Background & Etiology
The elbow joint is a connection point between the humerus (arm bone) and the radius and ulna (forearm bones.) Ligaments are strong, fibrous connective tissues made of collagen that attach bone to bone. These structures are a key component of a strong joint, providing stability and strength that allows the elbow to move with precision.
Ligaments can be stretched by an injury, excess strain on the joint, or through improper stretching techniques that weaken the elbow joint because stretched-out ligaments can cause joint instability. Ligaments can be highly susceptible to injury, and can lead to complications in the function of the joint. These injuries can range from sprains, which are typically mild, to tears that may require interventions like surgery to heal properly.
The anular ligament in a strong band of fibers that wrap around the head of the radius and attach to the ulna, thus stabilizing the radius bone in the elbow joint. It is responsible for rotation motions of the hand, like those used to turn a key or a screwdriver. Injury to the anular ligament can cause pain on the lateral side of the elbow, the pain does not go away over time. This condition can be confused with tennis elbow (lateral epicondylitis.)
Ulnar Collateral Ligament
The ulnar collateral ligament (UCL) attaches the ulna (forearm bone) to the distal end of the humerus. The UCL allows the arm to flex by pivoting at the elbow joint. Damage to the UCL typically causes pain along the inside of the elbow, which can sometimes cause these injuries to be mistaken for injuries to the nearby medial epicondyle. This is most common in overhead throwing athletes such as baseball pitchers. If this ligament is torn surgery to repair or reconstruct the ligament would be indicated.
Little League Elbow
Injuries referred to as Little League Elbow are injuries that occur to the structures of the medial area of the elbow (the medial epicondyle, the medial epicondylar apophysis and the medial collateral ligament.) These conditions are typically the result of overuse and excess stress placed on the elbow joint, particularly by year-round athletic training.
- Repetitive Strain Injuries (RSI) caused by overuse of the ligaments in the elbow
- Conditions that cause instability in a joint, like dislocations
- Traumatic injuries, like avulsion fractures
- Improper stretching mechanics that loosen the ligaments
- Single-sport participation and year-round training in the younger population (particularly for baseball or softball pitchers)
- Anular ligament pain along the lateral side of the elbow
- UCL pain along the medial side of the elbow
- Pain on palpation of the area.
- Deformity along the medial epicondyle
- Pain with throwing
- Little league elbow pain along the medial side of the elbow
- Pain and numbness that spreads down the forearm into the hand
- A feeling of weakness in the arm, and elbow joint
Treatment for elbow ligament injuries may require resting the joint to allow pain and inflammation to subside. For severe injuries, like ligament tears surgery to reattach or repair the ligaments may be needed. How much movement should be restricted following the injury will depend on the severity of the ligament damage. Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore elbow motion.
Physical therapy interventions can help improve: range of motion, strength, coordination, proprioception and endurance. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the elbow.
Post surgery immobilization can have detrimental effects that can be improved through physical therapy including:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased mobility of the joint and connective tissues
- Decreased circulation
- Loss of active and passive motion
Goals for physical therapy post surgery immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the elbow and related muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: throwing) in use of the involved upper extremity in daily activities especially overhead activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the elbow joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe ligament tears or those that affect the integrity of the elbow joint. When the UCL ligament is torn surgery is indicated.
Rate of recovery and the prognosis from ligament injuries will depend on a number of factors:
- Severity – Minor ligament injuries do well with immobilization and physical therapy, while injuries that are more severe and require surgery or effect joint integrity take longer to recover. Patients may have residual motion and strength deficits.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
- By nine months to a year most individuals can return to throwing and normal function.