MCL

Question 1

MCL strain

Answer 1

medial epicondyle of humerus > tubercle on the proximal ulna, olecranon and joint capsule - • Posterior bands tighten with FLEXION
MO
I
o Traumatic (valgus force) between 120 and 70 degrees of elbow flexion
o Overuse - Repetitive valgus force with throwing (late cocking phase or early acceleration phase) cause microtearing/inflammation/scarring of the ligament leading to laxity, instability and eventually rupture
♣ May have felt a ‘pop’

• Complaints
o Problems with throwing
♣ Pain, decreased power, accuracy
♣ Paraesthesia: P&Ns (secondary symptom)
o Clicking, locking or stiffness
o May report a popping sound
o Possible night pain if completely ruptured

Question 2

MCL AX

Answer 2

Physical examination
Functional - Throwing aggravated and reproduces the pain
- Decreased power and accuracy
- Pain with movement of the affected joint itself

• Observation
o Swelling at medial elbow (2cm distal to medial epicondyle)
o Loss of continuity of medial epicondyle
o Holding the arm in slight flexion (flexion contracture of the forearm muscles)
o Synovitis/loose body formation around the olecranon

• Palpation
o Pain on palpation of MCL
o Swelling
o Hypersensitivity of ulnar nerve

• Movement and muscle exam
o Start with AROM
o Positive valgus stress test (opening medial aspect of joint)
♣ At 30 degrees elbow flexion and then full extension. Compare sides.
- Increased movement + Altered end feel

o Decreased extension ROM
♣ Decreased muscle length of elbow flexors
o Decreased power-specific throwing
o Throwers may have stiffness in elbow extension
• Positive test: valgus stress test (increased movement and altered end feel)

Question 3

MCL - other diagnosis

Answer 3

Imaging
• US, radiography especially for grade 2 or 3 tear, for prognosis
Differential diagnosis
• Medial epicondylalgia
• Flexor tendon tear
Be aware of possible associated problems
• Osteochondral deficits
• Loose bodies around olecranon (cartilage = clicking, lockig)
• Humeroradial joint problems (from repeated valgus stress)
• Ulnar nerve hypersensitivity

Question 4

MCL Mx

Answer 4

Aims
• Decrease pain during throwing
• Improve power and accuracy in throwing/javelin/ baseball
• Improve strength of wrist flexors and pronators
• Improve medial stability at the elbow
• Maintain CV fitness

OMs
•	Pain when throwing
•	Throwing accuracy
•	Throwing power
•	Can you use dynamometer??
Prognosis
•	Non-surgical Mx
o	RTS in American footballers was 90% at an average of 27 days (range of 1-17 weeks)
o	RTS in throwing athletes was 42% at an average of 24.5 weeks
Advice and education
•	Include prognosis
•	RICE
•	NSAIDs
•	Activity modification  no valgus stress
•	Gentle Rom to prevent stiffness
•	Technique correction

Question 5

Retting (2001)- Management approach

Answer 5

• Phase 1
o Rest from throwing for 2-3 months
o NSAIDs
o Ice elbow for 10 minutes, times daily
o Tape especially important in the first 10 days to protect the structure
o Gentle active and passive ROM for elbow flexors and pronators
* After 2 weeks progress to loading on the wrist flexors- guided by symptoms. Must not be tender over MCL.
- Can start isometrics and motor control earlier

• Phase 2 (if pain free)
o Discontinue splint or brace
o Progress to upper extremity strengthening program to all muscle groups
- Improve power for throwing: tricep dips, rotator cuff
o Begin throwing progression at 3 months
- o Elbow hypoextension brace may be used for throwing/lifting

Question 6

prognosis

Answer 6

Prognosis
• RTS not recommended for one year
• Surgery yields a 90% excellent result rate
• Conservative Mx usually adequate for general population

surgery: Removal of loose bodies etc and sometimes ligament reconstruction

Question 7

Manual therapy

Answer 7

• Will hold elbow in flexion therefore address any extension deficits.
o AP glides
o Gentle ROM
o No valgus stress

• Strengthen wrist flexors and forearm pronators - stabilise medial elbow
o Pain-free strengthening
o 5-8 pain-free ROM

• Function specific strengthening of the shoulder and elbow muscles
o Specific muscles required for specific functional tasks
o Progress from general postures to functional postures
Eccentric control… 5-8 RM

Question 8

Throwing specific exercises

Answer 8

• Power training for the wrist flexors and forearm pronators
o 1-3 RM with high velocity (explosive)
• Power training for the shoulder and elbow muscles
o Consider functional needs and positions
o 1-3 RM with high velocity (explosive)

Question 9

Correction of biomechanics (often happens in conjunction with a coach)

Answer 9

• (often happens in conjunction with a coach)
  • Correction of throwing biomechanics
  • Rotation of the body out of the late cocking phase too early
  • Retraining the athlete to contract the wrist flexors and pronators through the acceleration stage so as to provide greater stability to the MCL

Question 10

Progressive pain-free throwing program

Answer 10

• Phase 1- Reinold
o Appropriate mechanics from the flat ground (no mound)
o Progress velocity by increasing throwing distance eg 14m to 50m
o Progress volume starting at 15 throws

• Phase 2 -Reinold
o Off the mound for pitchers
o Progress velocity by altering perceived effort from 50% to 75% to 100% Or distance 14m to 50m
o Progress volume:
♣ From 2 sets to 3 sets of 25 throws pain free