MCL Insufficiency

AetiologyTommy John Surgery

 

Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity

 

History

 

Initially

- lose velocity / accuracy

 

Develop medial pain

 

40% ulna nerve symptoms

 

Examination

 

Pain on palpation of anterior bundle MCL

 

CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion

 

Jobes test

 

Valgus stress with elbow flexed 25o to unlock olecranon

- forearm pronated to prevent false positives due to lateral side laxity

- problem is shoulder ER

 

Modification

- lie patient prone

- apply valgus stress

 

Elbow MCL Test ProneElbow MCL Test Prone 2

 

Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain

 

MIlkers Sign 1Milkers Sign 2

 

Anatomy

 

Elbow MCL Anatomy

 

X-rays

 

40% calcification MCL

 

Stress view

- > 3mm difference from opposite side

 

MRI

 

Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings

 

Management

 

Non Operative

 

RICE

NSAIDS

 

Physio      

- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction

 

Really amounts to 6/12 rest

- problem for professional athletes

 

Operative

 

Tommy John Surgery

 

Named after famous American baseball pitcher

- first to have this surgery

 

Options

 

1.  Repair

- not often able to be done

- perhaps in acute tear

 

2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described

 

UCL reconstruction

 

Tommy John Surgery

 

Numerus techniques described

 

Palmaris longus / gracilis graft

 

Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP

 

Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve

 

Figure of 8

- tension at 30o

- suture both limbs together to improve tension

 

Post-Op

 

Immobilise for 10/7

ROM brace for 4/52

 

No throwing for 6/12

No sport for 12/12

 

Results

 

Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months

 

Posterior Elbow Impingement

 

Symptoms

 

Cause posteromedial pain

- probably related to subtle UCL instability

 

May be protective

 

Examination

 

Pain posteromedially with full extension

 

CT

 

Identify posterior olecranon osteophytes

 

Management

 

Arthroscopic Resection

 

Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective