Treatment of Medial Collateral Ligament injury (Tommy John Procedure)

April 24th, 2007

The medial collateral ligament (MCL) of the elbow is critical for valgus stability of the elbow and is the primary elbow stabilizer. As such, the MCL plays an important role in most throwing sports, including baseball and javelin, as well as racquet sports and ice hockey. Elbow injuries in young athletes generally are chronic, with persistent pain and instability from repetitive overhead activities. In the athlete, ligamentous injury can also be heralded by an acute traumatic event such as an elbow dislocation. This can lead to chronic pain and valgus instability.

Medial elbow pain in athletes who throw is the most common symptom. Pain may be especially prominent during the acceleration phase of the overhead throw. Pain is often chronic or recurrent and may lead to a slow erosion of throwing ability. Athletes may report similar pain in previous seasons. Rest generally helps relieve pain. Occasionally, athletes may experience acute pain over the medial elbow, sometimes associated with a popping sensation, during a single throw that causes them to stop throwing immediately.

Medial elbow tenderness and swelling are the most notable findings. MCL tenderness may occasionally be difficult to differentiate from flexor pronator tendonitis, but the pain of flexor pronator tendinitis is aggravated by resisting forearm pronation. Loss of elbow range of motion (ROM) is occasionally observed. With acute rupture, ecchymosis may be observed over the medial elbow. Pain may be reproduced on making a clenched fist. Valgus stress with the elbow in 25° of flexion (elbow abduction stress test) reproduces pain and may cause joint opening. The affected side should be compared with the contralateral elbow as a reference for baseline laxity. Preseason documentation of baseline elbow laxity in elite athletes, especially pitchers, may be helpful for comparison if an injury occurs during the season because some throwing athletes have a baseline asymmetry.

Surgical Intervention
Direct repair of the ligament is not generally indicated. Reconstruction of the MCL is the more common approach to surgical treatment using a palmaris longus tendon autograft. Repair of the anterior bundle of the UCL is undertaken with a palmaris longus tendon graft or with allograft.

Physical Therapy
After surgery, the elbow is immobilized in a posterior splint for 10 days in 90° of flexion. Active ROM is initiated after removal of the posterior splint. A hinged brace that prevents valgus stress should be used. At approximately 1 month after surgery, isometric strengthening exercises should be initiated. Limited progressive strengthening can be initiated at 8 weeks and plyometrics at 12 weeks. Shoulder and elbow exercises should be instituted as soon as feasible, but valgus stress of the elbow should be avoided for at least 4-6 months until the graft has had sufficient time to incorporate. After 4-6 months, throwing may be resumed with a training program designed to return to competitive throwing by 9-12 months after surgery.

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