The medial collateral ligament (MCL) of the elbow, also known as the ulnar collateral ligament (UCL), is essential for stabilising the inside of the elbow. An elbow medial collateral ligament tear is a serious injury that affects throwing athletes. This injury can result in elbow pain and instability, requiring careful treatment to ensure a full return to sports performance.
What is the Medial Collateral Ligament?
This ligament consists of the anterior, posterior and transverse bands. The anterior band is the strongest and provides the primary restraint force during throwing.
Generally, during a throw, massive forces are placed on the elbow, stretching the inside and compressing the outside. These forces can lead to tearing of the medial collateral ligament and compression of the outside, leading to OCD (osteochondritis dissecans) of the elbow.
Causes of an Elbow Medial Collateral Ligament Tear
The primary cause of a medial collateral ligament tear is repeated stretching (valgus force) on the elbow, which occurs frequently in overhead sports. Baseball pitchers are particularly at risk due to the extreme stretching forces placed on the elbow during the cocking and early acceleration phases of throwing. Other athletes involved in javelin throwing, tennis, gymnastics, and wrestling are also at risk.
Acute MCL tears can occur due to trauma, such as a fall onto an outstretched arm or the arm suddenly getting pulled back. In some cases, ongoing damage from excessive throwing can weaken the ligament, leading to a complete rupture with a single high-force throwing movement.
Symptoms of an Elbow Medial Collateral Ligament Tear
Athletes with an MCL tear typically have pain along the inner side of the elbow, which worsens with throwing, gripping, or pushing movements. Sometimes, a popping or tearing sensation can occur, particularly in cases of acute rupture.
Other symptoms include a feeling of instability in the elbow, particularly when throwing. Frequently, athletes lose strength in the arm and hand. In some cases, swelling or bruising can occur on the inside of the elbow. As the ulnar nerve sits close to the medial collateral ligament, some athletes report ulnar nerve irritation, leading to pins and needles and numbness in the ring and little fingers. If loose bodies form in the joint, clicking or catching can occur.
Clinical Assessment of MCL tear Elbow
A sports medicine doctor will examine to assess ligament integrity and rule out other potential causes of medial elbow pain. The most common test for evaluating these injuries is the valgus stress test, in which the doctor applies pressure to the elbow. Increased joint movement or pain during this test indicates a ligament sprain or tear. Your doctor will also assess the range of movement of the elbow, with loss of joint extension being common in these injuries. Irritability and instability of the ulnar nerve will also be assessed.
Investigations and Imaging
Often, we use a combination of imaging to help confirm the diagnosis of an elbow medical collateral ligament tear and determine the severity of the injury.
- X-rays are used first to rule out fractures, loose bodies and bone abnormalities.
- MRI is the investigation of choice for diagnosing MCL tears. It provides information on ligament inflammation and tears and associated injuries such as cartilage damage.
- Ultrasound can also be used to assess ligament stability and detect thickening or tearing of the ligament.
Other Causes of Inner Elbow Pain in Athletes
Several conditions can mimic MCL tears of the elbow:
- Golfer’s Elbow: Chronic overuse can lead to flexor tendonitis, causing pain along the medial elbow.
- Ulnar Nerve Entrapment: Compression of the ulnar nerve at the elbow can lead to medial elbow pain, numbness, and tingling in the ring and little fingers.
- Elbow Arthritis: Degeneration of the elbow joint can cause pain and stiffness.
- Plica Syndrome Elbow: Irritation of the synovial fold in the elbow can cause pain, particularly in athletes performing repetitive arm motions. Although pain from plica usually occurs on the outside of the elbow, it sometimes causes pain on the inside.
- Snapping Triceps Syndrome: Sometimes, the medial part of the triceps tendon can snap over the inside of the elbow during throwing, causing pain and clicking.
- Elbow stress Fracture: Stress fractures of the elbow are an uncommon cause of elbow pain in athletes. They generally affect the olecranon or distal humerus.
Treatment Options of an Elbow Medial Collateral Ligament Tear
Treatment depends on the severity of the injury, ranging from conservative management for partial tears to surgical intervention for complete ruptures.
Non-Surgical Management of MCL Tear Elbow
Conservative treatment is preferred for MCL sprains or partial tears.
Rest and Activity Modification is essential to help heal the MCL. Athletes should avoid throwing or overhead activities to allow healing. Gradual return to sport should be based on pain and ligament stability. Physiotherapy focusing on the flexor-pronator muscles (which help stabilise the elbow) can aid recovery. Exercises include wrist flexion, pronation, and forearm isometric holds. Other muscles around and above the elbow should also be strengthened. Strengthening the pelvis and lower legs will place less load on the elbow. A hinged elbow brace can provide stability and protection during the healing process. Generally, we use a brace for partial tears with some laxity when testing. Taping techniques may also help reduce stress on the joint during a return to sport.
Non-steroidal anti-inflammatory Drugs (NSAIDs) such as ibuprofen can help reduce pain and inflammation and can be used for a few weeks, especially in the initial stages of rehab. Some studies suggest that PRP therapy may help promote ligament healing in partial tears, though the evidence remains mixed. We generally use PRP injections in elite athletes where an accelerated return to sport is essential.
Athletes undergoing conservative treatment typically require 6–12 weeks of rehabilitation before returning to sport.
Surgical Treatment of MCL Tear Elbow
Surgery is indicated for complete MCL tears, ongoing instability, or cases where conservative management fails. The most common surgical procedure is medial ligament reconstruction. During this surgery, a tendon graft is harvested from another part of the body to reconstruct the torn ligament.
Post-surgical rehabilitation is a long process, with a return to throwing activities usually taking 9–12 months. The success rate of reconstruction is generally good, with a return to sports rates of 65-90%. However, these operations must be followed by proper rehab and graded return to throwing. Also, strengthening the other parts of the body, such as the shoulder, core and lower legs, will protect the elbow and help prevent re-injury. Finally, an athlete’s throwing technique should be modified and improved to prolong their throwing career.
Final Word from Sportdoctorlondon regarding an Elbow Medial Collateral Ligament Tear
An elbow medial collateral ligament tear is a significant injury, particularly in overhead athletes. Early diagnosis and appropriate management are crucial to prevent chronic instability. Other possible causes of inner elbow pain need to be considered. Conservative treatment is effective for partial tears, while surgical reconstruction is required for complete ligament ruptures.
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