The elbow is a hinge joint that connects the humerus (upper arm bone) to the radius and ulna (forearm bones). The joint allows both flexion (bending the elbow) and extension (straightening the elbow) movements.
There are three main ligaments in the elbow joint; the medial collateral ligament, the lateral collateral ligament and the annular ligament. Ligaments are short tough bands of fibrous connective tissue. They are attached to bones or cartilage and are responsible for holding bones together and stabilising joints.
In the elbow the medial collateral ligament is found on the inside of the elbow, the lateral collateral ligament on the outer aspect of the elbow and the annular ligament encircles the head of the radius, stabilising it inside a groove known as the radial notch. Although ligaments are relatively strong and rigid by nature, it is possible to injure them.
Ligament injuries, also known as ligament sprains, are caused when the fibres become stretched or torn, or even when a ligament completely ruptures. The worse the sprain or injury the more it will affect the ligament. Ligaments sprains or injuries can be classified into three grades:
- Grade 1 - is a stretching of the ligament or very mild tear. There is little to no instability of the joint resulting from this type of sprain and whilst there may not be much pain or inflammation, a mild sprain can increase the risk of re-injury.
- Grade 2 - is a more severe but still incomplete tear of the ligament. This results in some joint laxity or loss of stability. Swelling and bruising are usually present with this grade of ligament injury and use of the joint can be difficult.
- Grade 3 - is a complete tear or rupture of the ligament. This will result in severely swelling, bruising and bleeding under the skin. As a result of a grade 3 ligament injury the joint is unstable and unable to bear weight resulting in a severe loss of function.
There are two main causes of elbow ligament injuries and these are trauma and overuse.
Lateral collateral ligament injuries are generally much most associated with trauma, especially fracture or dislocation, or forceful movements into what is known as a varus position (inward angulation of a joint), and activities such as falls or forced twisting of the arm.
Medial collateral ligament injuries are generally more associated with overuse, specifically activities that result in significant what is known as valgus force (outward angulation of a joint).
The most common activities associated with this are overhead activities such as throwing or pitching. Medial collateral ligament sprains are sometimes referred to as "little league elbow" because they are very prominent in young people who play baseball and perform a lot of throwing.
They can be diagnosed through the taking of a full medical history and through physical examination by a doctor or physiotherapist. This will usually involve the doctor or physiotherapist asking you to perform a number of elbow movements, resisted tests and other examination techniques such as palpation of the ligaments.
The ligaments of the elbow will be tested through the use of what are known as valgus and varus stress tests. This is when the elbow joint is passively stressed by force into both valgus and varus positions.
A positive test can be either the reproduction of your symptoms, such as pain or discomfort, or an increase in joint laxity or instability. If necessary, an MRI scan can be performed in order to confirm the diagnosis and highlight the extent of the damage to the ligament.
There are a number of different treatments available to help treat elbow ligament injuries.
Usually the options include a stepped up approach to care, meaning that the least invasive treatment options are considered first and the more invasive treatment are considered if the injury is severe enough. The choice of treatments will also depend on the extent of the injury.
Non-invasive treatments for elbow ligament injuries include:
- Activity modification: avoiding, adapting or resting from certain activities for a period of time in order to allow the ligament chance to heal.
- Pain relief: Painkillers such as paracetamol or non-steroidal anti-inflammatories such as ibuprofen can be effective in relieving the pain and inflammation associated with acute elbow ligament injuries.
- Ice therapy: applying an ice pack to the affected area regularly for 10-15 minutes at time for the first 10-14 days following an elbow ligament injury can help to reduce and manage any inflammation.
- Taping, braces and supports: There are specific braces or supports that you can get which help to provide support for the elbow joint, especially when performing strenuous or potentially painful and harmful activities. Similarly there are a number of taping techniques that can be used with rigid athletic tape in order to again stabilise and support the elbow joint and can usually be seen in athletes and sportspeople such as rugby players.
- Exercises: specific elbow exercises can be very effective in managing symptoms that arise from elbow ligament injuries. Circles highly-skilled physiotherapists can construct an exercise programme with specific individualised exercises that are appropriate for people with elbow ligament injuries. Elbow mobility exercises and stretching can be very effective in helping to improve or maintain range of movement. Strengthening and resistance exercises can be very effective in helping to strengthen the muscles around the elbow in order to try and provide as much stability as possible in the elbow joint. Strengthening and loading injuries are especially important in ligament injuries as usually there is an increased laxity in the ligament following an injury or sprain. This will then cause an increased amount of movement and instability at the joint and will therefore increase the likelihood of re-injuring the same ligament. However by strengthening the muscles and reloading the joint gradually we can increase the stability of the joint gradually over time.
If an elbow ligament injury results in a grade 3 complete tear or rupture of the ligament then surgery can be performed if necessary.
- Medial collateral ligament reconstruction surgery is a surgery performed under general anaesthetic designed to restore full medial elbow stability following a complete tear or rupture. It is usually only considered for athletes or people who need to be able to perform high level activities requiring significant elbow stability and control, such as baseball pitchers. The surgery involves removing the ruptured or damaged ligament through an incision in the medial aspect of the elbow and is replaced by a tendon which is taken from a different area within the body.
- Lateral collateral ligament surgery is rare and is typically associated with a fracture or dislocation of the elbow. Due to the decreased structural stability of the joint an open reduction and internal fixation surgery of the elbow may be performed. The surgery involves inserting a combination of pins, screws and wires through an incision site at the elbow in order to stabilise the joint and allow the fracture and other damage to heal properly in the right place. You are likely to then be in a cast for 3-6 weeks before undergoing a period physiotherapy and recovery.
Grade 1 ligament sprains usually heal within a few weeks. Maximal ligament strength will occur after six weeks when the collagen fibres have matured.
Grade 2 ligament injuries usually take somewhere between six to eight weeks to heal, at which point activity should then be progressed gradually, with a full recovery of strength and function taking anywhere up to two to three months.
Grade 3 ligament injuries usually take anywhere between three and six months to fully recover, however this obviously depends on the activities the person is looking to return to and whether or surgery is required.