Anatomy
- In LLE, MCL is affected (binds ulna to humerus, consists of : Anterior oblique, posterior oblique and transverse) - provides support against valgus stress woith the flexor-pronator muscles
MCL
- LLE is a traction apophysitis, meaning a traction injury of the tendon/ligament occurs at the apophysitis due to excessive loading and repetitive microtrauma
Terminology
Physis: Cartilaginous growth plate - near end of a long bone
Epiphysis: Cap of a bone - located between growth plate and joint cartiliage
Apophysis: Outgrowth - attachment for tendons/ligaments - attached to the host bone via growth plate
Growth plates of the elbow
Capitellum: appears at 1-2 years old, fuses at 10-15 |
Radial Head: Appears at 2-5 years old - fuses at 12-16 |
Trochlea: Appears at 8-10 years old - fuses at 10-18 |
Olecranon: Appears at 8-10 years old - fuses at 13-16) |
Lateral epicondyle: Appears 8-13 years old - fuses at 12-16 |
Medial Epicondyle: Appears at 2-8 years old - fuses at 15-17 (last to close) |
Causes
- Usually child athletes (throwers) |
- Overhead pitching (compressive stress on lateral elbow and valgus stress on medial) |
- Softball, tennis, racquetball, handball, javelin, water polo, gymnastics and weight lifting |
Presentation
- Young athlete complaining of medial elbow pain in their throwing arm |
- often mid-late season - busy |
- Point tenderness over medial epicondyle |
- Swelling, elbow stiffness, inability to achieve full extension |
- +ve valgus stress test (Apprehension/discomfort) |
- Neuro should be normal - Ulnar nerve should be checked |
- Core and hip instablity can affect biomechanics of elbow |
- Check - scapular dyskinesis, dysfunction breathing, spinal instability, hip abductor weakness |
Imaging
- Imaging only if unresponsive to conservative care/ another pathology is suspected, signigicant swelling and fixed flexion positioning should be imaged (avulsion/epicondylar f#) |
- MRI - occult osteocartilaginous pathology, ligament injury, and myotendinous findings |
DDx
- F# |
- Avulsion |
- Infection |
- Neoplasm |
- Exotosis |
- Osteochondritis Dissecans |
- Meniscoid Lesion |
- Cx radiculopathy (C8) |
- Ulnar neuropathy (CTS) |
- Posteromedial impingement |
- Sprain/strain - flexor/pronator tendon, MUCL, joint capsule |
Management
- Rest from offending activity - 4-6 weeks |
- Encourage remaining active |
- Splinting/wrist braces |
- Ice for 10 minutes , 4 times per day |
- NSAIDs/creams |
- Neurodynamic technique for ulnar and median nerves |
- Early strengthening of extension and supination until pt can tolerate flexion and pronation |
- Progress to isotonic strengthening of wrist flexors, extensors, pronators and supinators (low resistance/high reps) |
- Reverse Tyler Twist |
- Strengthening of FCU and FDS |
- Scpula stabilisation exercises (lower traps and serratus anterior) |
- Shoulder external rotation and retraction exercises (Brugger, low row and lawmower) |
- Core and hip exercises (Bridging, posterior lunges, semi-stiff deadlift, clams,) |
- Gradual return to throwing when there is no longer point tenderness over medial elbow (no more than 10%) |
- Proper coach communication is important |
- Pitchers should not : pitch on consecutive days/multiple games per day/on multiple teams with overlapping seasons |
- Players should have 2-4 months breaks with no throwing |
- Consider surgical intervention if: Conservative care fails, MCL disruption, >2mm of medial epicondyle separation, avulsion f# >5mm |
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