Medial Collateral Ligament Injuries

Ligaments are strips of very strong tissues that connect bones making joints. In the elbow, the ligament complexes are exceptionally important because they give stability to the joint. On the inner side of the elbow joint, three clusters of ligaments form the medial collateral ligament (MCL) complex: the oblique anterior bundle, the oblique posterior bundle and the transverse bundle. The oblique anterior bundle seems to be the most important in providing valgus stability to the elbow. This ligament becomes tight in flexion and in extension. It also helps antero-posterior stability of the elbow joint. The posterior bundle becomes tight in flexion and it may have fewer roles in valgus stability of the elbow.

A baseball pitch comprises of five phases: Wind-up, cocking, acceleration, ball release, and follow-through. (Figure 1.) During a baseball pitch, the player gets ready for a stride by winding up. The glove side foot touches the ground during the cocking phase. The arm enters the acceleration phase with the arm in maximum external rotation. The arm accelerates and the ball is released. Significant amount of valgus (outward) force is generated during this acceleration. The MCL, especially its anterior portion resists most of this force. The MCL injuries rarely happen at once; instead, they result from accumulation of small tears progressing over time with pitching.

The player complains of pain with pitching, and later, with daily activities. Weakness and decrease in performance follow. In the later stages, instability interferes with activities of daily living. The elbow in 30 degrees of flexion shows opening of the joint on the medial side when valgus force is applied. However, most of the time patient applies to the doctor with pain only and one cannot elicit any instability. The MRI is diagnostic at this point: there is leak of the joint fluid to the tissues and disruption of the ligament off the bone is seen.

In partial ligament ruptures, conservative treatment can be tried. Refraining from throwing is important and should be tried at least 8 to 10 weeks. Prolotherapy can be tried. Prolotherapy aims at irritating tissues to proliferate the ligament. When conservative treatment fails, surgery is recommended if the patient wants to continue baseball. If they choose to withdraw from baseball, the treatment is merely observation.

Before the “Tommy John Surgery”, players had to give up baseball. This procedure involves reconstruction of the MCL with a tendon graft, using an “extra” tendon that is present in the wrist: the Palmaris Longus (PL) tendon. Removal of this tendon causes no function loss. We pass the tendon graft through holes we drill in the ulna at the attachment site of the MCL. Then we tension the tendon after passing it through holes drilled in the distal humerus, at the axis of rotation of the joint. Recently, we started using absorbable screws to fix the tendon on the holes. The tension created in the ligament seems more readily achieved with these screws. After the reconstruction, we keep the patients in a brace that allows for gradual flexion and extension exercises, but prevents varus-valgus stresses. Therapy achieves full ROM at about 8 weeks. Then they begin gradual strengthening. We allow the patients to start weight lifting to train the shoulder and arm muscles after the 12th week. They continue strengthening and are back to gradual throwing at six to nine months after surgery.

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