Elbow Ligamentous Injuries: Difference between revisions

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'''Original Editor '''­ [[User:Lydia Armacost|Lydia Armacost]] and [[User:Wendy Matson-Harris|Wendy Matson-Harris]] as part of the [[Temple University Evidence-Based Practice Project|Temple University EBP Project]]
'''Original Editor '''- [[User:Lydia Armacost|Lydia Armacost]] and [[User:Wendy Matson-Harris|Wendy Matson-Harris]] as part of the [[Temple University Evidence-Based Practice Project|Temple University EBP Project]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
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'''Lead Editors'''  &nbsp; 
== Clinically Relevant Anatomy<br> ==
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== Clinically Relevant Anatomy<br>  ==
The [[elbow|elbow joint]] is stabilized primarily by three ligaments:
#Medial collateral ligament
#Lateral collateral ligament
#Annular ligament


The elbow joint is stabilized primarily by three ligaments; the medial collateral ligament, lateral collateral ligament, and the annular ligament.&nbsp;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.<ref name="Chumbley">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.</ref><br>  
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.<ref name="Chumbley">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.</ref><br>  


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== Mechanism of Injury / Pathological Process<br>  ==
== Mechanism of Injury / Pathological Process<br>  ==


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:<br>• Forced twisting of the arm <br>• Falling on an outstretched arm <br>• Repeated overhead movement (such as in pitching, volleyball, or tennis)  
'''Lateral collateral ligamentous''' injuries are typically associated with fracture or [[Posterior Elbow Dislocation|dislocation]] (shown below). '''Medial collateral ligamentous''' injuries are typically caused by overuse. Some common causes of elbow ligamentous injuries include:<br>
*Forced twisting of the arm
*Falling on an outstretched arm
*Repeated overhead movement (such as in pitching, volleyball, or tennis)  


<br>  
<br>  
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== Clinical Presentation  ==
== Clinical Presentation  ==


Although ligamentous injuries are rare, patients may present with varus or valgus laxity due to overuse or trauma. Lateral Collateral Ligament is often associated with trauma and forceful motion into varus and is 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, an 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.<br>  
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|Little League Elbow Syndrome]].<br>  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Varus Stress Test, tests for laxity of the Lateral Collateral Ligament.<br>  
*[[Elbow Varus Stress|Varus Stress Test]], tests for laxity of the Lateral Collateral Ligament (LCL).<br>
*[[Elbow Valgus Stress|Valgus Stress Test]], tests for laxity of the Ulnar Collateral Ligament (UCL). <br>
*[[Moving Valgus Stress Test]], tests for chronic UCL sprain or tear from overuse (sensitivity: 100, specificity: 0.75). <br>
*[[Elbow_Examination#Palpation|Palpation]], in order to manually exam the integrity of the ligaments.<br><br>  


Valgus Stress Test, tests for laxity of the Ulnar Collateral Ligament (UCL). <br>
{| width="100%" cellspacing="1" cellpadding="1"
 
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Moving Valgus Stress Test, testing chronic UCL sprain or tear from overuse (sensitivity: 100, specificity: 0.75). <br>Palpation in order to manually exam the integrity of the ligaments<br><br>
|{{#ev:youtube|96EMB7SWF0I|300}}
|{{#ev:youtube|0MqSOdHwwX0|300}}
|}


[[Image:Valgus Testing.png|250x250px|Valgus Stress Test]]&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:Varus Testing.png|250x250px|Varus Stress Test]]  
[[Image:Valgus Testing.png|250x250px|Valgus Stress Test]]&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:Varus Testing.png|250x250px|Varus Stress Test]]  
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== Outcome Measures  ==
== Outcome Measures  ==


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


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. <br>  
#The [[DASH Outcome Measure|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. <br>  
 
#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. <br>  
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. <br>  
#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. <br>  
 
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. <br>  


== Management / Interventions<br>  ==
== Management / Interventions<br>  ==


• Due to lack of high quality literature for these conditions, it is recommended that an impairment-based approach be used to guide management.<br>• 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. <br>• 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.<br>• 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.<ref name="Dines">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</ref>&nbsp;<br>• 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.<br>• Pain and swelling may be relieved through the intermittent application of ice during the acute stages.<br>• Surgery for the UCL is indicated in complete tears and 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. <br>• 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. <br><br>  
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, [[Effusion tests|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.<ref name="Dines">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</ref>&nbsp;<br>
*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 [[cryotherapy|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. <br>


== Differential Diagnosis<br>  ==
== Differential Diagnosis<br>  ==


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


'''Lateral Elbow Differential Diagnosis'''<br>• Radial Tunnel Syndrome<br>• Lateral Epicondylalgia<br>  
'''Lateral Elbow Differential Diagnosis'''
*Radial Tunnel Syndrome
*[[Lateral Epicondylitis|Lateral Epicondylalgia]]<br>  


'''Medial Elbow Differential Diagnosis'''<br>• Cubital Tunnel Syndrome<br>• Medial Epicondylalgia  
'''Medial Elbow Differential Diagnosis'''
*[[Cubital Tunnel Syndrome II|Cubital Tunnel Syndrome]]
*Medial Epicondylalgia  


== Key Evidence  ==
== Key Evidence  ==
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== References  ==
== References  ==
References will automatically be added here, see [[Adding References|adding references tutorial]].


<references />  
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   [[Category:Elbow]]  [[Category:Musculoskeletal/Orthopaedics]] [[Category:Temple_Student_Project]]
   [[Category:Elbow]]  [[Category:Musculoskeletal/Orthopaedics]] [[Category:Temple_Student_Project]]

Revision as of 01:36, 29 December 2013


Original Editor ­ Lydia Armacost and Wendy Matson-Harris as part of the Temple University EBP Project Top Contributors - Wataru Okuyama, Wendy Matson, Admin, Rachael Lowe, Kim Jackson, Scott A Burns, Daphne Jackson, Kai A. Sigel, WikiSysop, Lydia Armacost, Laura Ritchie, Naomi O'Reilly, Celine De Wolf, Claire Knott and Wanda van Niekerk


Clinically Relevant Anatomy
[edit | edit source]

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.[1]


1.png                                        Elbow Ligaments.png

Mechanism of Injury / Pathological Process
[edit | edit source]

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)


         X-Ray Elbow1.png                                 Elbow Dislocation.png

Clinical Presentation[edit | edit source]

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[edit | edit source]

Valgus Stress Test                                  Varus Stress Test

Outcome Measures[edit | edit source]

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
[edit | edit source]

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.[2] 
  • 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
[edit | edit source]

  • 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

Medial Elbow Differential Diagnosis

Key Evidence[edit | edit source]

Szekeres M, Chinchalkar SJ, King GJ. Optimizing Elbow Rehabilitation After Instability. Hand Clinics. 2008 Feb; 24(1):27-38

Resources
[edit | edit source]

Richard M, Aldridge M, Wiesler E, Ruch D, Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair. The Journal of Bone and Joint Surgery. 2008;90:2416-2422.f

Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint. A prospective randomized study. J Bone Joint Surg Am. 1987 Apr;69(4):605-8.

Case Studies[edit | edit source]

Muller MS, Drakos MC, Feeley B, Barnes R, Warren RF. Nonoperative Management of Complete Lateral Elbow Ligamentous Disruption in an NFL Player: A Case Report. HSS J. 2010 Feb;6(1):19-25.

Yang C, Li W, Gong YB, Li SQ, Qi X. Posterolateral rotatory instability of the elbow: a case report and literature review. Chin J Traumatol. 2010 Dec;13(6):380-2.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 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.
  2. ↑ 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
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