MCL Sprain or Tear Flashcards
Pathophysiology
- MCL originated at medial epicondyle of humerus and insert onto the tubercle on the proximal ulna, olecranon and joint capsule
- posterior band tightens in flex
- May be associated with RH joint damage and osteochondral deficits
- GRADES
Prevalence
Throwers/ pitchers
MOI
- Traumatic (valgus force) between 120-70 degrees of elbow flexion
- Overuse= Repetitive valgus force with throwing (late cocking or early acceleration phase)–> cause micro tearing/inflammation/scarring of the ligament leading to laxity, instability and eventual rupture
- may have felt a pop
Complaints
- problems with throwing = pain, decreased power, accuracy
- paraesthesia (secondary symptom)
- clicking, locking, or stiffness
- may report a popping sound
- possible night pain if complete rupture
Physical examination
Functional
- throwing aggravated and reproduces the pain
- decrease power and accuracy
- pain with movement of the affected joint itself
Physical exam:
Observation
- swelling at medial elbow (2cm distal to medial epicondyle)
- loss of continuity of medial epicondyle
- holding the arm in slight flexion (flex contracture of the forearm muscles)
- Synovitis/loose body formation around olecranon
Physical exam:
Palpation
- pain on palpation of MCL
- swelling
- hypersensitivity of ulnar nerve
Physical exam:
Movement and muscle exam
- start with AROM
- Positive valgus stress test (opening medial aspects of joints)= 30 deg elbow flex and full ext, compare side.
- Decreased ext ROM= decreased muscle length of elbow flexors
- Decreased power-specific throwing
- throwing may have stiffness in elbow extension
Physical exam:
Special test
Valgus stress test (increased movement and altered end feel).
Imaging
US, radiography–> especially for grade 2 or 3 tear, for prognosis
Differential diagnosis
- Medial epicondylagia
- flexor tendon tear
Aware of associated problems -osteochondral deficits loose bodies around olecranon -Humeralradial joint problems -Ulnar nerve hypersensitivity
Treatment Aims
- decreased 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
Outcome measures
- Pain when throwing
- throwing accuracy
- throwing power
Prognosis
Non- surgical
- 25 wks 42% throwing
- 27 days 90% footballers
Surgical
83% thrower at 10-26 mths
Treatment A&E
- include prognosis
- RICE
- NSAID’s
- activity modification–> no valgus stress
- gentle ROM to prevent stiffness
- technique correction
Management approach
Phase 1
- Rest throwing 2-3 months
- NSAIDS
- Ice elbow 10 mins, times daily
- Tape–> very important first 10 day to protect structures
- Gentle active and passive ROM for elbow flex and pronators
- after 2 wks progress to loading on wrist flexors =guide by symptoms, can start isometric and motor control earlier
Phase 2 (if pain free)
- discontinue splint or brace
- progress to UL strengthening program to all muscle groups= improve power for throwing (tricep dips, rotator cuff)
- begin throwing progression at 3 mths
- elbow hypertension brace may be used for throwing/lifting
Treatment manual therapy
Will hold elbow in flex therefore address any ext deficits
- soft tissue massage
- AP glides
- Gentle ROM
- No valgus stress
Strengthening wrist flexors and forearm pronators–> stabilise medial elbow
- pain-free strengthening
- 5-8 pain free ROM
Functional specific strengthening of shoulder and elbow muscles
- specific muscles required for specific functional tasks
- progress from general postures to functional postures
- eccentic control.. 5-8 RM
Throwing specific exercises
Power training for wrist flexor and forearm pronators
-1-3 RM with high velocity
Power training for the shoulder and elbow muscles
Correction of biomechanics
- 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 phases so as to provide greater stability to MCL
Pain free throwing program
Phase 1
- Approp mech from flat ground no mound
- progress velocity by increasing throwing distance
Phase 2
- off the mound for pitchers
- increasing perceived effort 50–>75–>100%
- increase volume from 2 sets to 2 sets of 25 throw pain free
