Less common soft tissue

Medial Collateral Ligament (MCL) Strain

An MCL strain at the elbow occurs when there is over stretching or tearing of the ligament.  This can occur during a specific incident involving a sideways or valgus force to the elbow, or more commonly, due to a repetitive strain associated with overuse injuries (e.g. repetitive throwing) (Beltran, 2013).  A MCL tear can be graded as follows (Desharnais et al, 1997):

• Grade 1 tear: a small number of fibres are torn resulting in some pain but allowing full function
• Grade 2 tear: a significant number of fibres are torn with moderate loss of function.
• Grade 3 tear: all fibres are ruptured resulting in elbow instability and major loss of function. Other structures may also be injured such as the cartilage and joint capsule of the elbow.

Symptoms include pain at the medial side of the elbow and tenderness to touch.  If the injury resulted from a direct trauma an audible snap may have been heard at this time (David, 2003).  If the injury resulted from overuse the symptoms are gradual onset (David, 2003).

In minor cases, patients can develop elbow stiffness and pain during activities which gradually worsens with time.  If a full rupture has occurred, pain is usually severe at the time of injury, which may subside (David, 2003).  There tends to be rapid swelling and bruising.  Patients often report the elbow as feeling unstable. 

Differential Diagnosis

Elbow fracture, osteochondral lesion, golfers elbow

Lateral Collateral Ligament (LCL) Strain

An LCL strain at the elbow occurs when there is over stretching or tearing of the ligament.  This tends to occur in association with fracture or dislocation of the elbow joint (Schaeffeler et al, 2013).  An LCL tear can be graded as follows (Desharnis 1997):

•  Grade 1 tear: a small number of fibres are torn resulting in some pain but allowing full function
• Grade 2 tear: a significant number of fibres are torn.
• Grade 3 tear: all fibres are ruptured resulting in elbow instability and major loss of function.

Symptoms include pain at the lateral side of the elbow and tenderness to touch.  There is normally a history of trauma (Schaeffeler et al, 2013). 

For minor tears function will remain at a high level, full tears will result in restricted ROM and instability (Baghdadi et al, 2014).  If a full rupture has occurred, pain is usually severe at the time.  There tends to be rapid swelling and bruising (Baghdadi et al, 2014).  Patients often report the elbow as feeling unstable.

Olecranon Bursitis

Bursitis presents as a swelling over the posterior elbow.  Bicipital bursitis presents with slight swelling and pain in the antecubital fossa.  This can occur following trauma or present for no specific reason (Buono et al, 2012).  It can be classified as acute, chronic, septic or non-septic (Buono et al, 2012).   The time it lasts is variable and it can resolve spontaneously (Buono et al, 2012).

Medial Collateral Ligament (MCL) Strain

Palpation

Tenderness over medial aspect of the joint

Valgus stress test (Video link)

Patient is in supine, shoulder in slight abduction and elbow in approximately 20° flexion.  The clinician supports the upper arm above the elbow joint line, as close to the joint line as possible without impeding movement.  Their other hand is positioned on the medial surface of the forearm as close to the joint line as possible.  The clinician then applies a gapping force to the medial joint line and applies a valgus force.  Laxity +/- pain is a positive result(Day et al, 2009).

Moving valgus stress test (Video link)

The patient is positioned in sitting with their shoulder in 90° flexion/abduction, their elbow in full flexion.  The clinician stands in front with one hand supporting the upper arm above the elbow joint and the other hand holding the wrist.  A medial rotation force is applied to the humerus whilst fixing the forearm at the wrist.  Whilst maintaining this valgus force the elbow is moved in to flexion and extension.  The test is positive if there is pain reported between 70 and 120° (Day et al, 2009).

Lateral Collateral Ligament (LCL) Strain

Palpation

Tenderness over lateral aspect of the joint

Varus stress test (Video link)

Patient is in supine, shoulder in slight abduction and elbow in approximately 20° flexion.    The clinician supports the upper arm above the elbow joint line, as close to the joint line as possible without impeding movement.  Their other hand is positioned on the lateral surface of the forearm as close to the joint line as possible.  The clinician then applies a varus force.  Laxity +/- pain is a positive result (Day, 2009).

Olecranon Bursitis

Olecranon
- Palpable, visible swelling at the posterior aspect of the elbow

Bicipital
- Palpable, visible swelling in the antecubial fossa
- Pain with elbow pronation

Medial Collateral Ligament (MCL) Strain

X-ray, ultrasound and MRI can be used to identify the extent of the injury and any other structure that are involved.  If a fracture is suspected early referral for imaging is required.

Lateral Collateral Ligament (LCL) Strain

X-ray, ultrasound and MRI can be used to identify the extent of the injury and any other structures that are involved and rule out fracture.  If a fracture is suspected early imaging is advised.

Olecranon Bursitis

X-ray can be used in traumatic cases to rule out any bony injury.  MRI may be required to investigate further pathology such as abscesses. 

Overview

• Optimise pain management
• Restore normal function of elbow and shoulder joint
• CSI (Bursitis if non-septic)
• Gradual return to activities (MCL / LCL)

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Medial Collateral Ligament (MCL) Strain

Rehabilitation - Conservative management – no specific evidence on guidance of exercises (therefore aim to restore ROM/strength etc)

• Avoid activities that put a large amount of stress on the MCL (Freehill & Saffron, 2011)
• Use of ice and NSAIDs
• Pain free ROM exercises
• Pain free strengthening exercises
• Ensure normal shoulder ROM and muscle patterning (Freehill & Saffron, 2011)
• Taping(Freehill & Saffron, 2011)
• Gradual return to sport (David, 2009)

Surgical Cases - as per surgeon/protocol

Lateral Collateral Ligament (LCL) Strain

Rehabilitation - Conservative management – no specific evidence on guidance of exercises (therefore aim to restore ROM/strength etc)

• Avoid activities that put a large amount of stress on the LCL (Schaeffeler et al, 2013)
• Use of ice and NSAIDs
• Pain free ROM exercises
• Pain free strengthening exercises (Schaeffeler et al, 2013) 
• Ensure normal shoulder ROM and muscle patterning
• Gradual return to sport

Surgical Cases – as per surgeon/protocol.

Bursitis

Rehabilitation - Conservative management – no specific evidence on guidance of exercises (therefore aim to restore ROM/strength etc)

• Use of ice and NSAIDs (Shell et al, 1995)
• ROM and strength maintenance
• CSI if non-septic (Buono et al, 2012)  

Surgical Cases – as per surgeon/protocol.

Non-evidence based strategies

Medial Collateral Ligament (MCL) Strain

Electrotherapy

Insufficient evidence to support use from recent literature search.

Acupuncture

Insufficient evidence to support use from recent literature search.

Deep transverse frictions

Insufficient evidence to support use from recent literature search.

CSI

Insufficient evidence to support use from recent literature search (Dugas et al, 2014).

Lateral Collateral Ligament Strain

Electrotherapy

Insufficient evidence to support use from recent literature search.

Acupuncture

Insufficient evidence to support use from recent literature search.

Deep transverse frictions

Insufficient evidence to support use from recent literature search.

CSI

Insufficient evidence to support use from recent literature search (Noerdlinger & Fadale, 2001).

Bursitis

Electrotherapy

Insufficient evidence to support use from recent literature search (Shell et al, 1995).

Manual therapy

Insufficient evidence to support use from recent literature search.

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

Medial Collateral Ligament Strain

If there is a full MCL tear/instability then referral to orthopaedics may be required to be considered for reconstruction surgery.

Lateral Collateral Ligament Strain

Referral onwards to orthopaedics may be required if there is a full rupture due to the associated instability.

Bursitis

Referral onwards to orthopaedics may be required if the bursa does not reduce and the patient would consider surgery.  The timeframe for the bursa to reduce varies with each individual and can vary from weeks to months.

If the bursa appears septic the patient should seek urgent medical attention.

NICE Guidelines

Baghdadi, Y., Morray, B., O’Driscoll, S., Steinmann, S. and Sanchez-Sotello, J. (2014). Allograft Ligament Reconstruction for Post-Traumatic Elbow Posterolateral Rotatory Instability: A Mid-Term Follow-Up Study. Journal of shoulder and elbow surgery. 23(9): 235-236.  Link Here (link correct as of 16/08/19).

Del Buono, A., Franceschi, F., Palumbo, A., Denaro, V. and Maffulli, N. 2012.Diagnosis and management of olecranon bursitis.  Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland, 10(5), pp. 297-300. Link Here  (link correct as of 16/08/19).

Desharnais, L., Kaplan, P.A., and Dussault, R.G. 1997. MR imaging of ligamentous abnormalities of the elbow.  Magnetic resonance imaging clinics of North America, 5(3), pp. 515-528.

David, T.S., 2003. Medial elbow pain in the throwing athlete.  Orthopedics, 26(1), pp. 94-103.

Day, R., Fox, J. and Paul-Taylor, G. (2009). Neuro-Musculoskeletal Clinical Tests: A Clinicians Guide. Churchill Livingston.

Del Buono, A., Franceschi, F., Palumbo, A., Denaro, V. and Maffulli, N. 2012.Diagnosis and management of olecranon bursitis.  Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland, 10(5), pp. 297-300. Link Here  (link correct as of 09/10/2015).

Dugas, J., Chronister, J., Cain, E.L. and Andrews J.R. 2014. Ulnar collateral ligament in the overhead athlete: a current review. Sports Medicine & Arthroscopy Review, 22(3), pp. 169-182.

Freehill, M.T. and Safran, M.R., 2011. Diagnosis and management of ulnar collateral ligament injuries in throwers.  Current Sports Medicine Reports, 10(5), pp. 271-278. Link Here (link correct as of 09/10/2015).

Noerdlinger, M. and Fadale, P. 2001. The Role of Injectable Corticosteroids in Ortrhopaedics. Orthopaedics. 24 (4): 400-405

Schaeffeler, C., Waldt, S. And Woertler, K. 2013. Traumatic instability of the elbow - anatomy, pathomechanisms and presentation on imaging. European radiology, 23(9), pp. 2582-2593.

Shell, D., Perkins, R. and Cosgarea, A. 1995. Septic olecranon bursitis: recognition and treatment. Journal of the American Board of Family Practice, 8(3), pp. 217-220.

NHS GGC Physiotherapy Service - Elbow

NHS Inform - Elbow Problems