Medial Collateral Ligament of the Elbow

Original Editor - Rania Nasr Top Contributors - Rania Nasr, Amanda Ager and Kim Jackson

Description

The elbow consists of a complex of joints (the ulnohumeral joint and the radiohumeral joint), which together form a compound synovial joint. In addition, the elbow is made more complicated by the consideration of the superior radioulnar joint. The three joints together are known as the cubital articulations. It is important to note that the capsule and joint cavity are continuous for all three joints [1].

The combination of these joints allow for two degrees of freedom (movement) at the elbow; notably the trochlear joint (flexion and extension) and the radiohumeral and superior radioulnar joints allow for rotation.

The radiohumeral joint is the hinge joint (between the capitulum of the humerus and the head of the radius) and is known to be one of the most congruent (maximum contact between bony surfaces) of the human body.

As a ginglymus (hinge) joint it affords rotational stability in the sagittal plane and in varus and valgus motion.

Our elbows are used extensively in various daily activities and are constantly receiving medial overloads (pressure to inside of the elbow complex, when in the anatomical position), particularly when in extension. This overload can often lead to acute or chronic injuries to the elbow complex. The major static elbow stabilizers are the medial (ulnar) and lateral (radial) collateral ligaments and the ulnohumeral joint[2].

  • The medial (ulnar) collateral ligament (MCL) supports the ulnohumeral and radiohumeral joints medially, and is a fan-shaped structure.
  • The lateral (radial) collateral ligament (LCL) also supports the ulnohumeral and radiohumeral joints, but laterally. It is more of a cord-like structure.

Attachments

The medial collateral ligament originates from the anterior inferior surface of the medial epicondyle and joins the ulna to the humerus, providing support and resistance in valgus overloads. This ligament is divided into an anterior band, which is stressed during elbow extension; a posterior band, which is stressed during elbow flexion; and a transverse band, which joins the anterior and posterior bands[2].

It is important to stress-test all bands of the MCL during a physical examination.

Vascular Supply

Generally, the vascular supply to the proximal elbow joint - ulnar collateral artery, radial collateral artery, middle collateral artery. While the distal part of the elbow is supplied by - radial recurrent artery, ulnar recurrent artery. However, the vascular supply of the MCL is unknown. A recent study found a difference in the vascular supply to the MCL. The proximal MCL was well vascularized, while the distal MCL was hypovascular. This difference in vascular supply may be a factor in the differential healing capacities of the MCL based on the location of injury[3].

Nerve Supply

The medial collateral ligament is innervated by branches of the radial, ulnar and medial nerves in the elbow joint. A close relationship was observed in a study between their capsular and motor branches[4].

Function

The anterior band is the only structure of the MCL whose isolated sectioning allows the valgus opening of the elbow, acting as the main elbow stabilizer in valgus instability. When the posterior band is sectioned separately or in association with the sectioning of the articular capsule, keeping the anterior band intact, valgus opening of the elbow does not occur. In the interval from 50° to 70° of elbow flexion, there is a maximum valgus opening when the anterior band, articular capsule and posterior band of the MLC are sectioned[2].

Clinical Relevance

The MCL is commonly injured in overhead throwing athletes, such as pitchers, javelin throwers, quarterbacks, tennis, volleyball, and water polo players, when a valgus moment is placed on the elbow during the late cocking and early acceleration phases of the movement. Excessive strain or rupture of the ligament leads to a values instability, which has varying clinical presentations and consequences. Patients may complain of instability, however, most will report pain, reduced accuracy, and decreased velocity with movements of the affected upper extremity. Clinically significant pathologies (2nd degree tear or rupture) often requires surgical intervention[5].

Assessment

A MCL tear can be diagnosed through a history and physical examination. A valgus stress test, during which a physician tests your elbow for instability, is the best way to assess the condition of the MCL.

[6]

Areas of assessment:

  • If the patient is complaining of an important weakness or neurological symptoms, examination of the cervical spine, dermatomes and myotomes is indicated.
  • A scan of the peripheral upper limb joints (digits, hands, wrist, shoulder)
    • Swelling / colouring / bruising / deformities / pain on palpation / difference to asymptomatic side.
  • Active Range of Motion (Extension / Flexion / Supination / Pronation)
    • Flexion: usually 140° - 150°
    • Extension: 0° or up to -10° (hyper extension - especially with women)
    • Supination: 90°
    • Pronation: 80° - 90°
    • **Keep in mind that 75° of supination / pronation occurs in forearm, the remaining 15° occurs at the wrist.
  • Passive Range of Motion (idem AROM)
  • Palpation and mobilization of individual joints and body structures
  • Manual muscle testing (resisted isometric movements) or use of a dynamometer (Wrist flexors / extensors / supinators / pronators and Elbow flexors / extensors)
  • Elbow Stress Tests (Valgus and Varus pressures, at different angles to test all bands of the MCL)
  • Verify with static positions and repetitive movements cause pain or physical limitations
  • Functional assessment: weight bearing positions, lifting activities, provocative testing (what activities are causing pain)

If a patient cannot complete a movement, but is pain-free, there is a possibility of a contractile tissue rupture or a neurological injury and diagnostic imaging may be indicated.

Special Tests: These should only be performed if relevant and help to confirm the diagnosis.

  • Nerve root compression tests
  • Reflexes and cutaneous distribution tests
  • Ligamentous instability tests (including the moving values stress test)
  • Lateral epicondylitis tests
  • Elbow flexion test (ulnar nerve)
  • Posterolateral pivot-shift apprehension test of the elbow
  • Pinch grip test (medial nerve and anterior interosseous nerve)
  • Joint dysfunction tests

Differential Diagnosis

  • Referred cervical pain (radiculopathy)
  • Localized neuropathy (typically median never: C6-C8, T1, the anterior interosseous nerve, or ulnar nerve (C7-C8, T1))
  • Anterior interesses nerve syndrome (Kiloh-Nevin Syndrome)
  • Referred pain from the shoulder
  • "Double Crush" injury to the upper extremity neuromuscular bundle
  • Biceps tendon pathology (tendinitis, tendinosis)
  • Triceps tendon pathology (tendinitis, tendinosis)
  • Olecranon Bursitis
  • Medial Epicondylistis
  • Lateral Epicondylitis
  • Radial head instability (annular ligament instability)
  • Radial tunnel syndrome
  • Elbow joint instability
  • Avulsion fracture of any soft tissues surrounding the elbow
  • Fracture to surround osseous tissues
  • Compartment syndrome (such as Volkmann's ischemic contracture)

Physiotherapy Management

Damage to the medial collateral ligament of the elbow from an instability episode usually heals with non-operative treatment. In some cases, residual instability may occur, leading to a functional impairment. Non-operative management can be successful when bracing, taping and therapy are used to stabilise the elbow. A recent report detailing the efficacy of platelet-rich plasma in effectively treating medial collateral ligament injuries in throwers has shown promise. However, there remain specific groups that should be considered for repair or reconstruction. These may include throwing athletes, wrestlers and some individuals involved in highly active physical activity which demands stability of the elbow. The results of surgical repair and reconstruction allowing a return to sports are quite good, ranging from 84% to 94%. Complications are generally low and mostly centered around ulnar nerve injuries[7].

Rehabilitation program following medial collateral ligament reconstruction using the docking procedure[8]:

Postoperative Phase 1: Weeks 1-4

Goals:

  • Promote healing: reduce pain, inflammation, and swelling
  • Begin to restore range of motion to 30-90°
  • Independent home exercise program.

Precautions:

  • Brace should be worn at all times
  • No passive range of motion of the elbow

Treatment strategies:

  • Brace set at 30° to 90° of flexion
  • Elbow, active range of motion in brace
  • Wrist, active range of motion
  • Scapula isometrics
  • Gripping exercises
  • Cryotherapy
  • Home exercise program

Criteria for advancement:

  • Elbow, range of motion: 30°-90°
  • Minimal pain or swelling

Postoperative Phase 2: Weeks 4-6

Goals:

  • Range of motion: 15°-115°
  • Minimal pain and swelling

Precautions:

  • Continue to wear brace at all times
  • Avoid passive range of motion
  • Avoid valgus stress

Treatment strategies:

  • Continue active range of motion in brace
  • Begin pain-free isometrics in brace (deltoid, wrist flexion/extension, elbow flexion/extension)
  • Manual scapula stabilization exercises with proximal resistance
  • Modalities as needed
  • Modify home exercise program

Criteria for advancement:

  • Range of motion: 15°-115°
  • Minimal pain and swelling

Postoperative Phase 3: Weeks 6-12

Goals:

    • Restore full range of motion
    • All upper extremity strength: 5/5
    • Begin to restore upper extremity endurance

Precautions:

  • Minimize valgus stress
  • Avoid passive range of motion by the clinician
  • Avoid pain with therapeutic exercise

Treatment strategies:

  • Continue active range of motion
  • Low-intensity/long-duration stretch for extension
  • Isotonics for scapula, shoulder, elbow, forearm, wrist
  • Begin internal/external rotation strengthening at 8 weeks
  • Begin forearm pronation/supination strengthening at 8 weeks
  • Upper body ergometer (if adequate range of motion)
  • Neuromuscular drills
  • Proprioceptive neuromuscular facilitation patterns when strength is adequate
  • Incorporate eccentric training when strength is adequate
  • Modalities as needed
  • Modify home exercise program

Criteria for advancement:

  • Pain-free
  • Full elbow range of motion
  • All upper extremity strength 5/5

Postoperative Phase 4: Weeks 12-16

Goals:

  • Restore full strength and flexibility
  • Restore normal neuromuscular function
  • Prepare for return to activity

Precautions:

  • Pain-free plyometrics

Treatment strategies:

  • Advance internal/external to 90/90 position
  • Full upper extremity flexibility program
  • Neuromuscular drills
  • Plyometric program
  • Continue endurance training
  • Address trunk and lower extremities
  • Modify home exercise program

Criteria for advancement:

  • Complete plyometrics program without symptoms
  • Normal upper extremity flexibility

Postoperative Phase 5: Months 4-9

Goals:

  • Return to activity
  • Prevent reinjury

Precautions:

  • Significant pain with throwing or hitting
  • Avoid loss of strength or flexibility

Treatment strategies:

  • Begin interval throwing program at 4 months
  • Begin hitting program at 5 months
  • Continue flexibility exercises
  • Continue strengthening program (incorporate training principles)

Criteria for discharge:

  • Pain-free
  • Independent home exercise program
  • Independent throwing/hitting program

Resources

References

  1. Magee, D.J. Chapter 6: Elbow. In Orthopaedic Physical Assessment. 5th Ed. Musculoskeletal Rehabilitation Series. Saunders, an imprint of Elsevier Inc. 2008.
  2. 2.0 2.1 2.2 Tribst MF, Zoppi Filho A, Camargo Filho JC, Sassi D, Carvalho Junior AE. Anatomical and functional study of the medial collateral ligament complex of the elbow. Acta ortopedica brasileira. 2012 Dec;20(6):334-8.
  3. Buckley, P.S., Morris, E.R., Robbins, C.M., Kemler, B.R., Frangiamore, S.J., Ciccotti, M.G., Huard, J., LaPrade, R.F. and Hackett, T.R., 2019. Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study. The American journal of sports medicine47(5), pp.1117-1123.
  4. Cavalheiro CS, Razuk Filho M, Rozas J, Wey J, de Andrade AM, Caetano EB. Anatomical study on the innervation of the elbow capsule. Revista Brasileira de Ortopedia (English Edition). 2015 Nov 1;50(6):673-9.
  5. Labott JR, Aibinder WR, Dines JS, Camp CL. Understanding the medial ulnar collateral ligament of the elbow: Review of native ligament anatomy and function. World journal of orthopedics. 2018 Jun 18;9(6):78.
  6. Physiotutors. Elbow Valgus Instability Stress Test⎟Medial Collateral Ligament. Available from: https://www.youtube.com/watch?v=3xF9_5fbJ8A [last accessed 31/10/2019]
  7. Savoie FH, O’Brien M. Chronic medial instability of the elbow. EFORT open reviews. 2017 Jan;2(1):1-6.
  8. Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports health. 2009 Jul;1(4):301-13.