Medial Collateral Instability of the Elbow

CSES Residents CourseCalgary AB

February 1-3, 2017WD Regan MD

Disclosures

I have no disclosures to report

AnatomyMedial Collateral Ligament

Anterior ObliquePosterior ObliqueTransverse Ligament

AMCL Origin – Antero-inferior medial epicondyle

Insertion-sublime tubercle medial coronoid

AnatomyMedial Collateral Ligament

MCL undersurface is a sequential ligament insertion greater sigmoid fossa (anterior to posterior)

Regan et al. 1991 (CORR)

• CAM Effect• Based on degree of

elbow flexion• Anterior oblique

• tight in extension• Posterior oblique

• tight in flexion

Reciprocating relationship

MCL Anatomy and Biomechanics

Calloway et al JBJS 1997

MCL Biomechanics

Potted origin and insertion of AMCL & PMCL8 Specimens

AV

L

W

AMCL PMCL

21mm 16mm

7.6mm 8.8mm

Regan et al.1991 (CORR)

MCL Biomechanics

AMCL PMCL260 N 159 N

Stiffness1528 N 861N

Palmaris Longus10 fold greater stiffness

than AMCL.Regan et al. 1991(CORR)

MTS load to failure

MCL The injury

5 phases of throwing Late Cocking and acceleration phases

Flexion

Rapid

Extension

90-120o

30- 40 milisec.

25o of Flexion

Peak angular velocity 4500 degrees per secondWilson et all AJSM 1983

MCL Insufficiency Symptoms

Microscopic tears of Ligament = AttenuationGradual onset of medial elbow pain Progressive valgus laxity“Pop” with immediate onset of pain50% Jobe’s Series

Conway & Jobe JBJS 1992

Associated PathologyValgus extension Overload

Laxity AMCLValgus stress

Hypertrophic changes develop posteromedial olecranon against the olecranon fossaJobe 16% casesAltchek 45%

Pain on forced extension

Ulnar Neuritis

Secondary to:

1. Direct Trauma2. Traction Compression: Hypertrophy of

common flexors3. Subluxation of nerve - 40% of cases.

Imaging Studies

RadiographsCalcification of MCLTraction spursValgus gravity stress test-medial opening

CT ArthrogramThin cuts 3mm100% sensitive complete tearsCT arthrogram better than MRI for partial tears

71% CT arthro14% MR

Magnetic Resonance Imaging Based Classification for UCL Injuries

(Joyner et al. 2016)

• MRIs from 240 patients undergoing UCL reconstruction (Andrew’s)

• Classification type synonymous with valgus laxity • Type 1: 0.13mm• Type 2: 0.2mm• Type 3: 0.63mm• Type 4: 0.76mm

Magnetic Resonance Imaging Based Classification for UCL

Injuries con’t

Timmerman SignType 3 UCL from sublime

tubercle Partial UCL tear

Type 2 UCL

Arthroscopy

• 1 mm-open indicates AMCL attenuation

• 3 mm-complete tear

Altchek et al. 2009 (AJSM)

Valgus stress testElbow flex 30 deg.Humerus in abduction + external rotationValgus stress Pain over MCL + Opening

Distinguish medial epicondylitis by pain on forced resisted flexion-pronation

Moving Valgus Stress Test

Active Milking testShoulder abducted 90o

Elbow maximally flexedConstant valgus load applied to elbowElbow quickly extended to 30o

flexion.

O’Driscoll AJSM 2005

Moving Valgus Stress Test

Pain must reproduce MCL painMaximal pain 120-70o “Shear Range”Sensitivity 100%17 of 17 patientsSpecificity 75%3 of 4 ptsMRI 6-15 40% pts

Conservative Care

• Partial or complete UCL tear• 3 months rest and

rehabilitation

• Dismal Results • 42% return to play• Average time return to play

24.5 weeks• Duration of symptoms,

acuity of injury, nor age did not predict return to play

Rettig et al. 2001 (AJSM)

Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet-Rich Plasma

• 34 patients with partial UCL injury (MRI diagnosis)

• 5mL PRP under ultrasound guidance in site of injury

• 12 weeks of rehabilitation

• Follow-up 70 weeks• 30/34 (88%) return

to play without complaints

• Significant improvement in DASH score

(21 +- 16 to 1 +-6)

Podesta et al.Am J Sp Med, 41:7, 2013

Indications for Surgery

• Complete/partial rupture in throwing athlete• Chronic pain without improvement after 3 months (conservative)• Rest, bracing, rehabilitation 40% return to throwing (Rettig)

• Reconstruction advised vs. repair

Modification to the Original Technique

Muscle splitting approach -Ulnar nerve protected but not transposed

Open tunnelsPalmaris Tendon autograft83 pts33 pts > 2 yr follow upNo operation for Ulnar Nerve

dysfunctionAll athletes return to their sport93% excellent result5% Ulnar Nerve Paresthesiae (transient)

Thompson and Jobe et al JSES 2001

Modifications – ALTCHEKDocking Technique

Arthroscopic treatment first of valgus extension overload osteophytes

Muscle Splitting aproachUlnar Nerve not transposedDocking of 2 ends of tendon graft tensioned in to a single

humeral tunnel closed(Avoid medial epicondyle fracture)

Technique

MCL Reconstruction Classic Open Tunnels

Systematic Review Of UCL ReconstructionTechniques

• 21 studies: Medline, Pubmed, Cochrane• 7 Biomechanical, 14 clinical• 1368 patients• 78.9 % Return to play.• 18.6 complication rate.

Watson et Al.Am J. Sp.Med: 2013

Return to Play

Overall 78.9% Return To Play

Complications Author/Technique Specific

Mainly Neurologic (Ulnar Nerve)

Overall Complication Rate

• Jobe Technique 29.2%• Modified Jobe Technique 19.1• Interference Screw Technique 10%• Docking Technique 6%

Summary• AMCL most important stabilizer to Valgus load

• Best History = “pop” but ALL pitchers lose velocity/control with chronic AMCL attenuation

• Associated injuries include valgus extension overload, medial epicondylitis, Ulnar Neuritis.

• Best physical test: Moving Valgus Stress Test

• Reconstruction with autograft yields best outcome Muscle splittingNo neural nerve transposition Open tunnels Vs Docking technique

• 1 yr Rehabilitation

• 79-80% return to competitive throwing/ 18% complication rate