- Function:
- primary medial stabilizer of the flexed elbow joint;
- in full extension MCL provides about 30 % of stability versus about 54% in 90 deg flexion (some estimate that the ligament provides over 70%);
- in contrast the radial head is an important secondary stabilizer in extension as well as flexion (provides 30-33% of stability);
- resection of the anterior band of the MCL will result in gross instability except in full elbow extension;
- resection of both the MCL and the radial head results in gross instability of elbow, and
may produce subluxation or dislocation;
- MCL laxity most often results from repetitive valgus loading such as throwing;
- Anatomy:
- humeral origin of MCL lies posterior to axis of elbow flexion, creating cam effect;
- hence, anterior fibers are stressed in extension & posterior fibers are stressed in flexion;
- anterior oblique, posterior oblique ligament, & small transverse ligament are 3 major portions of the elbow MCL;
- anterior oblique ligament:
- primary stabilizer of elbow for functional ROM from 20-120 deg;
- note that a significant portion of anterior band inserts near coronoid process and that significant MCL instability may result from low coronoid process frx;
- posterior oblique ligament:
- weak fan-shaped thickening of capsule, which is absent in primates;
- it arises at the posterior aspect of the medial epicondyle and inserts over the olecranon;
- it forms the floor of the cubital tunnel;
- this functions as a secondary stabilizer only at 30 deg of flexion;
- references:
- Experimental elbow instability after transection of the medial collateral ligament.
- Biomechanics of elbow instability: the role of the medial collateral ligament.
- Valgus stability of the elbow. A definition of primary and secondary constraints.
- Biomechanical study of ligaments around the elbow joint.
- Valgus stability of the elbow.
- The Medial Collateral Ligament of the Elbow Is Not Isometric.
- Effect of the Posterior Bundle of the Medial Collateral Ligament on Elbow Stability
- Role of MCL in Flexion Contracture of the Elbow: (see Flexion Contracture of the Elbow)
- Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness.
- The medial approach for operative release of post-traumatic contracture of the elbow.
- Radiographs:
- w/ MCL tear, look for abnormally wide joint space on the medial side;
- MRI:
- w/ MCL tear, MRI (T2) images will show focal discontinuity of the ligament and joint fluid extravasation;
- MRI arthrography is the imaging study of choice for evaluation of medial collateral ligament injuries.
- references:
- Noncontrast MR imaging and MR arthrography of the ulnar collateral ligament of the elbow: Prospective evaluation of two-dimensional pulse sequences
for detection of complete tears. Skeletal Radiol 2001;30:625-632.
- Anterior bundle of ulnar collateral ligament: Evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross anatomic and histologic
analysis. Radiology 2004;231:797-803.
- Medial epicondylitis and cubital tunnel syndrome in the throwing athlete
- Nonoperative Treatment of Ulnar Collateral Ligament Injuries in Throwing Athletes Arthur C. Rettig, MD. Volume 29, Number 1, January/February 2001
- Chronic MCL Laxity:
- power point slide show
- often occurs from chronic repetive throwing which stresses the elbow in mid-flexion;
- in about 30 deg of flexion, neither the radial head nor the anterior joint capsule provide significant resistance to valgus
stress, which leaves the MCL vulnerable to overload;
- posteromedial olecranon impingement occurs which results in inflammation, chondral injury, and eventual osteophytes and loose body formation;
- this condition is demonstrated by posteromedial elbow tenderness as a valgus force is applied against the fully extended elbow;
- osteochondrosis of medial epicondyle
- in children the medial epicondylar physis is weaker than the MCL complex and chronic injury to this apophysis results growth disturbances and overgrowth;
- diff dx: medial epicondylitis
- in the report by AC Rettig et al (2001), the authors evaluated 31 throwing athletes with ulnar collateral ligament injuries (from 1994 to 1997);
- the authors sought to determine what percentage of athletes could return to their sport without surgical intervention;
- nonoperative treatment included a minimum of 3 months’ rest with rehabilitation exercises, allowed 42% of the athletes (N = 13)
to return to their previous level of competition;
- those who returned to sports did so at an average of 24.5 weeks after diagnosis;
- surgical repair:
- w/ proximal tears, consider reattachment thru drill holes in medial epicondyle;
- w/ intra-substance tears consider augmentation w/ palmaris longus;
- references:
- Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair (letter to the editor and the response)
Textbook: Operative Treatment of Elbow Injuries:
Surgical management of chronic medial elbow instability.
Reconstruction of the ulnar collateral ligament in athletes.
Medial instability of the elbow in throwing athletes: Treatment by repair or reconstruction of the ulnar collateral ligament.
JE Conway et al. JBJS. Vol 74-A. 1992. p 67-83.
Evidence of Subclinical Medial Collateral Ligament Injury and Posteromedial Impingement in Professional Baseball Players.
Elbow Medial Ulnar Collateral Ligament Insufficiency Alters Posteromedial Olecranon Contact.
A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow.
The Modified Docking Procedure for Elbow Ulnar Collateral Ligament Reconstruction. 2-Year Follow-up in Elite Throwers.
Biomechanical Evaluation of 2 Techniques for Ulnar Collateral Ligament Reconstruction of the Elbow.
Medial Ulnar Collateral Ligament Reconstruction of the Elbow in Throwing Athletes.
Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
- Considerations Before Surgery:
- Acute Rupture:
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