WHAT YOU SHOULD KNOW
The elbow is primarily a hinge joint that bends (flexes) and straightens (extends).Forearm rotational movement (palm up – palm down) also involves the elbow and has a relationship to elbow stability. The elbow joint is stabilized by two main ligaments: the medial collateral ligament (MCL) and the lateral ulnar collateral ligament (LUCL). These ligaments are both very strong. It requires major force to rupture them, which usually occurs during specific trauma events. Sometimes the damage happens over time as in baseball pitchers that throw millions of pitches until eventually the medial collateral ligament “pops” during a particularly forceful throw.
MEDICAL HISTORY
The details of the specific trauma event are important to understand the types of forces that supposedly produced the injury and the direction of those forces. If the forces involved do not appear to be enough to have caused a ligament rupture by themselves, other factors that may have predisposed the ligament to already be weak must be sought out. The nature of the patient’s lifestyle and work are taken into account when selecting treatment options.
EXAMINATION
If the trauma was recent, the location of tenderness and swelling help to localize the ligament injury. If the ligament rupture was a long time ago, these signs are usually absent. The doctor will attempt to perform a manual test of the ligament’s stability, but an awake patient can easily react with muscle spasm in the arm, making it difficult to be sure if the ligament is really unstable or not. Sometimes, the final determination of the ligament’s stability is not made until the patient is examined under anesthesia.
ADDITIONAL TESTS: Basic x-rays should be performed to assess for any abnormalities in the bone structure of the elbow joint, but basic x-rays do not give direct information about ligaments. Advanced imaging studies such as a magnetic resonance (MR) arthrogram can be used to provide more information about ligament rupture. These studies are evolving in their technology, but current accuracy levels still leave a fair degree of uncertainty regarding ligament status.
TREATMENT OPTIONS
| NON-SURGICAL | LIGAMENT RECONSTRUCTION | |
| CONSISTS OF | Muscle strengthening exercises | Surgically creating a new ligament to replace the torn one |
| FEATURES | Goal is to compensate for the unstable ligament | New ligament made from an expendable tendon taken out of the forearm |
| ADVANTAGES | Avoids surgery; A low demand patient may be satisfied enough | Creates an actual ligament that can stand up to heavy demands |
| DISADVANTAGES | Joint is not actually made stable; insufficient treatment for an athlete or heavy work | Tendon tissue is 10 times less elastic than ligament tissue; Elbow can become stiff after surgery |
RECOVERY
Open reconstructive surgery of the elbow can easily lead to stiffness. A carefully designed rehabilitation program must be followed to both promote early motion and ensure that the new ligament is not pulled apart while it heals. In the first 6 weeks after surgery, the patient will follow a protected motion program. Then he / she will pursue unlimited motion followed by a gradual strengthening program. High force strengthening is not allowed until after 3 months of ligament healing. Complex multi-directional motions of the arm such as those used in ball-throwing sports are not permitted until after 6 months of initial rehabilitation.
