra-articular pathology can cause persistent symptoms. Preoperative MRI or diagnostic elbow arthroscopy will minimize this possibility.

Cain and associates1 reported a complication rate of 20% in their series. Only 4% of these were considered major complications.

 

REFERENCES

1. Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med 2010;38:2426-2434.

    

    

2. Ciccotti MG, Atanda A Jr, Nazarian LN, et al. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med 2014;42(3):544-551.

    

    

3. Ciccotti MG, Siegler S, Kuri JA II, et al. Comparison of the biomechanical profile of the intact ulnar collateral ligament with the modified Jobe and the Docking reconstructed elbow: an in vitro study. Am J Sports Med 2009;37:974-981.

    

    

4. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67-83.

    

    

5. Dines JS, ElAttrache NS, Conway JE, et al. Clinical outcomes of the DANE TJ technique to treat ulnar collateral ligament insufficiency of the elbow. Am J Sports Med 2007;35:2039-2044.

    

    

6. Dodson CC, Slenker N, Cohen SB, et al. Ulnar collateral ligament injuries of the elbow in professional football quarterbacks. J Shoulder Elbow Surg 2010;19:1276-1280.

    

    

7. Dodson CC, Thomas A, Dines JS, et al. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med 2006;34:1926-1932.

    

    

8. Erickson BJ, Gupta AK, Harris JD, et al. Rate of return to pitching and performance after Tommy John Surgery in Major League Baseball pitchers. Am J Sports Med 2014;42(3):536-543.

    

    

9. Gibson BW, Webner D, Huffman GR, et al. Ulnar collateral ligament reconstruction in major league baseball pitchers. Am J Sports Med 2007;35:575-581.

    

    

10. Jiang JJ, Leland JM. Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction. Am J Sports Med 2014;42(4):880-885.

     

     

11. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 1986;68:1158-1163.

     

     

12. 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;41:1689-1694.

     

     

13. Rohrbough JT, Altchek DW, Hyman J, et al. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 2002;30:541-548.

     

     

14. Savoie FH III, Morgan C, Yaste J, et al. Medial ulnar collateral ligament reconstruction using hamstring allograft in overhead throwing athletes. J Bone Joint Surg Am 2013;95:1062-1066.

     

     

15. Thompson WH, Jobe FW, Yocum LA, et al. Ulnar collateral ligament reconstruction in athletes: muscle-

    splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001;10:152-157.

     

     

16. Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. Am J Sports Med 2008;36:1193-1205.