Review 1,2 3 4,5 1,2,3 Obere Extremität 2018 · 13:173–179 Laurent Willemot · Filip R. Hendrikx · Ann-Maria Byrne ·Roger P. van Riet https://doi.org/10.1007/s11678-018-0465-1 Orthopedic Center Antwerp, Antwerp, Belgium Received: 21 March 2018 Monica Hospital, Antwerp, Belgium Accepted: 2 May 2018 University of Antwerp, Antwerp, Belgium Published online: 30 May 2018 © The Author(s) 2018 Blackrock Clinic, Dublin, Ireland Sports Surgery Clinic, Dublin, Ireland Valgus instability of the elbow: acute and chronic form A steady rise in the number of help safeguard elbow stability through- 60° and full ﬂexion . The posterior athletes participating in overhead out range of motion (ROM) and under band may play an important role in throwing sports has been observed external destabilizing forces. posteromedial instability of the elbow in recent years . This rise has been The ulnohumeral articulation acts as . The transverse band is believed accompanied by an increased the primary stabilizer at the end-ROM to regulate the relationship between the incidence of thrower-speciﬁc between 0° and 20° of extension and 120° anterior and posterior bands but has elbow injuries. Overhead athletes, 140° of ﬂexion. Both static and dynamic been shown to be of little signiﬁcance in such as baseball pitchers, javelin structures are required to stabilize the resisting valgus stress when sectioned in throwers, and handball players, are elbow in the midrange of 100° [34, 35]. acadaveric study . at risk of developing medial elbow The radial head serves as a secondary symptoms due to the high valgus stabilizer to valgus stress contribut- Both static and dynamic stresses generated during throwing. ing up to 30% of medial stability with an structures are required to Similarly, power grip (racket) sports, intact anterior band of the MCL [14, 24, stabilize the elbow gymnastics, and weight-lifting 28, 34, 35]. are associated with medial elbow In the case of MCL insuﬃciency, the injuries. In full extension, the osseous constraints, radial head becomes the primary stabi- the medial collateral ligament (MCL), lizer against valgus instability [24, 40]. A combination of tensile forces at the and the anterior capsule form the main- The dynamic stabilizers of the ﬂex- medial stabilizing structures, lateral stay of valgus stability , while the or–pronator muscle group counteract the compartment compression, and pos- MCL serves as a primary restraint be- valgus stress forces of the throwing mo- terior shear forces may lead to valgus tween 30°and 110° of ﬂexion . The tion and are of vital importance in pre- instability. Chronic problems are associ- MCL is composed of three distinct bands: vention and rehabilitation strategies . ated with repetitive motion and overuse, the anterior, posterior, and transverse Unfortunately, these musclescannotfully yet acute and acute-on-chronic injuries bands (. Fig. 1). The anterior band, compensate for a torn MCL complex and also occur. A thorough understanding which originates on the under-surface of electromyography (EMG) studies have of the functional anatomy of the elbow the medial epicondyle and inserts on the shown that, paradoxically, activity is de- as well as the biomechanics of throwing sublime tubercle of the proximal ulna, creased in the presence of an MCL in- is essential when treating this unique acts as the primary stabilizer to valgus jury. This reﬂects the inability of the ﬂex- type of sports injury. stress in ﬂexion between 30° and 120° or–pronator group to suﬃciently com- This reviewdiscusses the topic ofacute . Because of the anterior insertion, pensate for the loss of valgus stability andchronicvalgusinstabilityoftheelbow the anterior band is tighter in extension aer ft MCL rupture in overhead athletes covering the relevant anatomy, biome- and in early stages of elbow ﬂexion when . chanics, clinical examination, imaging compared with the posterior band. Since modalities, and treatmentoptions forthis the posterior band inserts posterior to Mechanisms of injury condition. the anterior band, it tightens more in further stages of ﬂexion. The posterior Most cases of symptomatic chronic val- bundle alone contributes little to overall gus instability occur as a result of repet- Anatomy and biomechanics stability; however, at 30° of ﬂexion it itive trauma to the medial elbow stabi- The elbow joint functions as a modiﬁed acts as a secondary stabilizer, becoming lizers in overhead athletes. Much of the hinge. Bothstaticanddynamicstabilizers functionally more important between research into valgus instability has fo- Obere Extremität 3 · 2018 173 Review Fig. 1 8 Cadaveric dissection of the medial side of the elbow. Three parts of the medial collat- eral ligament (MCL) complex are distinguished. H humerus, U ulna, ME medial epicondyle, A an- terior band of the MCL, P posterior band, T trans- verse band. (Courtesy of the MoRe Foundation) cused on throwing injuries in baseball pitchers. The overhead throwing mo- tion in baseball has been divided into six Fig. 2 8 Magnetic resonance image of a medial Fig. 3 8 Computed tomography scan of the el- stages: epicondyle apophysitis in a skeletally immature bowshowingafracturedosteophyteatthetipof 1. Windup athlete. (Courtesy of the MoRe Foundation) the olecranon. (Courtesy of MoRe Foundation) 2. Early cocking 3. Late cocking 4. Acceleration epicondyle apophysitis in the skeletally tive tissue disease, rheumatic conditions, 5. Deceleration immature patient (. Fig. 2). or neurological impairment. 6. Follow-through  At the end of the throwing motion, in Unrecognized or untreated valgus el- the so-called follow-through stage, shear bow instability can lead to early joint During thelatecocking andacceleration forces on the posterior compartment degeneration due to abnormal joint kine- phases, the MCL complex of the elbow may produce posteromedial olecranon matics creating high-stress areas and car- experiences valgus stresses reaching up impingement in extension, with a corre- tilage destruction. Moreover, recurrence to 64 Nm, exceeding the ultimate tensile sponding lesion in the olecranon fossa and symptoms of elbow instability may strength of the anterior bundle of the (. Fig. 3). Moreover, valgus stresses on inﬂuence the performance and earning MCL [2, 42]. Contraction of the ﬂex- the medial side are typicallyaccompanied potential of athletes. or–pronator group mitigates the remain- by overload in the lateral compartment ing force . However, if the muscular of the elbow. This can lead to abnor- Diagnosis compensation fails, injury to the MCL mally high compressive forces across may occur. Furthermore, due to the the radiocapitellar articulation. Such History simultaneous elbow extension that oc- forces may damage the cartilage, re- curs during the throwing motion, bend- sulting in chondromalacia, osteophytes, In the assessment of valgus elbow insta- ing moments arise within the anterior and loose bodies. A combination of bility, valuable information can be gained MCL bundle, which can lead to destruc- excessive medial tensile forces together from a thorough patient history. Details tive shear forces between the ligament’s with lateral compartment compression of the exact moment of the injury, the ﬁbers. Repetitive microtrauma to the lig- and posterior shear forces during throw- eventsleadinguptoandfollowingit, prior amentous complex can result in stretch- ing motion is termed valgus extension injuries, changes in training regimen, ing and attenuation of the MCL and can overload syndrome (VEOS) . racket tension and grip, and professional eventually lead to a full acute-on-chronic occupation must be obtained. In acute rupture. These acute-on-chronic rup- cases, the patient may recall a sudden Untreated valgus elbow tures are therefore oeft n intraligamen- tangible or audible “pop” accompanied instability can lead to early joint tous tears, whereas acute traumatic in- by acute pain and a limitation in ROM degeneration juries usually result in an avulsion of . More often, patients with chronic the ligament from its humeral insertion. injuries will report insidious but gradu- Secondary stabilizers and neurovascular Less frequently, valgus instability occurs ally worsening or ﬂuctuating symptoms, structures on the medial side of the elbow as the result of unrecognized or neglected speciﬁcally during a particular causative may also be injured as a result of valgus trauma or aer ft failed treatment for acute motion such as throwing. Athletes may laxity, resulting in ﬂexor–pronator mass elbow instability. In rare occasions, val- also report progressive loss of ball con- tendinopathy, ulnar neuritis, or medial gus instability is associated with connec- trol and throwing performance. The pain 174 Obere Extremität 3 · 2018 Abstract · Zusammenfassung usually reaches maximal intensity dur- Obere Extremität 2018 · 13:173–179 https://doi.org/10.1007/s11678-018-0465-1 © The Author(s) 2018 ing the late cocking and early accelera- tion phases, but with VEOS, athletes may L. Willemot · F. R. Hendrikx · A.-M. Byrne · R. P. van Riet alsoreportposteromedialpainduringthe deceleration phase caused by posterior osteophyte impingement. Ulnar nerve Abstract symptoms at rest or during the provok- This in turn can result in arthrosis and the There has been an increase in thrower- ing motion should also be recorded. formation of osteophytes. Ligament failure speciﬁc elbow injuries in recent years. High may eventually occur, making it impossible valgus stresses during the late cocking and Clinical examination for the athlete to continue their throwing acceleration phases of throwing need to be activities. The outcome of conservative compensated by the ﬂexor pronator muscles treatment with strengthening, improvement Clinical examination typically starts with as these can exceed the tensile strength of technique, and relative rest is often of the medial collateral ligament complex. inspection of the joint in resting posi- disappointing. Direct repair may no longer Prevention of injuries is the priority, with tion. Ecchymosis may be present in the be possible in these acute-on-chronic injuries a focus on strengthening, reducing throwing case of elbow dislocation (. Fig. 4). Pal- and a reconstruction with a tendon graft may frequency, decreasing force, and promoting pable fullness of the soft spot is a sign be necessary. a technique. The spectrum of thrower injuries of intra-articular eﬀusion. In the case ranges from a simple sprain to complete Keywords failure of the valgus stabilizing factors. of acute eﬀusion, the patient will hold Elbow · Athletes · Ligaments · Joint instability · The medial collateral ligament can stretch, the elbow at a ﬂexion angle of 70°, to Reconstructive surgery leading to posteromedial impingement accommodate the increased intracapsu- and radiocapitellar compression forces. lar volume. The carrying angle, between the humerus and forearm, may be higher than the average 11° and 13° in men and Valgusinstabilität des Ellenbogens: akute und chronische Form women, respectively, as a result of repet- Zusammenfassung itive valgus stretch and MCL elongation und Kompressionskräften zwischen dem In den letzten Jahren gab es einen Anstieg . Palpation of the bony structures Radius und dem Capitulum humeri führt. wurfspeziﬁscher Ellenbogenläsionen. Eine is paramount during the examination. Dies kann in einer Arthrose und der Bildung hohe Valgusbelastung während der späten Point tenderness at the MCL insertion von Osteophyten enden. Das Ligament kann Anspannungs- und Beschleunigungsphasen on the sublime tubercle, which is a fre- des Werfens muss durch die Flexoren und schließlich reißen, was es für den Sportler Pronatoren ausgeglichen werden, da diese unmöglich macht, seine Wurfsportart weiter quent site of pain in valgus injuries, is die Zugkraft des medialen kollateralen auszuführen. Das Ergebnis der konservativen indicative of valgus stress injury. Medial Therapie mit Stärkung, Verbesserung der Bandkomplexes übersteigen können. Der epicondyle pain in skeletally immature Technik und relativer Ruhe ist oftmals Prävention von Verletzungen wird der patients may indicate an avulsion injury enttäuschend. Eine direkte Rekonstruktion Vorzug gegeben, dabei liegt ein Fokus aer ft elbow trauma. Active and passive ist bei diesen chronischen Verletzungen mit auf der Stärkung, der Verminderung der akuter Phase ggf. nicht mehr möglich, und Wurfhäuﬁgkeit, der Verminderung des ROM should be assessed with special at- u. U. bedarf es einer Rekonstruktion mit Krafteinsatzes und einer ausgefeilten Technik. tention to pain, crepitus, and locking or einem Sehnenimplantat. Werferverletzungen umfassen ein Spektrum loss of motion. A hard extension block von Verletzungen von einer einfachen may indicatea loosebodyor posterior Schlüsselwörter Zerrung bis zum vollständigen Ausfall der osteophyte. Ellenbogen · Sportler · Ligamente · Gelenk- valgusstabilisierenden Faktoren. Das mediale instabilität · Chirurgische Rekonstruktion kollaterale Band kann gedehnt werden, was zu einem posteromedialen Impingement Speciﬁc tests The patency of the anterior bundle of the MCL is best evaluated by diﬀerent val- gusstresstests. Valgusstressisapplied the patient’s arm in 90° shoulder abduc- result, two conditions must be satisﬁed: in various angles of ﬂexion. To examine tion and 90° elbow ﬂexion. A valgus the pain elicited must be similar to that the MCL, the elbow is ﬂexed to 20°–30° stress is then applied by pulling down during the causative motion; and maxi- to unlock the joint. The examiner sta- on the thumb, as one would pull down mal pain must occur during the position bilizes the right humerus with the left when milking a cow. Reproduction of of late cocking (120° elbow ﬂexion) and hand just above the elbow and applies pain indicates a positive test result. early acceleration (30° elbow ﬂexion). avalgusmomentwith the right handon In the “moving valgus stress” test, the Particular attention should be paid to the patient’s forearm. The contralateral patientstandswiththeshoulderabducted theulnar nervein cases of valgus insta- elbow is then tested for comparison. at 90°. The shoulder is maximally exter- bility. The elbow should be evaluated for With the “milking maneuver” , nally rotated. The elbow is then rapidly a Tinel sign at the cubital tunnel, and valgus stress canbe applied tothe anterior extended from maximal ﬂexion to 30° nerve stability should be assessed when bundle ofthe MCL by grasping the supine under a constant valgus force applied to moving from extension to ﬂexion. patient’s thumb on the aﬀected side, with the patient’s thumb . For a positive Obere Extremität 3 · 2018 175 Review Fig. 4 8 Clinical photograph of the medial side of the elbow following an Fig. 5 8 Plain radiographic anteroposterior and lateral views of the elbow, elbow dislocation. Ecchymosis is indicative of a medial collateral ligament showing calciﬁcation of the medial epicondyle as an indirect sign of chronic injury. (Courtesy of the MoRe Foundation) instability. (Courtesy of the MoRe Foundation) . Saline-enhanced MRI facilitates the returned to their pre-injury sports level Imaging evaluation of leakage through the MCL, aer ft an average time of 24.5 weeks [ 32]. While the diagnosis of medial elbow in- increasing the sensitivity of the exami- Chronicity of the injury and patient age stability is primarily based on the pa- nation from 57 to 92% . did not seem to inﬂuence the prognosis tient history and clinical ﬁndings, imag- of conservative treatment in their study. ing studies may reveal unsuspected con- Treatment comitant lesions. Operative management Plain static radiographs may reveal Nonoperative management calciﬁcations of the MCL, indicating Indications for surgical MCL reconstruc- chronic valgus instability (. Fig. 5). Conservative treatment consists of a re- tion require a conﬁrmatory history, phys- Loose bodies, osteophytes, and radio- habilitation program after a period of ical examination, and imaging studies. capitellar pathology may also be seen on rest and adequate pain control. Immedi- High-demand patients with a diagnosis standard radiographs. ate mobilization is important in the pre- of MCL insuﬃciency for whom nonoper- Valgus stress radiographs can be help- vention of stiﬀness and has been shown ative treatment has failed are candidates ful in cases with equivocal clinical ﬁnd- not to increase the risk of recurrent in- for surgical reconstruction . ings. A medial joint line opening of stability . A dynamic brace can be Some authors advocate elbow arthro- more than 3 mm is considered consis- applied for comfort and for reducing val- scopy before formal MCL repair for two tent with valgus instability [19, 38]. Ad- gus stress on the elbow, with a stepwise reasons: (a) arthroscopy may play a role vanced imaging modalities such as com- increase to full extension. The program in the diagnosis of valgus instability puted tomography (CT) and magnetic should include strengthening of the wrist (. Fig. 8)—a gap of more than 1 mm resonance imaging (MRI) can be valu- ﬂexor–extensor  and ﬂexor–pronator at the medial ulnohumeral joint line is able toolsin the diagnosisofvalgus in- muscle groups together with retraining of indicative of valgus instability ; and stability (. Fig. 6). CT is most helpful in throwing mechanics in the case of over- (b) arthroscopy may be able to address cases with associated bone lesions such head athletes. Optimizing the technique potential concomitant lesions such as as osteochondritis dissecans, fractures, is most important in patients with VEOS posteromedial impingement and loose osteophyte formation, and loose bodies without an MCL tear. body removal. (. Fig. 7). Contrast-enhanced CT scans allow for the visualization of the me- Immediate mobilization Early surgery may be » » dial ligamentous structures. However, is important for preventing indicated in cases of acute valgus we prefer the use of MRI for soft tis- stiﬀness instability sue evaluation. MRI can aid in the de- tection of MCL tears, osteochondral in- juries, olecranon osteophytes, loose bod- The risk of recurrent symptoms is ex- Earlysurgerymaybeindicatedinthecase ies, and sites of neurologic compression tremelyhighifthe underlyingcause isnot of acute valgus instability, conﬁrmed on [11, 23, 26]. The addition of contrast corrected, even when conservative treat- imaging studies, in a high-demand pa- arthrography to MRI improves visualiza- ment is successful initially. Rettig et al. tient. Patients presenting with a partial tion of partial under-surface MCL tears noted that only 42% of baseball pitchers tear and the absence of bony abnormal- 176 Obere Extremität 3 · 2018 Fig. 8 8 Arthroscopic view of the posterome- dial elbow. There is signiﬁcant opening with val- Fig. 6 8 Magnetic resonance image of the el- gus stress, indicating a complete tear of the me- bow, showing a full-thickness tear of the medial dial collateral ligament complex.(Courtesy of collateralligament.(CourtesyoftheMoReFoun- theMoReFoundation) dation) Fig. 7 8 Three-dimensional computed tomog- raphy scanshowingsequelae ofosteochondritis dissecans caused by valgus extension overload syndromeprevalentinyoungthrowingathletes. (Courtesy of the MoRe Foundation) Fig. 9 8 Intraoperativeviewoftheelbowshowingcompleteavulsionofthe Fig. 10 8 Medial collateral ligament reconstruction using an extensor hal- medial collateral ligament.(Courtesy of the MoRe Foundation) lucis longus graft. The graft is ﬁxed through a bone tunnel in the ulna and a docking technique is used to ﬁx the graft in the humerus.(Courtesy of the MoRe Foundation) ities, yet who are resistant to conserva- and ulna (. Fig. 10). Graft options that trate the posterior humeral cortex. Al- tivetreatment, presentadecision-making have been previously described include though this technique was successful, it challenge. autologous and allograft palmaris longus was technically demanding and associ- Direct repair of the ruptured MCL is tendon, plantaris tendon, hamstring ten- ated with a high complication rate, most only indicated in cases of acute avulsion dons, and strips of Achilles or triceps oen ft related to ulnar nerve problems [ 19, from either the humeral origin or the tendon. Jobe and colleagues [19, 37] 31]. Since then, the technique has been coronoid insertion (. Fig. 9;[6, 7, 19]). described the original MCL reconstruc- modiﬁed. A muscle-splitting approach The direct repair may be reinforced with tion technique consisting of (a) tendi- has been developed to avoid detachment atendon graft via ahybrid technique. nous transection and reﬂection of the of the ﬂexor–pronator mass and tunnels Most MCL reconstruction techniques in- ﬂexor–pronator mass, (b) submuscular are drilled anteriorly on the humeral epi- volve a free tendon graft, typically placed transposition of the ulnar nerve, and (c) condyle to avoid the risk of ulnar nerve in bone tunnels through the humerus creation of humeral tunnels that pene- injury. The number of bone tunnels has Obere Extremität 3 · 2018 177 Review also been reduced to facilitate graft ten- face of degenerative changes in the el- mass, minimal handling of the ulnar sioning and avoid the risk of iatrogenic bow joint. If present, loose bodies or nerve, and treatment of concomitant fracture [1, 2, 33]. osteophytes should be removed arthro- medial and intra-articular elbow Several methods of graft ﬁxation have scopically. Elbow arthroscopy provides pathology. been described, including transosseous the added beneﬁt of direct MCL in- ﬁgure-of-eight reconstruction, docking spection. A medial opening of the joint Corresponding address technique, hybrid interference screw ﬁx- space by more than 1 mm is indicative ation, and EndoButton ﬁxation [2, 4, 33]. of insuﬃciency. R. P. van Riet, MD, PhD Monica Hospital Direct repair of the acutely avulsed Stevenslei 20, 2100 Antwerp, MCL may be indicated for selected pa- Outcome Belgium tients; however, as the quality of the liga- firstname.lastname@example.org Recent studies have demonstrated a 93% ment is usually low from chronic overuse, success rate [2, 8, 9, 29, 38]with cur- a reconstruction or hybrid technique is rent ligament reconstruction techniques. typically warranted. Surgical reconstruc- A high rate of return to play (RTP) in tion of the MCL is indicated in high-de- Compliance with ethical elite athletes and a high rate of return mand patients with complete MCL tears guidelines to a pre-injury or higher level have been or those with partial tears for whom reha- reported [4, 20, 33]. Azar et al.  bilitation has failed. Jobe’s original MCL Conﬂict of interest. R.P. van Riet is a consultant with noted an 81% return to pre-injury level, reconstruction technique has seen tech- Acumed and Wright Medical. L. Willemot, F.R. Hen- drikx, and A.-M. Byrne declare that they have no com- Rohrbough et al.  found a 92% RTP, nical modiﬁcations over the past 30 years. peting interests. and Erickson et al.  found that 83% A successful outcome aeft r MCL recon- of patients were able to return to the same struction hinges on decreased dissection This article does not contain any studies with human participants or animals performed by any of the au- level. of the ﬂexor–pronator mass, minimal thors. handling of the ulnar nerve, and recogni- tionandtreatmentofconcomitantmedial Open Access This article is distributedunder the terms Summary of the Creative Commons Attribution 4.0 International and intra-articular elbow pathology. License (http://creativecommons.org/licenses/by/ The incidence of medial-sided elbow in- 4.0/), which permits unrestricted use, distribution, juries has risen in recent years owing to and reproduction in any medium, provided you give Practical conclusion appropriate credit to the original author(s) and the the increased participation in overhead source, providealinktotheCreativeCommonslicense, throwing sports. The spectrum of in- 4 Thrower-speciﬁc elbow injuries have and indicate if changes were made. juries comprises acute strain or rupture increased in recent years. of the MCL to chronic valgus overload 4 Prevention of injuries is the priority, syndrome, leading to arthritis and MCL with a focus on strengthening, reduc- References insuﬃciency. This common pattern of ing throwing frequency, decreasing 1. Ahmad CS, ElAttrache NS (2006) Elbow valgus symptoms is referred to as valgus exten- force, and optimizing the athlete’s instability in the throwing athlete. 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Obere Extremität – Springer Journals
Published: May 30, 2018
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