➢ The incidence of medial collateral ligament (MCL) injury and surgery is increasing. While MCL injuries are most commonly seen in pitchers, other athletes, such as javelin throwers and football players, may also present with this type of injury. Treatment should be unique to the patient and sport specific in nature.
➢ Specific features of the history, physical examination, and advanced imaging are critical in identifying coexisting pathology, expected success with nonsurgical management, and operative indications.
➢ Nonoperative management in well-selected patients requires a multimodal approach to identify modifiable risk factors for elbow injury, to implement therapeutic modalities to mitigate symptoms prior to rehabilitation, and to correct global kinetic chain flaws.
➢ Negative prognostic factors include prior elbow surgery, valgus-extension overload syndrome, ulnohumeral chondromalacia, associated flexor-pronator muscle tears, and calcification about the ligament. Elbow arthroscopy, while not routinely indicated, can be useful in addressing concomitant intra-articular pathology.
➢ Various reconstructive strategies have evolved since Jobe’s original description, although the principles of reconstruction remain the same: maximizing graft tension and fixation strength and reproducing the insertional anatomy of the native MCL. Ulnar neuritis remains the most common complication, and its incidence is increased with obligatory ulnar nerve transposition.
Medial collateral ligament (MCL) injury was first reported in a group of javelin throwers in 19461. Since that observation, MCL injuries have become well recognized in baseball players, most commonly in pitchers, along with other overhead throwing athletes. Prior to the introduction of MCL reconstruction, MCL injury was regarded as a career-ending injury for throwers. Initial operative attempts involved anterior transfer of the anterior oblique ligament to augment the remaining attenuated MCL2. This strategy was non-isometric, leading to limited extension, and weakened an already damaged ligament, resulting in unsatisfactory results. Another surgical strategy was to repair the MCL3. Due to altered tensile properties and qualitative defects of the diseased ligament, this treatment was also largely unsuccessful for most patients.
In 1974, Dr. Frank Jobe performed the first MCL reconstruction on Tommy John, then a professional baseball pitcher. The operation was a success and helped to change the perceptions among surgeons, athletes, and the lay public, who now refer to the operation as “Tommy John” surgery. Consequently, the number of MCL reconstructions has appreciably increased over the last three decades4.
Treatment recommendations rely heavily on specific history and the findings from the physical examination. Essential patient-specific factors that must be identified include patient age, type of sport, position, competitive level, future aspirations, willingness of the patient to change sport or position, and perceptions of surgery. Injury factors should be assessed, such as history of overuse (particularly in skeletally immature athletes), prior surgery (especially arthroscopic posteromedial decompression or olecranon stress fracture fixation), or change in pitching mechanics. Symptoms related specifically to the elbow should be ascertained, such as duration of symptoms, prior episodes, exact location of pain or discomfort, ulnar nerve symptoms, and posterior impingement signs.
The MCL is a ligament complex composed of the anterior bundle, the posterior bundle, and the transverse ligament. The anterior bundle is the strongest and primary restraint to valgus stress between 20° and 120° of flexion. It originates on the anterior-inferior aspect of the medial epicondyle and inserts on the sublime tubercle of the ulna (Fig. 1)5. It contributes approximately 55% of the relative valgus restraint of the MCL complex, with most of its resistance provided at 90° of flexion. The anterior bundle is subdivided into two bands: the anterior and posterior bands. The anterior band is active at lesser degrees of flexion up to 90°, while the posterior band is most active from 60° to higher degrees of flexion2,6,7. In addition to the MCL complex, the flexor-pronator mass, triceps, and anconeus provide dynamic valgus elbow stability8-10. Shoulder internal rotation and forearm pronation have also been noted to neutralize some of the valgus torque that is generated with throwing.
The medial aspect of the elbow should be inspected for swelling and palpated for tenderness about the course of the MCL at its origin or insertion sites. Local MCL tenderness should be distinguished from flexor-pronator mass injury. Absence of pain with resisted wrist flexion and pronation and pain posterior to the flexor-pronator origin distinguish MCL injury from flexor-pronator injury. Range of motion should be measured and compared with the contralateral side, and any physiologic hyperlaxity must be noted and documented. Lack of full elbow extension in throwers is not uncommon due to an adaptive flexion contracture. Ulnar nerve provocative maneuvers should be performed, including the Tinel test to detect evidence of nerve irritation and dynamic elbow testing to detect the presence of ulnar nerve instability or luxation.
Valgus instability is assessed with the elbow flexed between 20° and 30° to unlock the olecranon from its fossa. The examiner applies a valgus stress and assesses for medial ulnohumeral joint opening or the elicitation of pain. The milking maneuver is performed by either the patient or the examiner by pulling on the patient’s thumb to create valgus stress with the patient’s forearm supinated and the elbow flexed beyond 90° (Fig. 2). The moving valgus stress test is most sensitive and specific for MCL pathology and is performed by the examiner with the application of valgus torque while the patient’s elbow is then flexed and extended11. The test is considered positive if elbow pain is reproduced at the MCL and the pain is maximal between 70° and 120° of elbow flexion.
Global musculoskeletal assessment of the patient must be emphasized, as problems in the kinetic chain are intimately connected to upper extremity injury in the performance athlete. The ability of the patient to perform single leg squats should be assessed for the purpose of evaluating hip and core weakness. In addition, focused examination of the entire ipsilateral extremity is critical to identifying risk factors for MCL injury that may be specifically addressed with nonsurgical treatment. The scapula should be assessed with regard to periscapular muscle tone and bulk as well as normal scapulothoracic rhythm during physiologic shoulder motion. Scapular dysfunction is commonly found in throwing athletes and should be addressed during rehabilitation12. The glenohumeral joint should also be assessed with regard to strength and range of motion. Glenohumeral internal rotation deficit (GIRD) and lack of external rotation have been identified as risk factors for subsequent MCL injury13.
For all patients with a suspected MCL injury, standard anteroposterior, lateral, and oblique radiographs of the elbow should be made. In the presence of chronic injury, calcification may be noted along the path of the MCL. Loose bodies and osteophytes on posterior tip of the olecranon indicate posterior impingement with valgus extension overload. Other abnormalities, such as bone deficiency at the sublime tubercle or medial epicondyle from prior fracture, altered epicondylar morphology, or enthesopathy at the sublime tubercle, should be noted, as they may also influence treatment and surgical technique.
All patients with suggestive history and positive findings on examination undergo magnetic resonance imaging (MRI) of the elbow to allow for characterization of the MCL14. Because magnetic resonance arthrography improves the diagnosis of partial undersurface tears, enhancement with intra-articular gadolinium contrast is our preferred technique (Fig. 3)15,16. In addition to the presence of partial-thickness and full-thickness tears of the MCL, MRI also reveals concomitant pathology such as loose bodies, flexor-pronator tendinopathy, and posteromedial ulnohumeral chondromalacia17.
Indications for Surgery
Patients who wish to continue in the sport of competitive throwing, have failed nonoperative treatment, have an accurate diagnosis of MCL injury, and are willing to participate in the postsurgical rehabilitation are indicated for surgical reconstruction. In addition, seasonal timing may push toward surgical intervention in selected situations.
Although MCL injury is frequently considered to be a “thrower’s injury,” non-pitchers with an MCL injury necessitating surgery have increasingly been described in the recent literature. These patients must be appropriately indicated for surgery and have their postoperative course tailored to their respective sports, as underscored by a recent series of ten javelin players with MCL injury who underwent reconstruction18. While baseball pitchers typically begin a throwing regimen approximately four months after surgery, javelin throwers may delay throwing for as long as eight months and return to sport for as long as sixteen months after surgery. This allows more time for MCL healing as well as lower-extremity, core, and scapular muscle strengthening and stabilization, which is necessary given the higher weight of a javelin as compared with that of a baseball and the complexity of the synchronous throwing motion when throwing a javelin as compared with the motion involved when pitching a baseball19. Following surgical reconstruction and an individualized rehabilitation course, nine of ten javelin throwers returned to a higher than pre-injury level of competition18. Quarterbacks are another group of athletes requiring sport-specific treatment considerations. However, unlike baseball pitchers, elite football quarterbacks with MCL injury can be managed nonoperatively with a high rate of success18.
Petty et al. reviewed the outcomes of twenty-seven high-school-level baseball players following MCL reconstruction4. Seventy-four percent were able to return to competition at or above their previous level, which is a lower percentage than that reported for higher-level baseball players4. Female athletes who participate in various overhead throwing sports, including softball, tennis, and volleyball, are susceptible to MCL injury20,21. Other non-throwing sports, such as gymnastics and cheerleading, are also associated with MCL injury13.
Reconstruction Rationale and Techniques
The evolution of MCL reconstruction techniques (Table I) began with the original description by Jobe et al.8,22. Subsequent reconstruction modifications have been developed that differ with regard to number, size, and orientation of bone tunnels, detachment or split of the flexor-pronator mass, ulnar nerve transposition, number of graft strands, and type of graft fixation.
In the Jobe technique, the flexor-pronator mass is fully detached and two tunnels are drilled into the ulna and three into the humerus, with the distal humeral tunnel drilled posteriorly into the medial epicondyle8,22. The graft is passed in a figure-of-eight pattern, and a submuscular ulnar nerve transposition is performed in all patients (Fig. 4). Conway et al. reported on Dr. Jobe’s initial series of sixty-eight patients and noted a successful return to preoperative level of competition in 68%. Among professional baseball players, 75% were able to return to competition. A relatively high rate of ulnar neuropathy was noted with their technique (fifteen of sixty-eight patients, or 22%)8.
Representing a progression in reconstruction strategy, Thompson et al. reported their results using a similar figure-of-eight technique23. However, in contrast to the original technique performed by Jobe8,22, the MCL was approached through a flexor-pronator muscle split along the posterior third of the fibers, as described by Smith et al.24. One significant advantage of this approach was that it mitigated the need for obligate ulnar nerve transposition and avoided the morbidity associated with complete muscle detachment from the epicondyle. With this approach, 94% of patients (thirty-one of thirty-three) without prior surgery were able to return to the prior level of competition. In addition, only 5% of the patients developed ulnar nerve neuritis, all of which resolved without additional surgery23.
Modified Jobe Technique
Dr. James Andrews developed a modified Jobe technique25, which is a figure-of-eight pattern without flexor-pronator detachment. This technique exposes the native MCL by mobilizing the ulnar nerve (which is subsequently transposed following the completion of the reconstruction) and elevates the humeral attachment of the flexor carpi ulnaris. Cain et al. documented the outcomes in 743 (79%) of 942 athletes with a minimum of two-years of follow-up26. Four hundred and thirty seven patients (46%) underwent concomitant procedures, most of which were posteromedial osteophyte excisions (77%). Eighty-three percent returned to their previous level of competition. Seventy-six percent of professional baseball players returned to their prior level of competition. Complications were noted in 20%, most of which involved ulnar nerve symptoms (83%). One patient had permanent ulnar nerve dysfunction even after neurolysis. Fifty-five patients underwent a combined total of sixty-two subsequent surgeries, most commonly arthroscopic olecranon osteophyte excision (n = 53), with nine patients undergoing revision MCL reconstruction26.
In 2002, Rohrbough et al. reported on the results of a novel technique for MCL reconstruction, termed the docking technique, with a focus on creating a less complicated method to pass and tension the graft27. The sublime tubercle is exposed through a muscle-splitting approach (although without obligatory ulnar nerve transposition), and two ulnar drill holes are created with a 2-cm bone bridge, similar to the Jobe technique. A unicortical inferior humeral tunnel (1.5 cm in length) is made. Two small suture exit tunnels are drilled and connected to the inferior humeral tunnel. The graft is passed through the ulnar tunnels, “docked” into the humeral tunnel, tensioned, and tied securely (Fig. 5). Outcomes in 100 athletes (ninety-six baseball players, two quarterbacks, and two tennis players) who had undergone MCL reconstruction with use of the docking technique were subsequently reported28. Ninety patients (90%) returned to or exceeded their previous level of competition. Seven patients returned to sport, but at a lower level than previously. Two patients developed ulnar neuropathy that required ulnar nerve transposition, and another patient required an arthroscopic lysis of adhesions eleven months after reconstruction28. Of note, all patients underwent elbow arthroscopy and the presence of MCL injury and/or incompetence was confirmed prior to reconstruction29. This investigative group has since abandoned the practice of performing routine arthroscopy unless there is preoperative evidence of loose bodies, chondral damage, or posterior osteophytes30. As a result of the reported success with this method, the docking technique has gained wide appeal as a safe and effective procedure with several modifications subsequently described by various authors.
Three-Strand Docking Technique
In their attempts to strengthen the repair construct, some authors have described a “three-strand” docking technique. Koh et al. described this modification in their report of nineteen athletes who underwent MCL reconstruction with use of a three-strand modification through a muscle-splitting approach31. Of these nineteen patients, eight patients had three-strand reconstructions with a double anterior band and a single posterior band. The supplementary anterior band is not passed through the ulnar tunnel; rather, it is sutured to the primary anterior band. At a mean follow-up of 41.9 months, eighteen of nineteen patients had returned to their previous level of competition or higher. Average time to return to competition was 13.1 months. The authors did not note any differences between the results obtained with use of the three-strand technique and those obtained with use of the two-strand technique31. In another report, Bowers et al. documented the results associated with the use of a similar three-strand technique in twenty-one baseball players30. Nineteen of the twenty-one players returned to their previous level of competition for at least one year (a score of “excellent” on the Conway scale). The three-strand technique may be particularly beneficial when the harvested graft is noted to be small in caliber.
Four-Strand Docking Technique
A four-strand modification of the docking technique was described by Paletta and Wright32. In their series of twenty-five athletes, a four-strand construct was created by doubling over the tendon graft, which consisted of palmaris tendon in twenty-two and gracilis tendon in three. The two opposing ends of the tendon were then sutured together and “docked” into the humeral tunnel anteriorly at the other end. With this technique, 92% of athletes returned to their previous level of competition. One patient developed transient ulnar neuritis. Another patient developed a stress fracture about the ulnar tunnel bridge fourteen months after surgery.
Hybrid Fixation (the DANE TJ Technique)
The David Altchek, Neal ElAttrache, Tommy John (DANE TJ) modification is a combination of the docking technique of David Altchek for humeral fixation and the screw ulnar fixation of Neal ElAttrache for Tommy John surgery. The impetus for this technique was the desire to combine the proven biomechanical strength of interference screw fixation with that of the docking technique28,33. Furthermore, the method avoids potential fracture through bone tunnels into the sublime tubercle and attempts to more closely match the native narrow MCL ulnar insertion34 through the use of a single tunnel at the exact insertion site (Fig. 6).The outcomes following MCL reconstruction with use of this technique were reported in their series of twenty-two athletes35. Four of these athletes had a history of prior elbow surgery (failed MCL reconstruction in three and prior elbow arthroscopy in one). At a mean follow-up of thirty-six months, 86% were able to return to their previous level of competition. One of the three patients with prior MCL reconstruction had a poor result, while the other two had excellent outcomes. There were four complications: two patients had transient ulnar neuritis, and two others had revision surgery for lysis of adhesions.
Screw fixation in both the humerus and ulna has also been described. Kodde et al. presented their data from a study of twenty European athletes who underwent MCL reconstruction by means of a strip of triceps fascia that was secured proximally and distally with interference screws. Despite good initial results, the investigators noted that only 70% of athletes were able to return to and stay in sports36. It is unclear if the method of fixation or graft choice is responsible for this inferior outcome.
Suspensory Button Fixation
In both primary and revision surgery in the setting of ulnar cortical bone loss, MCL reconstruction may be performed with the use of suspensory cortical button fixation. Lee et al. performed a cadaveric study simulating ulnar cortical bone loss in MCL-deficient elbows37. Humeral fixation was achieved via the docking technique, whereas ulnar fixation was achieved with a 30-mm cortical button secured against the far lateral cortex. Using this technique, they were able to restore the elbow kinematics to the intact state. While load to failure was lower in the reconstruction group than it was in the native MCL group, these findings compared favorably with biomechanical analysis of other reconstruction techniques.
Suture Anchor Fixation
The use of suture anchors for graft fixation was first documented by Hechtman et al.5. In their biomechanical study, they investigated the elbow kinematics and mean valgus load strength of native elbows and compared those results with the kinematics and mean valgus load strength of elbows that were reconstructed with bone tunnels and suture anchors, respectively. They noted that, although both reconstructions were weaker than the native elbow, bone tunnel reconstructions had a greater valgus load strength to failure than suture anchor reconstructions had. However, fixation with anchors more closely mimicked the kinematics of the native elbow. In a follow-up clinical study, Hechtman et al. reported the clinical results associated with use of a hybrid technique involving suture anchor humeral fixation and bone tunnel fixation in the ulna through a flexor-pronator split38. In this retrospective review of thirty-four athletes over a six-year period, twenty-nine patients (85%) had returned to their previous level of competition with a 2% complication rate.
There has been considerable interest in improving the methods by which to evaluate outcomes of MCL surgery, specifically in high-performance throwing athletes. Conway et al. regarded return to equal or higher level of competition as the primary outcome measure of interest for evaluating success following MCL surgery8. A modified version of the Conway scale was created for more descriptive results, as follows: Excellent = return to pre-injury level of competition or performance for at least one season after MCL reconstruction; Good = return to play at a lower level of competition or performance for more than one season or, specifically for baseball players, able to throw daily batting practice; Fair = able to play recreationally; and Poor = unable to return to previous sport at any level35.
Gibson et al. reported statistical performance measures such as innings pitched, earned run average (ERA), and walks plus hits per innings pitched (WHIP) as additional tools to evaluate pitcher performance following MCL surgery39. While such measures are applicable only to baseball pitchers, they represent relevant objective performance measures for this population in addition to patient-reported subjective outcomes.
Domb et al. developed the Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score as a validated outcome tool to specifically evaluate upper-extremity outcomes in high-demand throwing athletes40. The KJOC score was initially validated, with use of the Disabilities of the Arm, Shoulder and Hand (DASH) score as the reference standard, in a pilot study of fifty-five professional baseball players. The KJOC score improved the evaluation of high-performance throwing athletes by detecting subtle changes in subjective performance to which the DASH score was insensitive, particularly with respect to discriminating between players who have differing levels of pain.
Outcomes and Complications
In their systematic review published in 2008 to evaluate the results of 405 MCL reconstructions, Vitale and Ahmad found that 83% of reported patients had excellent results, with a complication rate of 10%. Six percent of the patients had complications involving the ulnar nerve. The review confirmed improved outcomes with the abandonment of flexor-pronator muscle detachment (70% had excellent results in the detachment group, whereas 87% had excellent results in the muscle-split group) as well as abandonment of obligatory nerve transposition41. Similarly, detachment of the flexor-pronator mass was associated with a higher rate of complications (23%) compared with the retraction (9%) or muscle-splitting (7%) approach. Of the studied sample, 1% of the patients had “graft site complications.” In another large series, Cain et al. noted that the most common reason for additional surgery was arthroscopic debridement of an olecranon osteophyte. In that series, thirty-eight (72%) of the fifty-three patients who required subsequent osteophyte excision were able to return to play26. In addition, 0.5% sustained avulsion fractures of the medial epicondyle at the humeral tunnel site. Most of those patients were treated with open reduction and internal fixation26.
Poor Prognostic Factors Affecting Reconstruction
While the reported outcomes of MCL reconstruction are encouraging, several factors have been identified that negatively influence outcome. Flexor-pronator tear in combination with MCL reconstruction significantly compromises success42. Osbahr et al. described a prevalence of 4% combined flexor-pronator and MCL tears in a series of 187 baseball players. There was a difference in age between the MCL tear group (20.1 years) and the combined flexor-pronator plus MCL tear group (33.4 years). Of the eight patients with combined flexor-pronator and MCL injuries, outcomes were excellent in one (12.5%), fair in two (25%), and poor in five (62.5%). Combined flexor-pronator and MCL injuries in baseball players indicate a worse prognosis, with a 12.5% return to prior level of play reported in the published literature42.
Younger high school athletes who undergo MCL reconstruction also have inferior results compared with the results seen in other patient groups4. Petty et al. reported on ulnar collateral ligament reconstruction in twenty-seven former high-school baseball players; overall, 74% returned to baseball at the same level or higher.
The presence of ulnohumeral chondromalacia noted at the time of MCL reconstruction has been associated with inferior outcomes as compared with historical results43. A recent retrospective review reported an 18% incidence (twenty-nine of 161 patients) of combined posteromedial chondromalacia and MCL injury. In this series, MCL reconstruction was accomplished with the docking technique, and posteromedial chondromalacia was addressed, on the basis of the Outerbridge classification, with observation or debridement (grade 2 or 3), and with debridement or microfracture (grade 4)44. Return to pre-injury level of competition was achieved in 76% of patients; 14% of the patients returned to lower levels of competition. The remaining patients did not return to high-level competition. The authors concluded that baseball players with concomitant posteromedial chondromalacia may have lower rates of return to the same or a higher level of play compared with historical controls.
The presence of either appreciable calcification in the ligament or bone deficiency is associated with inferior results45. Dugas et al. reported on 120 pitchers who underwent MCL reconstruction with use of gracilis autograft; forty-two (35%) had bone within, or replacing, the substance of the native MCL (osseous group), and seventy-eight (65%) had no osseous abnormalities (nonosseous group). In this series, the nonosseous group underwent MCL reconstruction with use of gracilis tendon graft due to the absence of a palmaris longus tendon. The percentage of patients who returned to the same or higher level of competition was higher in the nonosseous group (91%) than in the osseous group (81%), but this trend was not significant45.
Recurrent tears following successful return to sport after MCL reconstruction is unusual. Cain et al. presented their extensive experience, which included only a 1% to 2% incidence of re-tears26. In a report of fifteen high-level athletes undergoing revision surgery, the average time from initial reconstruction to revision surgery was thirty-six months. Pain was the usual complaint that required surgery. Seven of fifteen patients described an acute event that caused the recurrent tear. In this series of revision surgery, five of fifteen patients were able to return to their prior level of competition, but with an overall 40% complication rate. When indicated, revision surgery often requires versatility in reconstruction strategy. Often, a large graft, such as gracilis tendon with modified fixation strategy, is best to manage weakened or absent bone bridges, such as interference screw fixation or cortical suspensory button fixation. It is generally accepted that revision surgery has inferior outcomes as compared with the outcome after primary surgery.
In conclusion, the management of MCL injuries continues to evolve as the diagnosis and surgical treatment of these injuries becomes increasingly sophisticated. As a result of increased understanding and technical advancements, MCL injuries in the elite throwing athlete are no longer considered to be career-ending. We advocate surgical reconstruction as the procedure of choice in most high-demand athletes; however, there is a role for repair and nonsurgical management in carefully selected patients. Applying current reconstruction principles, one can expect over 80% of athletes to return to competition. The most common complication involves neuritis of the ulnar nerve, and this complication is usually transient with the use of current nerve-sparing techniques. The current literature suggests that the rate of ligament rerupture is low. In order to counsel patients appropriately, it is important for the treating surgeon to identify factors associated with inferior surgical outcomes. While many modifications of reconstruction techniques exist, further studies are needed to validate the clinical superiority of these techniques.
Source of Funding: There were no sources of funding associated with completion or publication of this research.
Investigation performed at the Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, New York, NY
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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