Lateral Ulnar Collateral Ligament Injury
What is a Lateral Ulnar Collateral Ligament Injury?
Ligaments are soft tissue structures that connect bones to bones across a joint. The best way to think of a ligament is as a tether between the bones, which gets tight when the joint moves. When a ligament is torn, the tether is no longer present and the joint becomes unstable. This can lead to pain, a sense of instability or looseness, and inability to work or do a sport.
In the elbow, the two ligaments primarily responsible for maintaining elbow stability are the Medial Collateral Ligament, and the Lateral Ulnar Collateral Ligament. The Medial Collateral Ligament (MCL), also known as the ulnar collateral ligament or UCL, is located on the inside of the elbow close to the body, and the Lateral Ulnar Collateral Ligament (LUCL) is located on the outside of the elbow away from the body. The MCL is a thick fan-shaped band of ligamentous tissue connecting the humerus (the upper arm bone), and the ulna (the bone of the forearm on the opposite side of the thumb). The LUCL is a thick band that extends from the lateral epicondyle of the humerus across to the ulna and is the main ligament stabilizer on the outside of the elbow. Also on the outside of the elbow are the Radial Collateral Ligament (RCL) and the Annular Ligament (AL). The Radial Collateral Ligament extends from the lateral epicondyle on the outside of the elbow to beneath the annular ligament and is a short and narrow fibrous band, less distinct than the LUCL. The Annular Ligament encircles the head of the radius and allows the radial head to freely rotate during pronation and supination.
The LUCL is frequently stretched or torn with elbow injury, dislocation, or with repetitive overuse stresses such as a throwing motion. When the elbow is put back in place, the LUCL may heal enough that is does not need to be fixed with surgery. Sometimes, however, the ligaments do not heal correctly and the elbow remains loose and/or unstable.
Signs and Symptoms:
Patients typically experience pain and instability along the outside of the elbow, along with some swelling or bruising (especially if the LUCL completely ruptured). The patient may also notice locking, clicking, catching, loss of elbow motion, and recurrent dislocation of the elbow. The patient may develop an apprehension to lift off from a chair using the arms as an abnormal clunk (dislocation) occurs with push off.
The goals of nonsurgical treatment of a torn LUCL are to restore stability to the elbow joint and to provide pain relief to the patient. Treatment consists of an initial period of rest with non-steroidal anti-inflammatory medications and application of ice with elevation to the elbow daily until the pain and swelling are gone. After inflammation of the elbow has decreased, the patient may begin physical therapy. The purpose of physical therapy is to strengthen the muscles around the elbow to compensate for the torn ligament.
If the patient wishes to return to strenuous overhead or throwing activities and they do not respond to non–surgical treatments, then surgical repair of the LUCL may be recommended.
When the condition fails to respond to the conservative care described above, surgery may be indicated. If pain is the primary symptom and there is no evidence that the elbow joint is grossly unstable, the surgeon may use an arthroscope (tiny camera) to look inside the elbow and see the condition of the joint and the soft tissue. The surgeon may debride any tissue fragments or frayed edges. During debridement the surgeon carefully cleans the area by removing any loose cartilage pieces or damaged tissue. Any bone spurs or areas of calcium build-up are also removed.
If arthroscopic debridement does not help the symptoms, further surgical care may be required. There are two types of surgery – 1) Repair the existing ligament or 2) Reconstruction (replacement) of the ligament.
1) LUCL Repair:
If it is an acute LUCL injury (within 2-3 weeks of initial injury) due to a fall on the outstretched arm, a direct repair of the ligament may be possible, especially in a young person. If the ligament has pulled off the humerus, it may be reattached with sutures through holes drilled in the bone. Direct repair of the existing ligament is only performed when the ligament has pulled away from the humeral attachment. This is known as an LUCL “avulsion” and is rare.
2) LUCL Reconstruction:
If the injury is more than 3 weeks old or the ligament has been damaged by constant overuse and is not strong enough to restore stability to the elbow joint if it is simply reattached or repaired, reconstruction of the LUCL is recommended. The torn LUCL will be replaced with a new ligament. Commonly, an accessory tendon from the forearm (called the Palmaris longus tendon) is used to reconstruct the LUCL. This is known as an “autograft” because the graft was harvested from somewhere else in the body. The LUCL can also be reconstructed with donor tendon called an “allograft.” The graft will be positioned over the LUCL complex and secured to the humerus and ulna with anchors.
Post Operative Rehabilitation:
Following Arthroscopic Debridement, gentle range of motion (ROM) exercises are begun right away. Full motion is restored as the pain and swelling resolve. Elbow strengthening exercises are begun with in the first few days to week after the procedure. A rehabilitation program is started and progressed, including a gradual throwing program. Full sports participation can be anticipated within one to three months.
The postoperative protocol is the same for Repairs or Reconstruction, and is as follows:
- Expect a surgical bulky dressing and splint.
- Elevate and ice for at least 3 days.
- Continue to elevate as often as possible until your next clinic visit. (Elevate above your heart.)
- Shower with a plastic bag covering the splint and seal with tape.
- Take your pain medication as needed and as prescribed. Call if any problems or questions arise.
3-4 Days Post Op (begin therapy):
- Dressing and splint will be removed.
- Therapist will fit patient with a static long arm removable splint—elbow at approximately 90° and wrist included in splint.
- Full pronation (palm down) for LCL repair.
- Begin gentle active wrist Range of Motion (ROM) extension/flexion as well as bicep and shoulder isometrics.
10 Days Post Op (at therapy):
- Sutures will be removed.
- Fitted with custom long arm splint fashioned by therapist.
- Begin active elbow flexion and extension exercises with a 30° extension block 3-5 times a day.
- To prevent loading of the repaired ligament, this is to be performed while lying supine with the arm overhead or across the chest while maintaining supination/pronation position.
- Therapist will assist with edema and scar management.
4 Weeks Post Op:
- Follow up appointment in clinic with P.A. or M.D.
- Gentle active supination and pronation initiated.
- Grip strengthening may be initiated with putty and a hand exerciser.
8 Weeks Post Op:
- Follow up appointment in clinic with P.A. or M.D.
- Splint may be discontinued as advised by M.D.
- Continue to work toward full range of motion (ROM) in elbow flexion and extension.
- Gentle passive ROM to the elbow, forearm, and wrist.
- Gentle strengthening only when active ROM is nearly full.
- A minimal (5-10°) extension loss is acceptable rather than forcing the movement and risk compromising the integrity of the collateral ligament.
- Avoid contact sports and heavy loading activities for 4-6 months.
- Plan slow and progressive return to full activities.
Note: These instructions are to serve as guidelines and are subject to Physician discretion. Actual progress may be faster or slower depending on the individual.