Incorporating Ulna Collateral Ligament (UCL) and Radial Collateral Ligament (RCL)

Understanding UCL and RCL Injuries

What are Gamekeeper’s thumb and Skier’s thumb, and the roles of the Ulnar Collateral Ligament (UCL) and Radial Collateral Ligament (RCL) in thumb stability?

Gamekeeper’s Thumb and Skier’s Thumb are both injuries involving damage to the Ulnar Collateral Ligament (UCL) of the thumb, but they typically arise from different activities.

Gamekeeper’s Thumb

This injury was originally associated with the repetitive stress of hunting, where gamekeepers would hold birds by the thumb. The UCL is torn or overstretched due to sudden force applied to the thumb, such as when the thumb is bent backward. It is often caused by chronic, repetitive trauma or a sudden, forceful injury.

Skier’s Thumb

Skier’s thumb occurs when a skier falls while holding a ski pole, causing their thumb to be forcefully pulled in an outward direction. The impact can tear or stretch the UCL, leading to instability and pain at the base of the thumb. This is typically an acute injury caused by a sudden, high-impact force.

Ulnar Collateral Ligament (UCL)

The UCL is crucial for the stability of the thumb, especially at the metacarpophalangeal (MCP) joint. It provides resistance against forces that would otherwise move the thumb away from the hand (radial deviation), helping the thumb maintain its position for gripping and pinching. Damage to the UCL causes instability, pain, and difficulty in performing precision movements like gripping objects.

Radial Collateral Ligament (RCL)

The RCL, in contrast, stabilises the thumb against forces that would move it in the opposite direction (ulnar deviation). While the UCL is more commonly involved in injuries like Gamekeeper’s or Skier’s Thumb, the RCL is important for preventing excessive motion of the thumb towards the hand.

Both ligaments work together to ensure thumb stability during functional movements like grasping, pinching, or holding objects. Damage to either ligament, especially the UCL, can significantly impair thumb function, requiring prompt medical attention and, in some cases, surgery.

Anatomy and Function

Understanding the thumb’s UCL and RCL and their importance

The Ulnar Collateral Ligament (UCL) and Radial Collateral Ligament (RCL) are key stabilising structures in the thumb, particularly at the metacarpophalangeal (MCP) joint.

• UCL: Located on the inner side of the thumb joint, the UCL stabilises the thumb against forces that would move it away from the hand (radial deviation). It is critical for maintaining the thumb’s ability to grip and pinch, particularly in precision movements. Damage to the UCL, such as in Gamekeeper’s or Skier’s Thumb, can result in instability and loss of function.
• RCL: Positioned on the outer side of the thumb, the RCL stabilises the joint against forces that would move the thumb towards the hand (ulnar deviation). While less commonly injured than the UCL, the RCL plays a role in overall thumb stability.

Together, these ligaments allow the thumb to perform fine motor tasks essential for gripping, holding, and manipulating objects. Damage to either ligament can significantly impair thumb function and require medical intervention.

Types of Thumb Ligament Injuries

Thumb ligament injuries can be classified based on their timing (acute vs. chronic) and the extent of the tear (partial vs. complete).

Acute vs. Chronic UCL and RCL Injuries

• Acute Injuries: These occur suddenly due to trauma, such as a fall or impact. For example, Skier’s Thumb results from a sudden forceful injury when a skier falls and hyperextends the thumb. Acute injuries often involve the UCL, causing immediate pain, swelling, and difficulty in using the thumb. Acute RCL injuries can also occur from trauma but are less common than UCL tears.
• Chronic Injuries: These develop over time from repetitive stress and overuse. Compared to acute injuries occuring from a single traumatic event. Gamekeeper’s thumb is a classic example, where the UCL undergoes gradual wear and tear due to repetitive motions (e.g., holding or twisting). Chronic RCL injuries are less frequent but can result from overuse or prolonged stress on the thumb joint.

Partial vs. Complete Ligament Tears

• Partial Tears: A partial tear involves only some of the damaged ligament fibres. The ligament may still provide some stability to the thumb, but it will be weakened. Symptoms include pain, swelling, and decreased movement. A partial tear can often be treated conservatively with rest, splinting, and physiotherapy.
• Complete Tears: A complete tear, where the ligament is fully ruptured or detached, results in significant thumb instability. The thumb may be unable to perform everyday functions like gripping or pinching, and there is often more severe pain, swelling, and deformity. Complete tears typically require surgical intervention to restore normal thumb function and prevent long-term instability.

Early diagnosis and management are crucial in both cases to prevent further damage and preserve thumb function. Access Ortho is an urgent care clinic for orthopaedic injuries. If you have concerns about your thumb injury, Access Ortho will offer rapid appointments, and no referral is required. 

Prevalence

How common are Gamekeeper’s thumb / Skier’s thumb injuries?

Gamekeeper’s Thumb and Skier’s Thumb are relatively common injuries, but their prevalence varies based on the activity and the population affected.

Skier’s Thumb

Prevalence: Skier’s Thumb is more commonly reported than Gamekeeper’s Thumb due to the popularity of skiing and snowboarding. It occurs when a skier falls while holding a ski pole, causing a hyperextension or outward force on the thumb.Statistics: Studies suggest that Skier’s Thumb accounts for 10-20% of all skiing-related injuries. It is considered one of the most frequent thumb injuries in skiers, particularly in those who use traditional ski poles with straps, which can increase the risk of the thumb being forced into an awkward position during a fall.

Gamekeeper’s Thumb

Prevalence: Gamekeeper’s Thumb was more common in the past among people who engaged in repetitive gripping or twisting motions, such as gamekeepers (hence the name), but today, it is more commonly seen in athletes or people who perform repetitive tasks that involve the thumb.

Statistics: The exact prevalence is less well documented, but Gamekeeper’s Thumb is generally considered less common than Skier’s Thumb. It has become a more prevalent diagnosis in sports like rugby, football, and hockey, where impact injuries are common. Additionally, chronic overuse in activities such as manual labour, repetitive gripping, or weightlifting can contribute to the development of the injury.

Summary

While Skier’s Thumb is relatively common due to the widespread participation in skiing, Gamekeeper’s Thumb is less frequent but still seen in athletes and individuals with repetitive thumb strain. Both injuries are typically diagnosed in individuals who participate in high-impact or repetitive activities involving the hands and thumbs.

Symptoms and Causes

Causes of UCL and RCL Injuries in the Thumb

UCL Injuries:

• Acute Trauma: The most common cause is sudden, forceful impact or hyperextension of the thumb, such as during a fall or collision. For example, Skier’s Thumb occurs when the thumb is pulled outward while holding a ski pole.
• Repetitive Stress: Chronic overuse and repetitive motions, especially those involving gripping or twisting, can lead to wear and tear on the UCL, as seen in Gamekeeper’s Thumb.

RCL Injuries:

• Acute Trauma: Similar to UCL injuries, RCL injuries may arise from a sudden impact or force applied to the thumb, causing instability on the radial side.
• Repetitive Use: Although less common, overuse can also lead to RCL injuries by repeatedly stressing the ligament over time.

Risk Factors for Gamekeeper’s Thumb / Skier’s Thumb

1. Activity Level: Participation in high-risk sports such as skiing, snowboarding, or contact sports (e.g., football, rugby) increases the likelihood of thumb injuries.
2. Equipment Usage: Use of ski poles or similar equipment that can create leverage on the thumb, particularly with straps that may catch during falls.
3. Repetitive Motions: Jobs or tasks that involve repetitive gripping or twisting movements can predispose individuals to chronic ligament injuries.
4. Previous Injuries: A history of thumb injuries may weaken the ligaments and increase the risk of subsequent injuries.
5. Poor Technique: Improper techniques in sports or activities can lead to increased stress on the thumb ligaments.

Complications of Untreated Thumb Ligament Injuries

1. Chronic Instability: Untreated UCL or RCL injuries can result in persistent instability in the thumb joint, leading to difficulty with gripping and pinching.
2. Arthritis: Chronic instability and abnormal motion can contribute to the development of osteoarthritis in the thumb joint over time, causing pain and reduced range of motion.
3. Loss of Function: Significant ligament injuries can impair thumb function, impacting daily activities and reducing overall hand strength.
4. Deformity: In some cases, untreated injuries may lead to structural deformities of the thumb, such as a “floating” thumb position or changes in alignment.
5. Increased Pain: Ongoing pain and discomfort can arise from continued use of an unstable thumb, affecting quality of life and possibly leading to compensatory injuries in other areas of the hand or wrist.

Early diagnosis and treatment of thumb ligament injuries are essential to avoid these complications and restore optimal function. Access Ortho is an acute injuries fracture clinic offering rapid appointments for acute musculoskeletal injuries. 

Diagnosis and Assessment

Gamekeeper’s Thumb and Skier’s Thumb injuries are typically diagnosed through medical history, physical examination, and specific diagnostic tests.

 Medical History

• The clinician will take a detailed history, including the mechanism of injury (acute trauma or repetitive strain), the onset of symptoms, and any previous thumb injuries.
• Patients are often asked about specific activities leading up to the injury, such as skiing or other sports.

Physical Examination

• The medical team will assess the affected thumb for pain, swelling, bruising, and visible deformities.
• Range of Motion: The clinician will evaluate the thumb’s range of motion and stability during movement.

Tests Used to Evaluate UCL and RCL Injuries

Several tests are commonly used to assess the integrity of the UCL and RCL:

1. Valgus Stress Test (UCL Test):

The patient’s thumb is held in extension, and a lateral (valgus) force is applied to the distal phalanx. Increased laxity or pain indicates a possible UCL injury.

2. Varus Stress Test (RCL Test):

The thumb is held in extension while a medial (varus) force is applied to the distal phalanx. Increased laxity or pain may suggest an RCL injury.

3. Thumb Extension Test:

The clinician extends the thumb and applies a force. Pain or instability during this maneuver may indicate UCL involvement.

4. Pinch Grip Test:

The patient is asked to pinch their fingers together. Weakness or pain during this activity may indicate ligament injury.

Specific Considerations for Stener Lesions

A Stener lesion occurs when the UCL is completely torn and retracted, often becoming interposed between the bones of the thumb, specifically the proximal phalanx and the metacarpal. This condition can complicate diagnosis and treatment.

Diagnosis of Stener Lesions

• Clinical Signs: The clinician may observe a palpable mass or a gap over the UCL area, often associated with significant instability.
• Imaging Studies:
  • Ultrasound: Can help visualise the UCL and assess for retraction.
  • MRI: This is the most definitive imaging study for diagnosing a Stener lesion, as it can clearly show the torn ligament and its position relative to the bone.

Considerations

• Surgical Intervention: If a Stener lesion is diagnosed, surgical repair is often necessary to restore thumb stability and function. Delayed treatment can lead to chronic instability and complications, making timely diagnosis crucial.

Summary

In summary, accurate diagnosis of Gamekeeper’s and Skier’s Thumb involves a thorough history, physical examination, and targeted tests to evaluate ligament integrity. Special attention must be given to the possibility of Stener lesions, which require careful assessment to determine the need for surgical intervention. It is important to get orthopaedic advice on thumb injuries to ensure accurate diagnosis and treatment. Access Ortho are specialists in orthopaedic care.

Management and Treatment

Management and Treatment of Thumb Ligament Injuries

Treatment of thumb ligament injuries depends on how severe the injury is, whether it is acute or chronic, and the specific ligament affected (UCL or RCL). Mild injuries may respond well to conservative management, while more severe or complete tears (such as Stener lesions) often require surgical repair.

Conservative Treatment Options

Conservative treatment can often restore function and stability for partial ligament tears or mild instability.

1. Immobilisation:

Splinting or Bracing: The thumb is immobilised in a splint (thumb spica or similar) to prevent movement, allowing the ligament to heal. Immobilisation typically lasts 4-6 weeks. This can be arranged in Access Ortho, or some patients will require a referral to a hand therapist for a custom splint. 

Taping: Once initial healing has occurred, taping can be used to provide additional support during activities, gradually allowing more movement.

2. Rest and Ice:

Rest from activities that strain the thumb, along with regular icing, can reduce inflammation and promote healing in the early stages.

3. Anti-inflammatory Medications:

NSAIDs may be prescribed to reduce pain and swelling.

4. Physiotherapy:

After immobilisation, gentle range-of-motion exercises are introduced to restore flexibility, followed by strengthening exercises for the thumb and hand. Physiotherapy is essential to regain full function and prevent stiffness.

Surgical Interventions

Surgery is typically recommended for complete ligament tears, significant thumb instability, or Stener lesions.

UCL Repair:

• Direct Repair: The torn ends of the UCL are sutured back together if the ligament is intact enough for repair.
• Reconstruction: In cases where the ligament is significantly damaged, a tendon graft (from the patient’s own wrist or finger tendons) may be used to reconstruct the UCL.

RCL Repair:

• Similar surgical techniques can be used to repair or reconstruct the RCL in cases of severe injury or chronic instability.

Surgery for Stener Lesions:

• In cases of Stener lesions, the UCL cannot heal on its own due to the ligament becoming trapped, requiring surgical repair to realign and reattach the ligament. Surgery typically involves reattaching the ligament to its bone with sutures or an anchor.

Post-Surgical Immobilisation:

• After surgery, the thumb is immobilised for 4-6 weeks to allow proper healing and stabilisation of the repaired ligament.

Rehabilitation Protocols for UCL and RCL Repairs

A structured rehabilitation program is essential following conservative or surgical treatment to restore thumb strength, stability, and range of motion. Exercises and rehabilitation must be done under the guidance of your medical team.

Phase 1: Initial Healing (0-6 Weeks Post-Injury or Surgery)

• Immobilisation: The thumb remains in a splint or cast, restricting motion to allow ligament healing.
• Edema Control: Ice and gentle hand elevation to reduce swelling.

Phase 2: Early Mobilisation (6-8 Weeks Post-Injury or Surgery)

• Range-of-Motion Exercises: Begin gentle, pain-free range-of-motion exercises focusing on the thumb, without stressing the healing ligament.
• Light Stretching: Gentle stretching to improve thumb flexibility.

Phase 3: Strengthening (8-12 Weeks Post-Injury or Surgery)

• Strengthening Exercises: Gradually introduce grip and pinch-strengthening exercises, targeting the muscles of the thumb and hand.
• Functional Training: Exercises are given to mimic daily activities, progressively increasing thumb load.

Phase 4: Return to Activity (12+ Weeks Post-Injury or Surgery)

• Activity-Specific Training: As strength and stability improve, patients can begin sport-specific or job-specific activities.
• Protective Bracing: During high-risk activities, using a protective brace may be recommended to prevent re-injury.

Summary

Conservative treatment, including immobilisation, physiotherapy, and gradual return to activity, can be effective for partial tears. Surgical repair or reconstruction is generally needed for complete ligament tears or Stener lesions, with rehabilitation following to ensure full functional recovery. Access Ortho is an urgent injury clinic focused solely on caring for orthopaedic injuries. Access Ortho offers emergency care and orthopaedic follow-up care.  

Prevention

Strategies to prevent Gamekeeper’s thumb / Skier’s thumb injuries

To prevent Gamekeeper’s Thumb and Skier’s Thumb, focus on proper equipment use, technique, and strengthening:

1. Use Proper Equipment: Use ski poles with quick-release straps or no straps to reduce thumb stress in falls. In other activities, use equipment that allows a comfortable grip.
2. Strengthen Thumb and Hand Muscles: Regular hand-strengthening exercises can increase thumb stability and resilience to injury.
3. Practise Proper Technique: Whether in sports or daily activities, use correct form to reduce strain on the thumb ligaments.
4. Protective Bracing: Consider using thumb supports during high-risk activities to stabilise the joint and prevent hyperextension.

These strategies can help maintain thumb strength and stability, reducing the likelihood of ligament injuries.

Prognosis and Recovery

Prognosis and Recovery for Thumb Ligament Injuries

Recovery after a thumb ligament injury depends on how severe the injury is and the chosen treatment approach (conservative or surgical). Most patients can expect a full return to function with proper treatment and rehabilitation.

Recovery Timeline

1. Conservative treatment (for partial tears or mild instability):
   • Immobilisation: The thumb is typically immobilised in a splint for 4-6 weeks.
   • Rehabilitation: Physiotherapy follows, with a gradual increase in movement and strengthening exercises.
   • Full Recovery: Most people regain full function in 8-12 weeks but may continue strengthening exercises for optimal stability.
2. Surgical treatment (for complete tears, Stener lesions, or chronic instability):
   • Post-Surgery Immobilisation: The thumb is immobilised in a cast or splint for 4-6 weeks.
   • Rehabilitation: Controlled exercises begin around 6 weeks post-surgery, progressing to strengthening at 8-12 weeks.
   • Full Recovery: Patients generally regain strength and stability within 12-16 weeks, though complete healing may take up to 6 months for high-impact activities.

What to Expect During Recovery

• Pain and Swelling: Initially, there may be pain and swelling, which typically subsides with immobilisation and rest.
• Gradual Improvement: As strength and flexibility improve, most patients experience a steady return to normal thumb function.
• Long-Term Outlook: With proper treatment, long-term outcomes are generally excellent, though severe injuries may have a slightly increased risk of arthritis or mild instability.

Adherence to rehabilitation exercises and precautions during recovery ensures the best outcome and decreases the risk of re-injury. To ensure the best outcome, you must attend regular follow-up visits with an orthopaedic team. Access Ortho offers all non-surgical follow-up care in the clinic.

When to Seek Medical Attention

After a thumb ligament injury, it’s important to seek medical attention if you experience any of the following signs:

1. Persistent Pain and Swelling: If pain or swelling does not improve after a few days of rest, ice, and immobilisation, it may indicate a more serious ligament injury.
2. Thumb Instability or Weakness: Difficulty gripping or pinching objects, or feeling that the thumb is “loose” or unstable, suggests possible ligament damage.
3. Visible Deformity or Bruising: Significant bruising, deformity, or abnormal positioning of the thumb may indicate a complete tear or severe injury.
4. Inability to Move the Thumb: Difficulty moving the thumb without pain or loss of normal range of motion can point to a ligament tear that requires medical evaluation.
5. Numbness or Tingling: These symptoms can indicate nerve involvement and should be assessed promptly.

Early medical assessment and treatment can prevent complications, support healing, and reduce the risk of long-term instability or arthritis. Access Ortho are specialists in orthopaedic care, offering emergency care at the time of injury and follow-up care until a full recovery is made. 

The Role of Hand Therapy

Importance of specialised therapy in thumb ligament injury recovery

Hand therapy plays a crucial role in recovering from thumb ligament injuries by guiding safe, progressive exercises to restore strength, flexibility, and function. Specialised therapy prevents stiffness, promotes proper healing, and reduces the risk of re-injury, especially after immobilisation or surgery. With customised exercises and support, hand therapy ensures optimal recovery and helps patients regain full use of the thumb for daily activities.

The Access Ortho team is highly trained in caring for orthopaedic injuries. They will guide you on the need for hand therapy. This may be to make a custom splint or for rehabilitation. It is essential to always get advice from your treating orthopaedic team before starting exercises following an injury. 

Commonly Asked Questions

What’s the difference between UCL and RCL injuries in the thumb?

UCL injuries affect the ligament on the inner side of the thumb (toward the index finger) and are more common, especially in sports. RCL injuries involve the outer side and are less common but can also cause thumb instability.

Can I still use my thumb with a ligament injury?

While mild injuries may allow some thumb movement, using the thumb too soon can worsen the injury. Immobilisation and rest are generally recommended to allow healing.

How long does it take for a Gamekeeper’s Thumb / Skier’s Thumb to heal?

With conservative treatment, recovery usually takes 8-12 weeks. After surgery, it may take 12-16 weeks, and full strength may take up to 6 months.

Will I need surgery for my thumb ligament injury?

Surgery is typically needed for complete tears, Stener lesions, or cases of severe instability. Partial tears or mild injuries often respond well to conservative treatment. It is important to get advice from medical practitioners specialised in treating orthopaedic injuries.

What exercises can I do to prevent Gamekeeper’s Thumb / Skier’s Thumb?

Strengthening exercises for thumb and hand muscles, such as thumb extensions, squeezes, and gentle resistance exercises, help prevent ligament injuries.

Are certain sports or activities more likely to cause UCL or RCL injuries?

Sports involving falls, gripping, or collisions, such as skiing, football, and contact sports, are more likely to cause UCL and RCL injuries.

How can I differentiate between UCL, RCL, and other thumb injuries?

UCL injuries cause pain on the thumb’s inner side, while RCL injuries cause pain on the outer side. Imaging tests, such as MRI, help confirm the diagnosis.

What is the long-term outlook for patients with Gamekeeper’s Thumb / Skier’s Thumb?

With proper treatment, most people regain full function, but severe injuries may slightly increase the risk of arthritis or minor instability.

Can a thumb ligament injury lead to permanent instability?

Untreated or severe injuries, especially complete tears, can result in long-term instability, which may affect thumb strength and increase arthritis risk.

Who should I see for my thumb injury?

If you have injured your thumb or finger, it is important to seek urgent care to minimise the risk of complications. Where possible, finding a medical team that specialises in orthopaedic injuries will ensure you get a rapid, accurate diagnosis. Access Ortho only treats acute orthopaedic injuries, ensuring all staff are highly skilled in urgent care and follow-up care of thumb and finger injuries, along with all musculoskeletal injuries of the upper and lower limbs.