Elbow Ligamentous Injuries
Clinically Relevant Anatomy
The elbow joint is stabilized primarily by three ligaments:
- Medial collateral ligament
- Lateral collateral ligament
- 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.
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)
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.
- 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.
Three common patient reported outcome measures are used for elbow ligamentous injuries:
- 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.
- 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.
- 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.(Level of evidence : level 3b)
- 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.
- 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
- Chumbley E. O'Connor F, Nirschl R. Evaluation of Overuse Elbow Injuries. American Family Physician. Feb 2000. Available at http://www.aafp.org/afp/20000201/691.html. Accessed March 2010.
- Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral Internal Rotation Deficits in Baseball Players with Ulnar Collateral Ligament Insufficiency. American Journal of Sports Medicine.2009 Mar;37(3):566-70