the ulna articulates with the radial head (Netter,
1987).- The ulnohumeral joint affords flexion and extension
of the elbow, while the proximal radioulnar joint
affords pronation and supination. The humeroradial
joint moves in both rotation and flexion/extension. - The primary restraints of the elbow are the congruous
ulnohumeral articulation, the anterior band of the
medial collateral ligament(MCL) and the lateral ulnar
collateral ligament(LUCL) (O’Driscoll et al, 2000). - The MCL, the main constraint to valgus instability,
originates on the anteroinferior medial epicondyle and
inserts onto the body of the coronoid process. The
injury pattern is usually midsubstance to proximal
failure. - The LUCL, the main constraint to PLRI, originates
from the lateral epicondyle and inserts into the annu-
lar ligament and on the supinator crest of the ulna. The
injury pattern is usually an avulsion of the humeral
origin.
HISTORY (MCL)
- MCL injuries are most common in overhead throwing
athletes (Conway, Jobe, and Glousman, 1992). - The most common complaint is pain typically felt
during late cocking and early deceleration of the
throwing motion. Throwing velocity may also be
diminished. - In elite pitchers, valgus forces in excess of 120 N-m
have been documented (Williams and Altchek, 1999). - Athletes usually do not have complaints of pain
during activities of daily living or symptoms of elbow
instability, such as popping, locking, or clicking; how-
ever, associated abnormalities such as synovitis, plica,
or loose bodies may present with these symptoms.
•Patients may also have neuritis of the ulnar nerve,
with numbness and tingling in the ulnar digits as well
as loss of strength in the finger intrinsic.
HISTORY (LUCL)
- Injury to the LUCL is usually the result of trauma
causing a dislocation, such as a fall on an outstretched
hand. An occasional iatrogenic cause may occur sec-
ondary to previous lateral tennis elbow surgery, espe-
cially if a full release was performed, instead of a
partial resection. - The main complaints of athletes are instability symp-
toms of popping and clicking of the elbow and a sen-
sation of giving way. Push-ups or lifting can be
painful (Hotchkiss and Yamaguchi, 2002).
PHYSICAL EXAMINATION (MCL)- Athlete may be tender to palpation over the MCL.
This is more easily appreciated when palpation is
done concurrently with valgus stress. - Possible Tinel’s sign may be present over the ulnar
nerve in the cubital tunnel.
•Valgus stability is tested with the elbow flexed beyond
25 ° to minimize the bony restraints, and a valgus
stress is applied while the examiner supports the
elbow (Williams and Altchek, 1999).
PHYSICAL EXAMINATION (LUCL)- The lateral pivot shift test is used for diagnosis. As
originally described by O’Driscoll (Jobe, Stark, and
Lonbardo, 1986), the patient is supine with the shoul-
der at 90°of flexion with the elbow flexed 90°over-
head. The examiner gently supinates the forearm, and
a valgus moment is applied. The arm is brought from
near extension to flexion. The athlete should have
apprehension during the beginning of the test, with
further flexion causing a reduction of subluxation and
diminution of the apprehension. We prefer a modifi-
cation of this test, first bringing the elbow from flex-
ion to extension, causing the apprehension or pain. As
the elbow is brought back into a flexed position, the
feeling of apprehension or pain is diminished. Frank
palpable subluxation and reduction is rare, unless the
patient is under general anesthesia or has had intra-
articular local anesthetic.
IMAGING STUDIES- Plain radiographs may reveal associated intra-articu-
lar loose bodies, osteophytes, or calcification of the
MCL (O’Driscoll, Bell, and Morrey, 1991). A shallow
ulnohumeral joint may be evident on the lateral view. - Stress views with a valgus force can show a side to
side difference, confirming MCL insufficiency. - Fluoroscopy can be useful for demonstrating PLRI.
- MRI can show damage to ligaments on either side,
and can be useful when the diagnosis is in doubt or for
preoperative planning. Injection of gadolinium dye
may enhance the MRI.
TREATMENT (NONOPERATIVE)- Immediate treatment is reduction of any dislocation
and splinting in 90°of flexion, with X-rays to look for
intra-articular pathology as well as associated fractures.
292 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE