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 also be tried, which 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. Either way, UofL Health – Hand Care is prepared to treat the injury.
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.
Osteochondritis Dissecans (OCD)
OCD is a disabling condition that may present with elbow pain, and catching or locking of the elbow joint. The cartilage and the bone under the cartilage are fragmented locally in the capitellum, the outer part of the elbow joint. Initially, the cartilage raises on one-side and interferes with elbow motion causing locking of the elbow joint. In later stages, the fragmented cartilage may fall into the radiocapitellar joint, forming loose bodies.
OCD is commonly seen in 10 to 16 year old baseball pitchers. Its cause is usually trauma. The medial collateral ligament complex may show laxity, which may cause more than usual deviation (valgus force) during the acceleration phase of throwing. With extreme forces on the capitellum, the bone breaks locally and there is shearing of the cartilage. The patient presents with a painful elbow and decreased range of motion. X-rays may be normal or rarely will show irregularities or flattening of the capitellum. However, MRI is diagnostic. It will show discrete area of cartilage and bone damage.
Nondisplaced fractures and pure cartilage lesions may be treated with immobilization and rest. Some surgeons recommend arthroscopic debridement and pinning if there is displacement. After removal of the cartilage, multiple holes are drilled in the defect using a pin to create fibrocartilage. However, more sophisticated treatment method of this condition is with replacement of the cartilage and the defect. For this purpose, the UofL Health – Hand Care team harvests cartilage and bone plugs from the non-weight-bearing surface of the knee. The surgeon maps the defect first then applies multiple osteochondral allografts. We harvest multiple 6 or 7 mm cylindrical shaped cartilage and bone plugs from the non-weight-bearing surface of the knee. Then same size holes are drilled in the elbow cartilage defect. The osteochondral graft plugs are applied with a press-fit effect, thus no fixation is necessary. Early elbow and knee motion is encouraged with braces. In about 8 weeks, the plugs heal and we start strengthening.
Tendinitis is an overuse syndrome, most commonly caused by chronic strain, overuse, or misuse of a muscle/tendon at its origin or insertion on bone. Different names are given to these conditions depending on the anatomic location: Biceps, Triceps, Medial epicondylitis (Golfers’ elbow), Lateral epicondylitis (Tennis Elbow) occur around the elbow; deQuervain’s, extensor or flexor tendinitis arise at the wrist. Medial Epicondylitis and Triceps tendinitis occur commonly in baseball players’ elbow.
Repetitive tasks with forceful muscle exertion without adequate relaxation would cause micro tears that heal with fibrosis and adhesions. There usually is not good blood supply locally, thus there is failure of repair of disrupted tissues. This is evidenced by irregular collagen, chaotically arranged mesenchymal cells, an excessive amount of matrix tissue, vascular buds with an incomplete lumen and insufficient elastin.
Clinically, short bursts of excruciating pain in the arm, back, shoulders, wrists, hands, or thumbs (typically diffuse – i.e. spread over many areas) are observed. The pain is worse with activity; there is weakness and lack of endurance.
The treatment initially is with rest, ice and anti-inflammatory medicines. Adequate relaxation of the involved muscles and enhancement of physical fitness are the keys for prevention of worsening. Occupational therapy initially deploys soft tissue mobilization, active release therapy, ultrasound, muscle stretches, and then strengthening. If the degenerated area progresses to a large tear surgical repair should be attempted.
In triceps tendinitis, tennis elbow, or golfers’ elbow surgery, we clean the degenerated area of irregular scar tissue and necrotic tissue. We prepare the bone for the tendon; and reattach the muscle and tendon on the bone using thick sutures. These sutures are passed through the bone and are quite strong, however the muscle and tendon tissue is weak and becomes even weaker after being torn. For this reason the elbow needs to be protected for tendon healing.
In the wrist, the tendons go through tight compartments that are formed by tight band-like structures around the wrist called the extensor retinaculum. The inflammation arises around the tendons within the compartments hence the treatment should be directed to these compartments. The tendinitis of the first extensor compartment, deQuervain’s tendinitis, is best treated with cortisone injections. If the treatment fails despite attempts of therapy and anti-inflammatory medication, surgery can be recommended. In surgery, the team at UofL Health – Kleinert Kutz Surgery Center releases the compartment: the band around the tendon is cut in a longitudinal fashion.
Synovial Fold Syndrome
One of the most difficult diagnoses in the elbow pain is synovial fold syndrome. These folds of synovial membrane are remnants of embryological synovial tissue in the elbow joint. With extension of the elbow patient feels pain at the back of the elbow. The baseball player usually feels the pain at the end of the pitch cycle during the release phase. The MR imaging is diagnostic. It shows the synovial fold in symptomatic patients posteriorly just above the olecranon or between the humerus and the radius in the radiocapitellar joint. This tissue averages 3 mm in thickness. The presence of synovial fold is not always symptomatic, but if symptoms arise, cortisone shots could be tried for relief. If the symptoms are bothersome and interfere with the game, the UofL Health – Hand Care team may recommend arthroscopic surgery. In elbow arthroscopy, your surgeon with the UofL Health – Kleinert Kutz Surgery Center can examine the entire elbow joint directly with 3.5 mm scopes and visualize the extent of the synovial fold. Your surgeon will remove this tissue with shavers. As soon as the incisions heal, patients are released to activity and sports.
Cubital Tunnel Syndrome
Cubital tunnel syndrome is an acute or chronic compression of the ulnar nerve at the elbow. The nerve runs between the olecranon (posterior aspect of the elbow) and the medial epicondyle (funny bone) at the elbow area. The nerve can be compressed by anatomical abnormalities such as “fibrous bands”, or by bony abnormalities such as bone spurs. Also, inflammation of the nerve could be the cause of chronic displacement of the nerve while bending and extending the elbow.
Fracture of the Hook of the Hamate
Hamate is one of the eight bones in the wrist. It has a bony extension on the palm side called “the hook”. The hook of the hamate forms the sidewall of the carpal tunnel. The roof of the carpal tunnel is a thick ligament, transverse carpal ligament that attaches on the hook of the hamate. One can feel the hook of the hamate in the pillar area (the heel of the palm) on the small finger side.
Fracture of the hook of the hamate is an uncommon condition. It often occurs with sports activities such as tennis, golf and baseball. It may go undiagnosed and can be the cause of long standing wrist pain. The blow of the bat or the racquet on the bone may cause a direct injury. With indirect injury, the force on the transverse carpal ligament wrenches the hook. The hamate breaks at its weakest point where the hook connects to the body. The blood vessel to the hook can be injured as well, causing disruption to the blood supply. The loss of blood supply can result in necrosis, -death and softening, of the bone. The loss of blood supply to the hook is the biggest challenge to fracture healing and may cause nonunion.
These fractures are better treated early and surgically if there is any displacement. Surgical treatment is better than cast treatment in these cases. Worried about the blood supply to the hamate, some surgeons will recommend removing the broken part. Others believe fixation of the fracture restores the anatomy and should be the choice in athletes. Both methods have satisfactory and comparable outcomes.