Elbow Ligamentous Injuries


Original Editor ­ Lydia Armacost and Wendy Matson as part of the Temple University EBP Project

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Introduction

Ulnar collateral ligament (UCL) injuries of the elbow joint have become common among overhead throwing athletes, particularly baseball pitchers. Recent studies reported the failure of nonoperative management of UCL injury in overhead athletes. On the contrary, UCL reconstructions in baseball players have been proven to be an effective procedure for return to play and performance. However, the rapidly increasing number of reconstructions is reported in the amateur and adolescent athletes. The avoidance of unnecessary surgeries associated with long recovery period should be beneficial in specific clinical scenarios. For the nonoperative management for the UCL injuries, such as the rehabilitation, the anatomic and biomechanical understanding of the medial elbow joint is necessary.

Clinically Relevant Anatomy.

The elbow joint is stabilized primarily by three ligaments:

1. Medial collateral ligament
2. Lateral collateral ligament
3. Annular ligament

The medial and lateral collateral ligaments provide valgus and varus stability, and allow for rotation. The annular ligament encircles the head of the radius, stabilizing it in the radial notch. Each of these ligaments can be injured by elbow trauma or overuse.

The  flexor-pronator  muscles(FPMs) are secondary dynamic stabilizers and have beenconsidered to exert a protective effect against ulnar collateral ligament (UCL) injury. Anatomical studies indicate that the FPMs lie in a goodposition to protect the UCL. Biomechanical studiesreport that the flexor digitorum superficialis (FDS) muscleplays the greatest role among the FPMs as an activestabilizer against valgus stress.

Mechanism of Injury / Pathological Process

Lateral collateral ligamentous injuries are typically associated with fracture or dislocation (shown below).

Medial collateral ligamentous injuries are typically caused by overuse. Some common causes of elbow ligamentous injuries include:

• Forced twisting of the arm
• Falling on an outstretched arm
• Repeated overhead movement (such as in pitching, volleyball, or tennis)

Clinical Presentation

Although ligamentous injuries are rare, patients may present with varus or valgus laxity due to overuse or trauma. Lateral Collateral Ligament injury is often associated with trauma and forceful motion into varus. These injuries are commonly associated with a fracture or subluxation at the elbow joint. An Ulnar Collateral Ligament tear or sprain could occur with valgus overload or stress movement from pitching or throwing. Typically seen in younger male pitchers, a UCL tear or sprain could also be found in athletes involved in repetitive overhead activities like tennis or volleyball. Another common name for UCL tear is Little League Elbow Syndrome.

Diagnostic Procedures

• Varus Stress Test, tests for laxity of the Lateral Collateral Ligament (LCL).
• Valgus Stress Test, tests for laxity of the Ulnar Collateral Ligament (UCL).
• Moving Valgus Stress Test, tests for chronic UCL sprain or tear from overuse (sensitivity: 100, specificity: 0.75).
• Modified Milking Maneuver, tests for UCL sprain or tear from overuse.
• Palpation, in order to manually exam the integrity of the ligaments.

Outcome Measures

Three common patient reported outcome measures are used for elbow ligamentous injuries:

1. The DASH is 30 questions scored from 0-100, 0 meaning no disability. The DASH is well studied and validated with a minimally clinical important difference or MCID of 15 point or MCD of 12.7 points.
2. The Quick DASH, commonly used in place of The DASH. The patient chooses the response that is the most true from 1-5 for each question. The scoring instructions are listed on the bottom of the form, however The Quick DASH has no known MCID unlike the DASH.
3. The Patient Specific Functional Scale is a scale where the patient chooses 5 activities that are difficult to perform and rates those tasks from 0-10, 0 being not able and 10 being able. The MCID for the average of the 5 activities is 2, while for 1 activity the MCID is 3.

Management / Interventions

Due to lack of high quality literature for these conditions, it is recommended that an impairment-based approach be used to guide management.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for relief of pain and inflammation. If pain is severe, a mild narcotic or corticosteroid injections may be prescribed.
• Common impairments to assess in examination could include decreased elbow or shoulder range of motion, joint effusion, and decreased strength of the upper extremity musculature. Glenohumeral internal rotation deficits are typically seen with pitchers and athletes performing repetitive overhead activities. Studies have shown a direct correlation with decreased internal rotation and excessive external rotation in baseball pitchers and UCL injuries. 
• It is recommended that individuals with these conditions remain active, while protecting the ligament from stress. Activities that aggravate the symptoms should initially be minimized in order to allow for ligamentous healing. Activity level can thereafter be increased gradually.
• Pain and swelling may be relieved through the intermittent application of ice during the acute stages.
• Surgery for the UCL is indicated in complete tears and for athletes wanting to resume previous level of activity. The most common surgical procedure, Tommy John surgery, is when the UCL is replaced with a tendon from elsewhere in the body (often from forearm, hamstring, knee or foot of the same patient). This procedure is most common with athletes from several sports, most notably baseball.
• Surgery to repair the LCL alone is rare and is typically associated with a fracture, dislocation, or subluxation of the elbow. Due to the decreased structural stability of the joint and ORIF may be considered at the discretion of the surgeon.

Differential Diagnosis

• Heterotopic Ossification: Considerable loss of passive range of motion without loss of strength
• Malignancy: Severe progressive pain that is not affected by movement
• Inflammatory Arthrithides: Abnormal systemic signs
• Fracture: History of trauma, Elbow Extension Test (specificity: 0.69, sensitivity: 0.97), marked limitations in range of motion and ecchymosis
• Dislocation: Exaggerated boney prominence, effusion, or appearance of elongation of forearm and could affect neurovascular status.
• Infection: Sudden swelling without trauma
• Vascular Compromise: numbness, tingling, pulse abnormalities
• Referred Cervical Pain
• Referred Shoulder Pain
  

Lateral Elbow Differential Diagnosis

• Radial Tunnel Syndrome
• Lateral Epicondylalgia
  

Medial Elbow Differential Diagnosis

• Cubital Tunnel Syndrome
• Medial Epicondylalgia

General Rehabilitation Guidelines

Rehabilitation following elbow injury or elbow surgery follows a sequential and progressive multiphased approach. The phases of the rehabilitation program should overlap to ensure proper progression. The ultimate goal of elbow rehabilitation is to return the athlete to his or her previous functional level as quickly and safely as possible.

• Phase 1: Immediate Motion The first phase of elbow rehabilitation is the immediate motion phase. The goals of this phase are to minimize the effects of immobilization, reestablish nonpainful range of motion (ROM), decrease pain and inflammation, and retard muscular atrophy.
• Phase 2: Intermediate Phase 2, the intermediate phase, is initiated when the following are achieved: full throwing ROM (as it was prior to the injury), minimal pain and tenderness, and a good (≥ 4/5) manual muscle test of the elbow flexor and extensor musculature. The emphasis of this phase includes maintaining and enhancing elbow and upper extremity mobility, improving muscular strength and endurance, and reestablishing neuromuscular control of the elbow complex.
• Phase 3: Advanced Strengthening The third phase involves a progression of activities to prepare the athlete for sport participation. The goals of this phase are to gradually increase strength, power, endurance, and neuromuscular control to prepare for a gradual return to sport. Specific criteria that must be met before entering this phase include full nonpainful external and internal rotation total ROM, no pain or tenderness, and strength that is 70% of the contralateral extremity.
• Phase 4: Return to Activity The final phase of elbow rehabilitation, return to activity, allows the athlete to progressively return to full competition using an interval throwing program. Interval programs are used for the tennis player and golfer.