Hand
Medial collateral ligament (MCL) injuries: MCL injuries occur most commonly in throwing athletes. Most non-throwing athletes, recreational athletes, and even professional football players who tear the MCL do not require surgical treatment. In throwing athletes, the MCL is an important ligament about the elbow, and usually needs to be repaired in order to allow the athlete to return to his previous level of athletics. If the MCL tears with an acute ‘pop’ an MRI with dye in the joint (MR arthrogram) will usually be ordered to confirm the diagnosis. If the MCL is torn in a high-level thrower, it should probably be repaired or reconstructed. In the absence of a pop, at least 3 months of nonoperative treatment, including strengthening the muscles about the elbow, should be tried to see if surgery can be avoided.
MCL reconstruction, also known as the “Tommy John” surgery, involves taking an extra, spare tendon from your forearm that doesn’t do much (sort of like an appendix), or a hamstring from a cadaver, and using it to recreate the MCL. I published a research project in 2008 showing that the tendon used doesn’t make much difference.1 I use the strongest technique available, called the ‘docking technique’. However it’s done, MCL reconstruction takes at least one year to fully recover from, and the rehabilitation after surgery is very important. The success rate is about 90% in mature throwers, but only 80% in teenagers. That’s why it’s important to monitor pitch counts closely in young throwers, who often ‘burn out’ their arms before they ever make it to college or the pros.
For technical issues of the surgery, please read a chapter that I wrote on MCL injuries: Medial Collateral Ligament Instability, Regan WD, Budoff JE, In: Master Skills in Wrist
and Elbow Arthroscopy and Reconstruction, The American Society for Surgery of the Hand, Trumble TE, Budoff JE, eds, Rosemont, IL 2006
1) Biomechanical Analysis of Medial Collateral Ligament Reconstruction Grafts, Prud’homme J, Budoff, JE, Nguyen L, Hipp JA.,American Journal of Sports Medicine 36: 728-32. 2008.
Lateral collateral ligament complex (LCL) injuries: LCL injuries,which includes the lateral ulnar collateral ligmanet (LUCL), are more common than are MCL injuries. They often occur following elbow dislocations or with elbow fractures. LCL injuries lead to posterolateral rotatory instability (PLRI) of the elbow, where the forearm rotates off of the humerus. This often leads to pain and feelings of instability or catching when pushing off or pushing up from an object. As opposed to MCL injuries, LCL injuries usually require surgery to repair the native ligament or reconstruct it with a tendon from the forearm or a cadaveric hamstring tendon. LCL injuries are often associated with radial head and coronoid fractures, both of which will have to be repaired to optimize elbow function.
I published a research project in the 2009 detailing exactly where the tunnels for tendon placement for ligament reconstruction should be.2 Both ligament repair and ligament reconstruction have a very high success rate.
Following surgery, these elbows will require special post-surgical protocols that are best performed by experienced therapists. That’s why I may get very picky about which therapist to send certain patients to after surgery – not all therapists have the knowledge and experience to optimally rehabilitate these injuries while avoiding stressing the repaired ligaments.
2) Goren D, Budoff JE, Hipp JA. Isometric Placement of Lateral Ulnar Collateral Ligament Tendon Reconstructions – A Biomechanical Study.
American Journal of Sports Medicine. Accepted for publication 5/28/09.
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