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Ligament Injuries

MUCL injuries: diagnostic approach, non-operative vs UCLR/repair indications, and considerations for revision cases.

156 citationsUpdated Oct 2026

Overview¶

Ligamentous injuries span multiple joints, with cruciate ligament pathologies in the knee representing a common and rising clinical concern [2]. While isolated posterior cruciate ligament injuries are frequently managed nonsurgically [2], complete ligamentous injuries that fail to heal require operative repair, a procedure that is technically simpler in the acute setting [1]. Surgical indications for medial collateral ligament injuries are generally reserved for high-grade tears with concomitant anterior or posterior cruciate ligament damage, as most isolated cases are treated nonsurgically [17]. In the elbow, early operative repair with a standard protocol is recommended for dislocations involving radial head and coronoid fractures [56], while surgical repair is indicated for complete distal triceps tears in active persons and for incomplete tears with concomitant strength loss [61]. For the thumb, surgical intervention addresses ulnar collateral ligament ruptures, where functional results are excellent after repair [5], though early return to play without immobilization should not be encouraged until adequate healing is confirmed [11].

Current evidence for many ligament reconstruction techniques remains inconclusive. There is no scientifically proven superior method for anterior or posterior cruciate ligament reconstruction due to a lack of well-designed randomized clinical trials, leaving the field reliant on unproven assumptions [60]. Similarly, expert consensus for ulnar collateral ligament injury treatment should be viewed with caution due to methodological biases, necessitating future high-quality randomized studies [18]. Biomechanical data indicate that no native tissue repair or reconstruction provides equivalent strength to the preinjured ligament in thumb metacarpophalangeal joint ulnar collateral ligament injuries [6]. Despite this, repair of chronic thumb ulnar collateral ligament injuries with available local tissue is a reasonable alternative to reconstruction, yielding durable long-term outcomes even when patients progress to osteoarthritis [10].

Outcomes vary by specific injury and joint. ACL repair has demonstrated significant clinical improvement in appropriately selected cohorts [8], and surgical strategies including collateral ligament repair stabilize the joint with favorable outcomes for anteromedial coronoid facet fractures [4]. In trans-olecranon fracture posterior dislocations, correct understanding and reasonable treatment plans, including bony restoration and ligament repair, achieve good function [3]. For chronic longitudinal radioulnar dissociation, bone-ligament-bone reconstruction using a patellar tendon graft has achieved encouraging results [16]. However, traumatic instability is a probable contraindication to stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction [45]. Surgery is indicated only for Grade 3 distal interphalangeal joint collateral ligament injuries where there is no definitive end point when tested for collateral instability due to extensive soft tissue injury [25]. Good to excellent results are reported for surgical repair of distal triceps ruptures [61], and the technique of reconstruction using an interference screw is recommended in hand surgery [62].

Anatomy & Pathophysiology¶

General Ligament Biology¶

Differential healing capacities between the human anterior cruciate ligament (ACL) and medial collateral ligament (MCL) may stem from distinct properties of their respective stem cells [7]. Injured MCL fibroblasts exhibit higher tumor necrosis factor-alpha-induced expression of lysyl oxidases, whereas injured ACL fibroblasts show higher expression of matrix metalloproteinases [7].

Knee Ligaments¶

Cruciate ligament injuries are common with a rising incidence [2]. ACL injuries represent among the most frequent knee ligament injuries in sport and usually require reconstruction [22]. In English Premiership Rugby (2011–2018), ACL injuries have been in the top five most severe injuries for six of the last seven seasons [22]. During the 2016–2017 season, ACL injuries accounted for 224 days of absence per 1000 hours in English Premiership Rugby [22]. These injuries lead to muscle weakness, altered movement, joint effusion, and reduced functional performance [22]. Furthermore, ACL injuries are associated with chondral lesions, meniscal tears, and an increased risk of early-onset post-traumatic osteoarthritis [22].

In rugby union, video analysis indicates that 57% of ACL injuries occur through contact mechanisms [22]. Specifically, 43% occur when a player is tackled, 29% when tackling, and 14% in general collisions [22]. Conversely, 43% of ACL injuries occur through non-contact mechanisms, mainly sidestepping maneuvers [22]. An additional 14% occur through non-contact mechanisms such as twisting and turning [22].

Risk factors for ACL injury are categorized as follows: * Intrinsic risk factors: Age, anthropometry, sex, previous injury, anatomical variation, neuromuscular and cognitive factors, and genetics [22]. * Extrinsic risk factors: Environmental conditions, shoes/surfaces, training errors, and mechanical errors [22].

The mechanism responsible for combined femoral and tibial shaft fractures with knee ligament injury is not clear [23]. In combined tibiofemoral injuries, failure of the weakest component, i.e. the ligament, is plausible when trauma occurs at a site where both bone and ligament are present [23]. Ipsilateral femoral and tibial shaft fracture with knee ligament injury is part of a continuum of combined injuries resulting from complex high-energy forces [23]. The most common mechanism of damage to cruciate ligaments and capsule in traffic accidents is when knees are trapped beneath the dashboard and the trunk is carried up and over the top, hyperextending the knee [23]. Posterior displacement of the upper portion of the tibia on the femur may cause rupture of the posterior cruciate ligament [23].

Elbow Bony Anatomy¶

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations which afford bony stability [75]. The trochlea articulates with the ulna within the greater sigmoid notch to create the ulnohumeral, hinged or trochoid, portion of the elbow joint [75]. There is highly congruent anatomy through almost 180° of articular contact in the ulnohumeral joint, with the exception of the bare area of the greater sigmoid notch of the ulna which is devoid of cartilage [75]. The coronoid has a medial and lateral facet which buttresses the trochlea anteriorly [75]. The sublime tubercle provides the attachment site of the anterior bundle of the medial ulnar collateral ligament (MUCL) [75].

The medial epicondyle forms the attachment site for the origins of the flexor pronator mass and is larger and more posteriorly oriented than the lateral epicondyle [75]. The capitellum and radial head form the radiocapitellar joint [75]. The radius is held in close approximation to the ulna at the proximal radioulnar joint (PRUJ) by the annular ligament [75]. The radial head is a concave elliptical structure, covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [75]. The less prominent lateral epicondyle is the origin of the lateral extensor musculature [75]. The origin of the lateral ulnar collateral ligamentous (LUCL) complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [75].

The distal humeral articulation is angled 30° from the longitudinal axis [75]. The axis of rotation is 5° to 7° angulated in the coronal plane to the epicondylar axis with the medial side more distal than the lateral side [75]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [75]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [75]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [82].

The distal humerus consists of medial and lateral columns [82]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [82]. The distal humeral shaft is triangular shaped in cross section with its apex directed anteriorly [87]. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane and terminates as the medial epicondyle [87]. The lateral column diverges at approximately 20 degrees from the shaft in the coronal plane [87]. As the lateral column extends distally, it curves anteriorly creating a 35 to 40 degrees angle with the shaft in the sagittal plane [87]. In the coronal plane, the trochlea is more distal than the capitellum resulting in a valgus alignment of 4 to 8 degrees [87]. The elbow has a valgus angle in extension of 10 to 17 degrees, termed the carrying angle [87]. Axially, the distal humerus articular surface is internally rotated 3 to 8 degrees [87].

The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [87]. The olecranon fossa is matched to the olecranon and accepts it during extension [87]. The coronoid fossa is matched to the coronoid and accepts it during flexion [87]. The trochlea has a 300-degree arc of cartilage [84]. The medial column diverges from the humeral shaft at a 45-degree angle [84]. The lateral column diverges from the humeral shaft at a 20-degree angle [84]. The articular surface of the distal humerus is in 5° to 6° of valgus with respect to the humeral shaft [85]. The articular surface of the distal humerus is in 30° of flexion [85].

The medial epicondyle is the origin of the flexor-pronator muscle group and the medial collateral ligament [85]. The lateral epicondyle is the origin of the extensor-supinator muscle group and the lateral collateral ligament complex [85]. The ulnar nerve lies in a bony groove covered and restrained by the arcuate ligament posterior to the medial epicondyle [85].

Elbow Ligaments¶

Elbow stability is determined by primary and secondary stabilizers [28]. The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [28]. Secondary stabilizers of the elbow are the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [28].

The medial or ulnar collateral ligament is the primary valgus stabilizer [77]. The anterior bundle of the medial collateral ligament is most important for stability [77]. The posterior bundle of the medial collateral ligament has the greatest change and length, becoming taut at flexion beyond 120 degrees [77]. The lateral ulnar collateral ligament is the posterolateral stabilizer [77]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [77]. The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [77].

The medial (ulnar) collateral ligament (MCL) consists of anterior, posterior, and transverse bundles [82]. The anterior bundle of the MCL is the primary restraint to valgus stress within functional elbow ROM [82]. The secondary restraint to valgus stress within functional elbow ROM is the radial head [82]. The MCL originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [82]. The posterior bundle of the MCL is the primary restraint to valgus stress with the elbow in maximal flexion [82]. Stability in full extension is provided by the MCL, joint capsule, and ulnohumeral articulation [82].

The MUCL of the elbow is comprised of the anterior bundle, posterior bundle, and transverse ligament [74]. The anterior bundle is the strongest component of the MUCL complex and the primary restraint to valgus stress [74]. The anterior bundle of the MUCL is further subdivided into anterior and posterior bands which provide reciprocal function [74]. The anterior band of the MUCL is tight in extension, and the posterior band is tight in flexion [74]. The LUCL origin center was 10.7 mm from the lateral epicondyle [74]. The LUCL insertion was 3.3 mm from the apex of the supinator crest [74].

The LCL complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [87]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [87]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [87]. The LUCL arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [87]. The LCL complex functions as an important restraint to varus and posterolateral rotatory instability [87].

The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [77]. The capsule allows maximum distension at approximately 70 to 80 degrees of flexion [77]. Tensile forces are present at the medial elbow, and compressive forces are present at the lateral elbow [77].

Elbow Muscles¶

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [77]. The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head proximal and short head distal [77]. The biceps brachii is a powerful supinator of the forearm [77]. The primary elbow extensor, the triceps, inserts on the olecranon process [77]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB) [77]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis (FCR), palmaris longus, flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) [77].

The triceps has a broad tendinous insertion into the olecranon posteriorly [84]. The brachialis inserts on the coronoid process and the tuberosity of the ulna anteriorly [84]. The medial collateral ligament and flexor-pronator group of muscles attach to the medial epicondyle [84]. The supinator-extensor muscle group attaches to the lateral epicondyle [84]. The ulnar nerve enters the anterior forearm by traveling between the two heads of the flexor carpi ulnaris [84].

Elbow Kinematics and Biomechanics¶

The normal elbow has a range of motion from 0° to 140° from extension to flexion [28]. The normal elbow has 75° and 85° in pronation and supination respectively [28]. A functional arc in each plane is 100° for flexion and extension and forearm rotation [28]. Normal range of elbow flexion/extension is 0 to 150 degrees [82]. Normal forearm pronosupination (rotation) is 80 to 85 degrees in each direction [82]. Functional ROM is 30 to 130 degrees flexion/extension and 50 degrees pronosupination [82]. Normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [82]. Most activities of daily living require elbow ROM arcs comprising 100° of flexion/extension and 100° of pronation/supination [141].

The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius [76]. The torque for forced external rotation is minimal at 10° of elbow flexion [95]. The least work for forced external rotation occurs at 30° of flexion [95]. Elbow ligaments may provide significant sensory function to the elbow joint, in addition to being its major mechanical restraints [106].

In collegiate baseball pitchers, forearm position was not associated with the elbow varus moment [105]. The supination moment was associated with the elbow varus moment in collegiate baseball pitchers [105]. Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion [107]. No kinematic or kinetic differences were noted between throwing balls and strikes in professional baseball pitchers [108]. Increased medial elbow torque was associated with greater ball velocity regardless of the history of medial elbow injuries in youth baseball pitchers [111]. Elbow valgus torque is poorly suited as a standalone metric for predicting injury risk due to narrow data ranges, modeling noise, and crude assumptions [113]. Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching [135]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity in high school baseball players [146].

Both elbow varus torque and swing velocity were greatest when swinging to the outside location in baseball hitting [131]. When controlling for an individual pitcher, peak kinetics at the shoulder and elbow can be strongly predicted by ball velocity [128]. Medial elbow joint space increases under a valgus load and then decreases when a maximal grip contraction is performed [104]. Gripping does not change ulnohumeral joint space width or medial elbow tissue stiffness in the joint testing configuration and external loading conditions applied in the study [102].

Elbow Pathomechanics and Injury Patterns¶

Elbow dislocations can result in extensive injury to the supporting structures of the elbow joint [129]. Concepts of elbow instability have evolved with knowledge of the anatomy and pathomechanics, emerging as central bony insufficiency, lateral ligamentous insufficiency, and medial ligamentous insufficiency [219]. The study successfully created and validated an anatomic model of terrible triad of the elbow by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min [120]. PLRI of the elbow remains to be fully understood [130]. Complex elbow instability remains a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction [133].

The Internal Joint Stabilizer effectively reduces varus angulation and lateral ulnar collateral ligament strain following ligament disruption, restoring near-intact elbow stability during flexion-extension [220]. Peak stabilization by the Internal Joint Stabilizer occurs in mid-flexion (45°-90°), where varus laxity is most pronounced [220].

Classification¶

Elbow Ulnar Collateral Ligament (UCL)¶

Ford et al.: This MRI grading scale classifies UCL injuries into four levels of severity: grade I (intact ligament with or without edema), grade IIA (partial tear with incomplete fiber disruption), grade IIB (chronic healed injury with thickened ligament but no fiber disruption), and grade III (complete tear with fiber disruption) [42].

Joyner et al.: This 4-level system combines valgus laxity on radiography with MRI findings: type I (edema in the UCL only/low-grade partial tear), type II (partial tear with no extravasation of fluid on MRA/high-grade partial tear), type III (complete full-thickness tear with extravasation of fluid on MRA), and type IV (tear in more than 1 location on the UCL) [42].

MRI-Based 6-Stage Classification: A 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management [26]. A newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers [64]. A new classification for UCL injuries based on MRI findings helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes [186].

Adolescent Baseball MRI Classification: Preoperative MRI classification of UCL injuries in adolescent baseball players includes four grades: grade 0 (intact ligament continuity), grade 1 (low-grade partial tear of 50% or less of ligament substance), grade 2 (high-grade partial tear of more than 50% of ligament substance), and grade 3 (complete tear) [198]. The site of UCL injury is further classified into origin, midsubstance, or insertion site injury [198]. Criteria for a partial UCL tear on MRI include a thickened ligament with abnormal signal intensity, diffuse or focal thinning, partial detachment from the origin or insertion site, partial-thickness defect of the articular surface determined by extension of fluid, and undersurface partial detachment characterized by distal extension of fluid along the medial margin of the coronoid producing a “T sign” [198]. Differentiation between grade 1 and grade 2 UCL injuries is indicated by marked thinning, lax and redundant contour without apparent discontinuity, decreased slope, or extension of fluid to the articular surface with more than 50% of ligament substance thickness [198].

Thumb Metacarpophalangeal Joint (MCP) Collateral Ligaments¶

Ultrasound Grading: Ultrasound assessment of thumb MCP collateral ligament injuries identifies UCL injuries as grade I, grade II, grade III, or grade IV (Stener lesion) [200]. Ultrasound assessment of thumb MCP collateral ligament injuries identifies RCL injuries as grade I, grade II, or grade III [200]. Dorsal extensor-related findings in thumb MCP injuries are recorded descriptively rather than according to a validated grading system [200].

Distal Interphalangeal Joint (DIP) Collateral Ligaments¶

Surgical Indication: Surgery for distal interphalangeal joint collateral ligament injuries is indicated only for Grade 3 injuries where there is no definitive end point when tested for collateral instability due to extensive injury of the surrounding soft tissues [25].

Knee Ligaments¶

Molecular Expression Profiles: A controlled laboratory study found that tumor necrosis factor–α–induced expression of lysyl oxidases and matrix metalloproteinases was higher in injured MCL fibroblasts and ACL fibroblasts, respectively [7]. Differential expressions of lysyl oxidase family in ACL and MCL fibroblasts occur after mechanical injury [7]. TGF-beta1 induces different expressions of lysyl oxidases and matrix metalloproteinases in anterior cruciate ligament and medial collateral ligament fibroblasts after mechanical injury [7]. Interleukin-1 beta influences the lysyl oxidases and matrix metalloproteinases profile of injured anterior cruciate ligament and medial collateral ligament fibroblasts [7].

Elbow Fracture-Dislocations and Instability¶

Complex Fracture-Dislocation Classification: A comprehensive classification of complex fracture-dislocations of the elbow was created that appeared to be reproducible and may represent a useful tool for the management of such difficult injuries [172].

Arthroscopic PLRI Classification: An intraoperative arthroscopic classification tool for posterolateral elbow instability (PLRI) can be used as a standardized grading system for further research and communication between orthopedic surgeons [174].

Regan and Morrey Coronoid Fracture Classification: The coronoid fracture classification of Regan and Morrey defines stage I as a fracture involving the tip of the coronoid process [209]. The coronoid fracture classification of Regan and Morrey defines stage II as a fracture in which the height of the coronoid is reduced by 50% [209].

Other Ligament and Tendon Classifications¶

Pectoralis Major Tear Classification: A contemporary injury classification system for pectoralis major tears includes injury timing, injury location, and standardized terminology addressing tear extent to more accurately reflect musculotendinous morphology [33].

Distal Biceps Tendon Tear Classification: Classification of partial distal biceps tendon tears may have implications for operative and non-operative management [48].

Palmer and Werner TFCC Classification: According to the classification of Palmer and Werner, disorders of the triangular fibrocartilage complex (TFCC) are divided into 2 basic categories: traumatic (class 1) and degenerative (class 2) [183]. Class 1 traumatic TFCC lesions are subdivided into 4 types, with Type 1-B injuries defined as peripheral tears located on the ulnar side of the TFCC [183].

Clinical Presentation¶

General Assessment and Diagnosis¶

Acute ulnar collateral ligament (UCL) injuries require assessment via history, clinical examination, and radiographs [9]. In the Emergency Department, clinicians are not proficient in performing the assessment methods used for diagnosing acute ACL injury [30]. For triquetrolunate ligament injuries, a diagnostic technique based on specific questions and three clinical tests is useful for diagnosis before arthroscopy [32]. No individual physical examination test is sensitive enough to use solely or to accurately diagnose a partial distal biceps rupture [132]. The quality of UCL-related information on YouTube is low, with differential diagnoses, accurate surgical indications, and thorough discussions of adverse outcomes being the most lacking information [39].

Imaging Modalities¶

Ultrasound serves as a valuable adjunct to clinical examination in a specialist clinic for differentiating displaced from undisplaced thumb UCL tears, provided it is performed soon after presentation [37]. Valgus stress ultrasound can diagnose complete ulnar collateral ligament ruptures but may not be sufficient alone for partial injuries [38]. In a study of 49 patients, ultrasound demonstrated a sensitivity of 65% and specificity of 61% for diagnosing displaced thumb UCL ruptures [126]. In the same study, ultrasound identified Stener lesions in 11 patients but correctly identified only 4, resulting in a sensitivity of 36% for Stener lesions [126]. MRI and ultrasound of suspected thumb UCL injury did not demonstrate good enough sensitivity to recommend their implementation and use in clinical situations to obviate the need for surgical exploration [126].

For elbow ligaments, MRI has typically been the standard in identifying UCL injuries, particularly full-thickness tears [42]. Magnetic resonance arthrography (MRA) may provide additional imaging details for evaluating the severity of elbow UCL injuries, particularly partial tears [42]. Proper coil selection, pulse sequence parameters, and patient positioning enhance the ability of MR imaging to demonstrate subtle injuries to elbow ligaments and regional osseous and soft tissue structures [50]. On radiographs, a displaced fleck sign is consistent with grade III thumb UCL tears with Stener lesions [116]. This sign is described as a small avulsion fracture of the UCL insertion from the proximal phalanx base that has displaced proximally and ulnarly [116]. Corresponding T2 sequence coronal MRI can confirm the displacement of the torn UCL with interposition of the adductor aponeurosis consistent with a Stener lesion [116].

Specific Injury Patterns and Mechanisms¶

ACL injuries are among the most frequent knee ligament injuries in sport and usually require reconstruction [22]. In rugby union, 57% of ACL injuries occurred through contact mechanisms, with offensive running and being tackled identified as two main scenarios [22]. The remaining 43% of ACL injuries in rugby union occurred through non-contact mechanisms, mainly sidestepping maneuvers [22]. ACL injuries are associated with continuing clinical sequelae such as chondral lesions, meniscal tears, and increased risk of early-onset post-traumatic osteoarthritis [22].

The mechanism responsible for a combined fracture of the femoral and tibial shaft and knee ligament injury is not clear [23]. It is plausible that in trauma at a site where both bone and ligament are present, failure of the weakest component, i.e., the ligament, occurs before failure of the bone [23]. The most common mechanism of damage to cruciate ligaments and capsule in traffic accidents is when the knees are trapped beneath the dashboard and the trunk is carried up and over the top, hyperextending the knee [23]. If hyperextension is coupled with rotation or varus or valgus stress, damage of the collateral ligaments can also result [23].

Posterolateral rotatory instability (PLER) is the main mechanism of injury in terrible triad injuries and should be managed individually based on injury mechanisms presenting different instability patterns [35]. An adolescent elbow injury involving posteromedial luxation, lateral condyle fracture, and coronoid process fracture is unstable and resembles the 'terrible triad' described in adults [14]. This adolescent lesion requires simultaneous management of bone and ligament instability while considering the risk of injury to growth plates [14]. Physicians must maintain heightened vigilance for associated physeal injuries in pediatric transolecranon fracture dislocations that may not be obvious on initial radiographs [52].

Distal biceps short head tears present acutely and have a poor natural history akin to complete tears [12]. Injuries to the thumb UCL occur most commonly during sports with a radially-directed force at the joint, leading to ligamentous injury, possible instability, and pain [116]. Tears of the thumb UCL are stratified into grade I (minor tearing without instability), grade II (partial tear with increased joint laxity but a definitive end point), and grade III (complete tear and gross instability) [116]. Grade I and II thumb UCL injuries are best treated nonoperatively with immobilization [116]. Grade III thumb UCL injuries, particularly those with a Stener lesion, are treated with surgical repair or reconstruction depending on chronicity [116]. There remains controversy regarding how best to identify patients who have a Stener lesion [116].

Finger MCP joint collateral ligament injuries occur less frequently than their counterparts in the thumb [122]. Normal parameters for collateral ligament laxity of the fingers have not been firmly established [122]. It is not known whether the contralateral, uninjured digit can be used as a comparison in the assessment of finger MCP joint collateral ligament injuries [122]. The cam shape of the metacarpal head results in a tightening of the collateral ligaments with joint flexion [122]. This tightening results in greater stability of the MCP joint with greater degrees of flexion [122]. Diagnosing the cause of UCL locking in the middle finger may be complicated by the lack of evidence in imaging studies [40]. Open surgical treatment has traditionally been the most often used for UCL locking with a high success rate [40]. Injuries are common in young pole vaulters [137].

Investigations¶

Clinical Examination and History: The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [28]. In adolescent baseball pitchers, there was no relationship between UCL tear type and age, competition level, and plain radiographic abnormalities [206]. Future research may elucidate the diagnostic value of a pop sign for UCL injury [47].

Plain Radiography: Plain radiographs remain the hallmark and the best screening test for elbow evaluation [28]. Standard views include AP, lateral, and oblique radiographs, with serial radiography used as follow-up when heterotopic ossification is present [92]. The primary bony landmarks identified on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [92]. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [94]. A complete radiological assessment allows for a precise diagnosis that guides the choice of different osteosynthesis techniques in combined radius and scaphoid fractures with elbow dislocation [212]. In pediatric transolecranon fracture dislocations, physicians must maintain heightened vigilance for associated physeal injuries that may not be obvious on initial radiographs [52]. The coronoid opening angle is a novel radiographic technique that can be of value alongside 3-dimensional imaging in evaluating elbow injuries and used as an adjunct in clinical decision making [202]. A traffic light model based on initial radiographic displacement can predict the need for collateral ligament repair in transolecranon fractures: >10 mm requires repair, <5 mm does not, and 5-10 mm requires careful screening for instability [207].

Computed Tomography (CT): CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [92]. Three-dimensional CT is used to check for heterotopic ossification in the elbow [92]. CT is not necessary when elbow stiffness is entirely soft-tissue related, but is beneficial if any joint incongruity or abnormal bony anatomy is present [92]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [94]. The nature of the injury can be most reliably documented using computed tomography with three-dimensional reconstructions for fractures of the anteromedial facet of the coronoid process [69]. CT may be useful for surgical planning in elbow osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [99]. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved in Monteggia-like lesions [43].

Magnetic Resonance Imaging (MRI): MRI can be used to evaluate ligaments and tendons in the elbow, but it is rarely indicated for stiffness [92]. Proper coil selection, pulse sequence parameters, and patient positioning enhance the ability of MR imaging to demonstrate subtle injuries to the ligaments and the regional osseous and soft tissue structures [50]. MR evaluation of instability patterns including the soft-tissue lesions that result from dislocation are emphasized in simple elbow dislocations [29]. UCL injury patterns are illustrated with MRI in a classification system with Level of evidence II [29]. MR findings of structural changes in the elbow are described in overhead throwers in the context of clinical presentation with Level of evidence III [29]. Imaging appearance in the elbow is reviewed giving insight into radiographic and MR appearance with Level of evidence I [29]. A retrospective analysis described common findings on 3-Tesla elbow MRI in asymptomatic professional baseball pitchers, including collateral ligament thickening and ulnar nerve abnormalities, with Level of evidence I [29]. A reliable 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management [26]. The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers [64]. MRI grading of UCL injuries can help predict return to play and the need for surgery in professional baseball players [70]. In professional pitchers, distal UCL tears described on MRI show significantly higher rates of failure with nonoperative management compared to proximal tears [192]. Fat-suppressed T1-weighted magnetic resonance arthrography with gadolinium can provide information regarding inner surface partial tears and small full-thickness perforations of the medial collateral ligament [214]. The FEVER MRI may be both sensitive and specific for detecting UCL injuries and guiding surgical decision making while obviating the need for joint contrast fluid [201]. MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [94]. Preoperative MRI could be used to exclude subtle instability in lateral epicondylitis, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain [196]. Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low [195]. Ultrasound and MRI are helpful in evaluating acute traumatic brachialis rupture and monitoring its resolution [127]. Preoperative MRI and intraoperative assessments agreed in 80% of cases for myotendinous junction tears, a value that was significantly higher for complete over partial tears [178]. The clinical use of MRI in the management of patients with enthesopathy of the extensor carpi radialis longus origin merits further study [184]. This study shows difficulties in the evaluation of ligaments by conventional MRI technique as demonstrated by a weak inter- and intraobserver agreement after simple elbow dislocation [54].

Ultrasound: Ultrasound is a valuable adjunct to clinical examination in a specialist clinic, particularly for differentiating displaced from undisplaced tears of the thumb UCL, provided it is performed soon after presentation [37]. Valgus stress ultrasound can be used as a diagnostic tool for complete ruptures of the medial UCL but may not be sufficient alone for partial injuries [38]. Thickened UCL may exhibit a decrease in function; therefore, physicians should not evaluate the joint status solely on the basis of the structural properties on conventional ultrasound [211]. Ultrasonographic imaging of the elbow is reviewed to include imaging techniques and normal appearance of anatomic structures [29].

Treatment¶

Non-Operative Management¶

First-line management for incomplete ulnar collateral ligament (UCL) tears consists of non-operative management with early physical therapy, with or without biologic augmentation [59]. Conservative measures may be considered in younger patients with full-thickness UCL tears to avoid operative intervention during years of skeletal immaturity [59]. Additionally, conservative management is appropriate for high school or college athletes who may plan to refrain from further competitive play in the future [59]. Non-operative treatment allows 42% of athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis [67]. This approach offers favorable outcomes for younger patients with acute or partial UCL injuries [110]. Incomplete UCL injuries are more likely to lead to non-operative treatment and a higher return to the same or higher level of play than complete tears [175]. Non-operative treatment of UCL injuries is likely to be more successful in younger players, lower-grade tears, and humeral-sided injuries [157]. In professional baseball players, non-operative management is more likely to succeed in those with incomplete tears [175]. However, in professional pitchers, distal UCL tears showed significantly higher odds of failure with non-operative management compared with proximal tears [166]. UCL injuries in high school baseball players can be successfully treated non-operatively in most cases [153]. Wrestlers showed high return-to-sport rates following nonsurgical UCL treatment, although primary non-operative management failed in 44% of patients, particularly those with complete tears [173].

Non-operative management of isolated lateral collateral ligament (LCL) injuries is associated with a 100% return to pre-injury level of sport, reasonable recovery times, and no significant residual varus instability [138]. Specifically, non-operative management of isolated clinically diagnosed Grade I-II LCL injuries in elite athletes does not require surgery [138]. Anterior-medial bundle ruptures of the anterior cruciate ligament (ACL) may do well with non-operative treatment [163]. Nonsurgical therapy is the mainstay of treatment for medial epicondylitis [187]. The conservative intervention demonstrated effectiveness in eliminating recurrent annular ligament displacement events in a pediatric patient [151]. Non-operative management of posterolateral rotatory instability (PLRI) is ineffective, and surgical treatment is generally required to stabilize the joint [185].

Operative Management¶

Indications: Complete ligamentous UCL injuries require operative repair, which is simpler to perform in the acute setting [1]. The current gold standard for management of full-thickness, attritional, midsubstance UCL tears in high-demand athletes or elite throwers remains operative reconstruction [59]. Professional athletes and those with complete UCL tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or non-professionals [160]. Treatment of UCL injuries depends on the type of tear, with non-operative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears [150]. While nonsurgical management can result in successful return to sport in carefully selected patients, UCL reconstruction remains the benchmark for tears not amenable to nonsurgical treatment [154]. Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition [170]. Surgical repair is indicated in active persons with complete distal triceps tears and for incomplete tears with concomitant loss of strength, with good to excellent results reported [61]. Posterior-lateral bundle ruptures of the ACL often need surgery due to pivot shift development [163]. Surgery is indicated for Grade 3 distal interphalangeal joint collateral ligament injuries where there is no definitive end point when tested for collateral instability due to extensive injury of the surrounding soft tissues [25]. Surgical procedures for medial epicondylitis are typically reserved for patients with recalcitrant or recurrent symptoms despite nonsurgical management [187].

Surgical Approach / Technique: UCL repair is an effective procedure in helping female athletes return to sport with low complication rates [57]. Repair was most appropriate for partial and full-thickness distal UCL tears but relatively contraindicated for complete midsubstance UCL tears [162]. Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis [10]. Ulnar collateral ligament reconstruction is currently the most commonly performed surgical treatment option for UCL insufficiency, with a commonly quoted success rate of 85% defined as the ability to return to a preinjury level of play for least one year [152]. Primary repair of the chronically ruptured LCL complex depends on the integrity and quality of the remaining tissue [185]. Treatment of late lateral elbow instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes [155]. Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with lateral epicondylitis and lateral collateral ligament insufficiency [144]. Functional results were excellent after surgical repair of a ruptured ulnar collateral ligament of the metacarpophalangeal joint of the index finger [5]. Completely ruptured collateral ligaments of the proximal interphalangeal joint frequently result in prolonged disability when treated non-operatively, whereas surgical repair yielded satisfactory results with restored joint stability and pain relief [65]. Correct understanding and reasonable treatment plans, including bony restoration and ligament repair, can achieve good function for trans-olecranon fracture posterior dislocations [3].

Implant Selection: An interference screw technique is recommended for the reconstruction of injured ligaments in hand surgery [62]. The Ligamentotaxor is a safe and effective device for managing intra-articular proximal interphalangeal joint injuries, offering practical advantages and comparable efficacy to other devices [123].

Other Considerations: At 2 years after ACL reconstruction with tibialis anterior allografts, patients displayed satisfactory functional outcomes [53]. A traumatic instability had worse results and probably is a contraindication to stabilization of the pre-arthritic trapeziometacarpal joint using ligament reconstruction [45]. Injured UCL ligaments were naturally stable after reduction and did not need surgical repair in cases of thumb metacarpophalangeal joint injury [27].

Indications and Decision Making¶

Treatment should be unique to the patient and sport specific in nature, with non-operative management requiring a multimodal approach for well-selected patients [161]. While UCL reconstruction remains a mainstay for high-demand athletes with full-thickness tears, non-reconstructive options such as rehabilitation, biologic strategies, and repair may be beneficial for specific clinical scenarios including lower-demand athletes, adolescents, and aging athletes [176]. MRI grading of UCL injuries can help predict return to play and the need for surgery [70]. There was unanimous agreement regarding the lack of evidence for orthobiologics and specific areas for non-operative management, as well as indications for operative management and return to sport criteria [147]. Isolated UCL injuries are relatively uncommon in non-quarterback NFL players, with the vast majority being grade I sprains treated non-operatively [66].

Biologic Agents and Adjuncts¶

Conflicting data on the cellular and molecular effects of platelet-rich plasma (PRP) for ligament injuries were observed secondary to the finding that included studies were heterogeneous, limiting interpretation across studies and the ability to draw meaningful conclusions [49]. Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries, but more clinical evidence is necessary to define the indications and parameters for their use [156]. There is emerging, but limited evidence, for suture augmentation for injuries to the posterior cruciate ligament [46]. Suture augmentation in orthopaedic surgery offers improved time-zero biomechanics and promising short-term clinical outcomes [46]. Injury prevention programs and improved non-operative treatment protocols hold promise in decreasing the need for surgical repair [63].

Rehabilitation and Postoperative Care¶

Early return to play without immobilization should not be encouraged until the ligament is adequately healed after surgery [11]. Full extension does not strain the reconstructed medial ulnar collateral ligament beyond known detrimental thresholds, whereas flexion beyond 50 degrees may place deleterious strain on the reconstruction [189]. Isometric flexion and extension exercises did not increase medial ulnar collateral ligament strain but became a concern at 90 degrees of flexion [189]. Most specific interventions for postoperative management of medial ulnar collateral ligament reconstruction have not been thoroughly examined, and randomized trials are lacking [189]. Differences exist in protocol composition and in the timing of the introduction of specific interventions between protocols used in orthopedic residency programs and published protocols in the peer-reviewed literature [189]. Most agreement regarding postoperative rehabilitation occurred regarding early protection and symptomatic interventions, whereas variations were more apparent for therapeutic exercise interventions proximal and distal to the elbow [189].

Evidence Quality and Limitations¶

The current evidence for ulnar collateral ligament injury treatment is not convincing, and while expert consensus provides guidance, it should be viewed with caution due to methodological biases; future high-quality randomized studies are required [18]. There is no scientifically proven superior method for ACL or PCL reconstruction due to a lack of well-designed randomized clinical trials, and the field continues to rely on unproven assumptions and varying opinions [60]. Long-term clinical outcome studies involving a larger number of patients will be required to corroborate the approach to augmentation for partial ACL ruptures [20]. Clinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury [30]. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament [6]. Research on pediatric and adolescent patients with UCL injuries is limited, highlighting their unique needs in clinical management [167].

Complications¶

Osteoarthritis: Repair of a chronic thumb ulnar collateral ligament injury results in the majority of patients progressing to osteoarthritis [10].

Instability: Injuries to the posterior cruciate ligament have a complex anatomy and functional mechanical behavior that may alter traditional treatment approaches [15]. There is no clear correlation between the site or type of the fracture and which of the ligaments of the knee are injured in combined tibiofemoral injuries [23].

Other Considerations: Long-term outcome with surgical management of complex elbow injuries is unknown [68]. Ulnar collateral ligament reconstruction of the elbow demonstrates low complication and revision rates at minimum 48-month mean follow-up [55]. UCL repair in female athletes is associated with low complication rates [57]. The incidence of early postoperative complications after primary medial elbow ulnar collateral ligament repair in young patients with no additional ligamentous, fracture, and dislocation-related diagnoses is 7.3% [171]. The rate of 2-year revision medial elbow ulnar collateral ligament surgery in young patients with no additional ligamentous, fracture, and dislocation-related diagnoses is 1.0% [171]. Conflicting data on the cellular and molecular effects of platelet-rich plasma for ligament injuries were observed due to heterogeneity in included studies [49]. Short-term follow-up of subpectoral biceps tenodesis using an all-suture anchor fixation has not shown any failure of fixation or residual biceps discomfort [71]. Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution [217]. No treatments have been proven to alter the course of enthesopathy of the extensor carpi radialis brevis origin [217].

Recovery¶

Light activity (weeks): The evidence base does not provide specific week ranges for light activity such as desk work, driving, or light activities of daily living.

Full activity (months): Specific month ranges for the return to manual work, sport, or full range of motion and strength are not defined in the provided evidence.

Complete recovery / outcome plateau (months): Specific month ranges for the stabilization of pain, strength, and final functional outcomes are not defined in the provided evidence.

Rehabilitation protocol: The provided evidence does not specify details regarding physical therapy phasing, immobilisation duration, weight-bearing or range of motion progression, or sling and brace removal timing.

Functional milestones: Surgical strategies including collateral ligament repair stabilize the joint and result in favorable clinical outcomes [4]. Functional results are excellent after surgical repair of ruptured ulnar collateral ligaments of the metacarpophalangeal joint, even when healing failure is probable due to the ligament lying within the joint [5]. Repair of a chronic thumb ulnar collateral ligament injury with available local tissue results in durable long-term outcomes, despite the majority of patients progressing to osteoarthritis [10]. Distal biceps short head tears have good outcomes with acute and delayed reconstruction [12]. No significant difference in clinical outcome or range of motion was observed after direct repair of traumatic tears of the lateral ulnar collateral ligament between acute and delayed treatment cohorts [24]. Injured ulnar collateral ligaments in the thumb metacarpophalangeal joint were naturally stable after reduction and did not need surgical repair [27]. Early diagnosis and surgical repair allow for a successful return to competitive sports in avulsion injuries of the serratus anterior muscle [41]. Repair of grade III radial collateral ligament injuries of the thumb metacarpophalangeal joint provided long-term stability, functional improvement, and relief of pain [51]. Ulnar collateral ligament reconstruction provides excellent patient-reported and clinical outcomes at medium-term follow-up with low complication and revision rates [55]. Surgical repair of completely ruptured collateral ligaments of the proximal interphalangeal joint yielded satisfactory results with restored joint stability and pain relief [65]. Nonoperative treatment allowed 42% of throwing athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis [67]. In nonthrowing athletes, patients undergoing ulnar collateral ligament repair and reconstruction show favorable outcomes at minimum 2-year follow-up [190]. Elbow ligament reconstruction effectively restores stability and limits progression to osteoarthritis in the long term [191]. Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both bioabsorbable and nonabsorbable screw groups [181]. In the long term, most patients undergoing phrenic nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension obtained satisfactory elbow flexion but poor elbow extension [188]. Surgical reconstruction of the medial ulnar collateral ligament gets athletes back to their previous level of play more than 80% of the time and has more favorable outcomes compared with primary repair [222]. The postoperative course for javelin throwers undergoing ulnar collateral ligament reconstruction is associated with an extended period of time until return to previous level of competition when compared with baseball players [223]. Correlations of risk for revision surgery after primary ulnar collateral ligament reconstruction may be younger age and less Major League Baseball experience at the time of the primary reconstruction [224]. Augmented ulnar collateral ligament repair clinically demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return [225].

Other Considerations: The evidence provided consists primarily of outcome assessments at various follow-up intervals rather than defined recovery timelines. Specifically, outcomes were evaluated at medium-term follow-up [55], minimum 2-year follow-up [190], more than 1 year [181], and in the long term [10, 188, 191]. One study noted an average of 24.5 weeks after diagnosis for return to competition in nonoperatively treated throwing athletes [67]. Another noted an extended period until return to previous level of competition for javelin throwers compared with baseball players [223]. These data points reflect observation periods or comparative return times rather than standardized recovery phases.

Key Evidence¶

[L5] As a result of their inability to heal, these complete ligamentous injuries require operative repair, which is simpler to perform in the acute setting. [1] (10.1016/0363-5023(94)90115-5)
[L4] Correct understanding and reasonable treatment plans, including bony restoration and ligament repair, can achieve good function. [3] (10.1186/s13018-023-03563-5)
[L4] Thus, surgical strategies including collateral ligament repair stabilize the joint and result in favorable clinical outcomes. [4] (10.1016/j.jse.2014.07.010)
[L4] Failure of ligament healing was probably a result of the ligament lying within the joint, but the functional result was excellent after surgical repair. [5] (10.1054/jhsb.1999.0334)
[L5] Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. [6] (10.5435/jaaos-d-22-00112)
[L4] ACL repair has demonstrated significant clinical improvement in an appropriately selected patient cohort. [8] (10.1177/2325967126s00016)
[L1] Patients with acute UCL injuries should be assessed with history, clinical examination, and radiographs. [9] (10.1177/17531934241274612)
[L4] Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis. [10] (10.1177/1558944716628482)
[L5] Early return to play without immobilization should not be encouraged until the ligament is adequately healed after surgery. [11] (10.1177/1558944717725380)
[L4] They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction. [12] (10.1016/j.jse.2020.04.038)
[L5] This lesion is unstable and resembles the 'terrible triad' described in adults, requiring simultaneous management of bone and ligament instability while considering the risk of injury to growth plates. [14] (10.1016/j.main.2013.11.005)
[L4] Recent studies have shed new light on the natural history of injury to the posterior cruciate ligament, as well as on its complex anatomy and functional mechanical behavior, and this new information is likely to alter the way that orthopaedic surgeons have traditionally treated injuries to this structure. [15] (10.2106/00004623-199309000-00014)
[L5] Encouraging results for treating chronic injuries have been achieved by bone-ligament-bone reconstruction using a patellar tendon graft. [16] (10.1016/j.hcl.2007.01.005)
[L5] Most isolated medial collateral ligament injuries are treated nonsurgically, while concomitant damage to the anterior or posterior cruciate ligaments is a common indication for surgical management of high-grade injuries. [17] (10.5435/00124635-200903000-00004)
[L5] The current evidence for ulnar collateral ligament injury treatment is not convincing, and while expert consensus provides guidance, it should be viewed with caution due to methodological biases; future high-quality randomized studies are required. [18] (10.1016/j.arthro.2023.02.003)
[L4] Nevertheless, long-term clinical outcome studies involving a larger number of patients will be required to corroborate this approach to augmentation for partial ACL ruptures. [20] (10.1007/s00167-010-1068-6)
[L4] [22] (10.3390/sports7060138)
[L4] [23] (10.1007/bf00393877)
[L3] No significant difference in clinical outcome or range of motion was observed after direct repair of traumatic tears of the lateral ulnar collateral ligament between acute and delayed treatment cohorts. [24] (10.1016/j.jhsa.2014.02.011)
[Case_report] Surgery is indicated only for Grade 3 injuries where there is no definitive end point when tested for collateral instability due to extensive injury of the surrounding soft tissues. [25] (10.1177/17531934211054769)
[L4] A reliable 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management. [26] (10.1016/j.jse.2018.11.063)
[L4] Injured UCL ligaments were naturally stable after reduction and did not need surgical repair. [27] (10.1177/1753193418790502)
[L1] Clinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury. [30] (10.1186/s12891-022-05595-0)
[L3] The authors describe a diagnostic technique based on specific questions and three clinical tests that is useful for diagnosing triquetrolunate ligament injuries before arthroscopy. [32] (10.1054/jhsb.1999.0269)
[L4] A contemporary injury classification system is proposed that includes injury timing, injury location, and standardized terminology addressing tear extent to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research. [33] (10.1016/j.jse.2011.04.035)
[L4] PLER is the main mechanism of injury and should be managed individually based on injury mechanisms presenting different instability patterns. [35] (10.1016/j.jse.2020.12.015)
[L2] Ultrasound is a valuable adjunct to clinical examination in a specialist clinic, particularly for differentiating displaced from undisplaced tears, provided it is performed soon after presentation. [37] (10.1054/jhsb.1999.0283)
[L3] It can be used as a diagnostic tool for complete ruptures but may not be sufficient alone for partial injuries. [38] (10.1016/j.jse.2019.12.005)
[L4] The quality of ulnar collateral ligament-related information on YouTube is low, with differential diagnoses, accurate surgical indications, and thorough discussions of adverse outcomes being the most lacking information. [39] (10.1016/j.asmr.2023.100769)
[L4] Although diagnosing the cause of UCL locking may be complicated by the lack of evidence in imaging studies, open surgical treatment has traditionally been the most often used with a high success rate. [40] (10.1016/j.jhsg.2022.08.003)
[Case_report] Early diagnosis and surgical repair allow for a successful return to competitive sports. [41] (10.1016/j.jse.2006.12.014)
[L4] [42] (10.1177/2325967117731296)
[L3] With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. [43] (10.1302/0301-620x.100b2.bjj-2017-0398.r2)
[L4] A traumatic instability had worse results and probably is a contraindication to this technique. [45] (10.1016/s1297-3203(02)00129-4)
[L5] [46] (10.1016/j.arthro.2023.01.012)
[L4] Future research may elucidate the diagnostic value of a pop sign for UCL injury. [47] (10.1016/j.jse.2019.01.017)
[L3] Classification of tears may have implications for operative and non-operative management. [48] (10.5397/cise.2023.00458)
[L1] Conflicting data on the cellular and molecular effects of PRP for ligament injuries were observed secondary to the finding that included studies were heterogeneous, limiting interpretation across studies and the ability to draw meaningful conclusions. [49] (10.1177/23259671211066504)
[L5] Proper coil selection, pulse sequence parameters, and patient positioning enhance the ability of MR imaging to demonstrate subtle injuries to the ligaments and the regional osseous and soft tissue structures, including those not easily visualized at surgery. [50] (10.1016/j.mric.2004.02.006)
[L4] The repair provided long-term stability, functional improvement, and relief of pain. [51] (10.1053/jhsu.2003.50008)
[L4] Physicians must maintain heightened vigilance for associated physeal injuries that may not be obvious on initial radiographs. [52] (10.1016/j.jhsa.2012.02.037)
[L4] At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes. [53] (10.1007/s00167-003-0371-x)
[L4] This study shows difficulties in the evaluation of ligaments by conventional MRI technique as demonstrated by a weak inter- and intraobserver agreement. [54] (10.1186/s12891-017-1451-2)
[L4] UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. [55] (10.1136/jisakos-2021-000614)
[L4] The authors recommend early operative repair with a standard protocol for these injuries. [56] (10.2106/jbjs.d.02933)
[L4] UCL repair is an effective procedure in helping female athletes return to sport with low complication rates. [57] (10.1016/j.xrrt.2025.02.007)
[L4] [59] (10.1007/s12178-020-09637-9)
[L5] There is no scientifically proven superior method for ACL or PCL reconstruction due to a lack of well-designed randomized clinical trials, and the field continues to rely on unproven assumptions and varying opinions. [60] (10.1007/s00167-001-0251-1)
[L5] Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength, with good to excellent results reported. [61] (10.5435/00124635-201001000-00005)
[L4] We recommend this technique for the reconstruction of injured ligaments in hand surgery. [62] (10.1097/00130911-200103000-00008)
[L5] Injury prevention programs and improved nonoperative treatment protocols hold promise in decreasing the need for surgical repair. [63] (10.1016/j.jse.2023.09.012)
[L2] The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers. [64] (10.1177/0363546518786970)
[L4] Completely ruptured collateral ligaments frequently result in prolonged disability when treated non-operatively, whereas surgical repair of fourteen fingers with complete rupture yielded satisfactory results with restored joint stability and pain relief. [65] (10.2106/00004623-196749020-00009)
[L4] Isolated UCL injuries are relatively uncommon in nonquarterback NFL players, with the vast majority being grade I sprains treated nonoperatively. [66] (10.1016/j.jseint.2025.04.010)
[L4] Nonoperative treatment allowed 42% of athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis. [67] (10.1177/03635465010290010601)
[L5] Long-term outcome with surgical management of complex elbow injuries is unknown. [68] (10.5435/00124635-200605000-00003)
[L4] The nature of the injury can be most reliably documented using computed tomography with three-dimensional reconstructions. [69] (10.1111/j.1758-5740.2009.00044.x)
[L4] MRI grading of UCL injuries can help predict return to play and the need for surgery. [70] (10.1177/0363546515621756)
[L5] Short-term follow-up of 20 procedures has not shown any failure of fixation or residual biceps discomfort. [71] (10.1007/s00167-014-3348-z)
[L5] The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius. [76] (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
[L5] We find the torque to be minimal at 10° of elbow flexion and the least work at 30° of flexion. [95] (10.1016/s1058-2746(02)86814-8)
[L4] Gripping does not change ulnohumeral joint space width or medial elbow tissue stiffness in the joint testing configuration and external loading conditions applied in this study. [102] (10.1186/s12891-025-08343-2)
[L4] Medial elbow joint space increases under a valgus load and then decreases when a maximal grip contraction is performed. [104] (10.1177/0363546518755149)
[L4] The results demonstrated that forearm position was not associated with the elbow varus moment, but the supination moment was associated with the elbow varus moment. [105] (10.1177/0363546517733471)
[L5] It was concluded that the elbow ligaments may provide significant sensory function to the elbow joint, in addition to being its major mechanical restraints. [106] (10.1016/s0363-5023(05)80470-8)
[L4] Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion. [107] (10.1177/0363546509336721)
[L3] No kinematic or kinetic differences were noted between throwing balls and strikes. [108] (10.1177/0363546517730052)
[L5] Nonoperative treatment can offer favorable outcomes for younger patients with acute or partial ulnar collateral ligament injuries. [110] (10.1016/j.otsm.2020.150733)
[L2] Increased medial elbow torque was associated with greater ball velocity regardless of the history of medial elbow injuries. [111] (10.1016/j.arthro.2022.07.016)
[L5] Elbow valgus torque is poorly suited as a standalone metric for predicting injury risk due to narrow data ranges, modeling noise, and crude assumptions; future efforts should focus on integrated, longitudinal metrics rather than single-session proxies. [113] (10.1002/arj.70098)
[L4] [116] (10.1016/j.jhsa.2024.12.003)
[L5] The study successfully created and validated an anatomic model of terrible triad of the elbow by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min. [120] (10.1186/s13018-024-05069-0)
[L2] [122] (10.1016/j.jhsa.2014.02.033)
[L4] The Ligamentotaxor is a safe and effective device for managing intra-articular PIPJ injuries, offering practical advantages and comparable efficacy to other devices. [123] (10.1177/1753193415578305)
[L4] [126] (10.1177/1753193420932496)
[Letter] Ultrasound and MRI are helpful in evaluating this injury and monitoring its resolution. [127] (10.1016/j.jse.2013.01.016)
[L4] However, when controlling for an individual pitcher, peak kinetics at the shoulder and elbow can be strongly predicted by ball velocity. [128] (10.1016/j.jse.2021.04.017)
[L5] Elbow dislocations can result in extensive injury to the supporting structures of the elbow joint. [129] (10.1016/s0278-5919(05)70247-7)
[L4] PLRI of the elbow remains to be fully understood. [130] (10.1016/j.arthro.2014.02.029)
[L5] Additionally, both elbow varus torque and swing velocity were greatest when swinging to the outside location. [131] (10.1016/j.jse.2025.02.001)
[Abstract] None of the individual tests is sensitive enough to use solely nor accurately diagnose a partial rupture. [132] (10.1016/j.jse.2022.01.062)
[L5] Complex elbow instability remains a challenging clinical entity requiring a balance between stability, mobility, and concentric reduction; further research, particularly multicenter prospective trials, is needed due to the rare nature of these injuries. [133] (10.1016/j.hcl.2007.11.010)
[L2] Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. [135] (10.1016/j.arthro.2020.12.208)
[L3] Injuries are common in young vaulters. [137] (10.1177/0363546507313571)
[L4] Non-operative management of isolated LCL injuries is associated with high return to pre-injury level of sport (100%), reasonable recovery times, and no significant residual varus instability. [138] (10.1177/2325967126s00022)
[L4] Simultaneous surgical treatment including open débridement and ligament reconstruction provides satisfactory pain relief and functional improvement in patients with LE and LCL insufficiency. [144] (10.1016/j.jse.2018.06.011)
[L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. [146] (10.1016/j.jse.2023.11.001)
[L5] There was unanimous agreement regarding the lack of evidence for orthobiologics and specific areas for nonoperative management, as well as indications for operative management and return to sport criteria. [147] (10.1016/j.arthro.2022.12.033)
[L5] Treatment of UCL injuries depends on the type of tear, with nonoperative management for low-grade partial tears and UCL reconstruction as the gold standard for complete tears. [150] (10.1016/j.arthro.2020.02.022)
[Case_report] The conservative intervention demonstrated effectiveness in eliminating recurrent annular ligament displacement events in this pediatric patient. [151] (10.1016/j.jht.2025.02.005)
[L4] Ulnar collateral ligament reconstruction is currently the most commonly performed surgical treatment option for UCL insufficiency, with a commonly quoted success rate of 85% defined as the ability to return to a preinjury level of play for at least one year. [152] (10.1136/bjsm.2005.025072)
[L3] UCL injuries in high school baseball players can be successfully treated nonoperatively in most cases. [153] (10.1016/j.jse.2020.09.022)
[L5] While nonsurgical management can result in successful return to sport in carefully selected patients, UCL reconstruction remains the benchmark for tears not amendable to nonsurgical treatment. [154] (10.5435/jaaos-d-24-00392)
[L5] Treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes. [155] (10.1016/j.jhsa.2012.10.030)
[L4] Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries, but more clinical evidence is necessary to define the indications and parameters for their use. [156] (10.1177/2325967113519935)
[L3] Non-operative treatment of UCL injuries will likely be more successful in younger players, lower grade tears, and humeral-sided injuries. [157] (10.1177/2325967119s00311)
[L4] Professional athletes and those with complete tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals. [160] (10.1016/j.jse.2017.08.005)
[L5] Treatment should be unique to the patient and sport specific in nature, with nonoperative management requiring a multimodal approach for well-selected patients. [161] (10.2106/jbjs.rvw.m.00057)
[L4] Repair was most appropriate for partial and full-thickness distal tears but relatively contraindicated for complete midsubstance UCL tears. [162] (10.1016/j.jse.2023.01.001)
[L5] There is no consensus about the treatment of partial ACL ruptures; anterior-medial bundle ruptures may do well with non-operative treatment, while posterior-lateral bundle ruptures often need surgery due to pivot shift development. [163] (10.1007/s00167-007-0384-y)
[L5] Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries. [165] (10.1016/j.jhsa.2021.11.026)
[L3] In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. [166] (10.1177/0363546517699832)
[Paper] [167] (10.2106/jbjs.rvw.25.00060)
[L5] Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition. [170] (10.5435/jaaos-22-05-315)
[L4] There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. [171] (10.1016/j.asmr.2023.100828)
[L3] The authors created a comprehensive classification of complex fracture-dislocations of the elbow that appeared to be reproducible and may represent a useful tool for the management of such difficult injuries. [172] (10.1016/j.jse.2011.06.003)
[L4] Wrestlers showed high return to sport (RTS) rates following both nonsurgical and surgical UCL treatment; however, primary non-operative management failed in 44% of patients, particularly those with complete tears, necessitating subsequent surgery. [173] (10.1177/2325967126s00505)
[L4] This new classification is a tool for an arthroscopic assessment of PLRI and can be used as a standardized grading system for further research and communication between orthopedic surgeons. [174] (10.1016/j.jseint.2023.02.016)
[L4] Incomplete UCL injuries are more likely to lead to nonoperative treatment and a higher return to the same or higher level of play than complete tears. [175] (10.1177/2325967114s00021)
[L5] While UCL reconstruction remains a mainstay for high-demand athletes with full-thickness tears, nonreconstructive options such as rehabilitation, biologic strategies, and repair may be beneficial for specific clinical scenarios including lower-demand athletes, adolescents, and aging athletes. [176] (10.1177/0363546517692548)
[L4] Preoperative MRI and intraoperative assessments agreed in 80% of cases, a value that was significantly higher for complete over partial tears. [178] (10.1016/j.jseint.2023.06.019)
[L3] Clinical and functional outcome at more than 1 year after distal biceps tendon repair was excellent in both groups. [181] (10.1016/j.jse.2015.12.007)
[L5] [183] (10.1097/bth.0b013e3181901b1)
[L3] The clinical use of MRI in the management of patients with enthesopathy of the ECRB origin merits further study. [184] (10.1016/j.jhsa.2009.02.023)
[L5] [185] (10.1302/2058-5241.160033)
[L4] We propose a new classification for UCL injuries based on MRI findings that helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes. [186] (10.1016/j.jse.2016.05.006)
[L5] [187] (10.5435/JAAOS-D-14-00145)
[L4] In the long term, most patients obtained satisfactory elbow flexion but poor elbow extension. [188] (10.1016/j.jhsa.2010.04.006)
[L5] [189] (10.1016/j.jse.2023.07.034)
[L4] In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. [190] (10.1177/03635465221120654)
[L4] Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. [191] (10.1016/j.jseint.2022.12.009)
[L3] In professional pitchers, distal ulnar collateral ligament tears described on MRI show significantly higher rates of failure with nonoperative management compared to proximal tears. [192] (10.1177/2325967116s00169)
[L3] Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. [195] (10.1016/j.jhsa.2023.03.025)
[L4] Preoperative MRI could be used to exclude subtle instability, and surgeons should consider checking for subtle instability, especially when patients have a history of multiple corticosteroid injections (≥3) or severe pain. [196] (10.1186/s12891-018-2069-8)
[L4] [198] (10.1016/j.jse.2016.09.007)
[L4] [200] (10.1007/s00402-026-06430-0)
[L2] Therefore, the FEVER MRI may be both sensitive and specific for detecting UCL injuries and guiding surgical decision making while obviating the need for joint contrast fluid. [201] (10.1177/2325967125s00096)
[L4] It can be of value alongside 3-dimensional imaging in evaluating elbow injuries and used as an adjunct in clinical decision making. [202] (10.1016/j.jse.2021.12.039)
[L3] There was no relationship between UCL tear type and age, competition level, and plain radiographic abnormalities. [206] (10.1177/03635465221094326)
[L3] A traffic light model based on initial radiographic displacement can predict the need for collateral ligament repair: >10 mm requires repair, <5 mm does not, and 5-10 mm requires careful screening for instability. [207] (10.1016/j.jse.2023.06.006)
[L5] [209] (10.1016/s1058-2746(03)00062-4)
[L4] Thickened UCL may exhibit a decrease in function; therefore, physicians should not evaluate the joint status solely on the basis of the structural properties on conventional ultrasound. [211] (10.1016/j.jse.2025.01.027)
[L5] A complete radiological assessment allows for a precise diagnosis that guides the choice of different osteosynthesis techniques. [212] (10.1016/j.main.2008.07.006)
[L5] Fat-suppressed T1-weighted magnetic resonance arthrography with gadolinium can provide information regarding inner surface partial tears and small full-thickness perforations. [214] (10.1067/mse.2000.107392)
[L5] Enthesopathy of the extensor carpi radialis brevis origin is a benign, self-limiting disorder with a natural history of spontaneous resolution, for which no treatments have been proven to alter the course. [217] (10.5435/jaaos-d-15-00233)
[L5] [219] (10.1097/bth.0b013e31826cef1c)
[L5] [220] (10.1016/j.jse.2026.04.058)
[L5] Surgical reconstruction of the medial ulnar collateral ligament gets athletes back to their previous level of play more than 80% of the time and has more favorable outcomes compared with primary repair. [222] (10.1016/j.hcl.2015.07.002)
[L4] However, the postoperative course is associated with an extended period of time until return to previous level of competition when compared with baseball players. [223] (10.1177/0363546511422350)
[L2] However, correlations of risk may be younger age and less MLB experience at the time of the primary reconstruction. [224] (10.1016/j.jse.2016.11.008)
[L4] Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. [225] (10.1016/j.arthro.2023.09.030)

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[127] Regarding “Acute traumatic brachialis rupture in a young rugby player: a case report” and “Acute brachialis muscle rupture caused by closed elbow dislocation in a professional American football player”. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.016

[128] Intra- versus inter-pitcher comparisons: Associations of ball velocity with throwing-arm kinetics in professional baseball pitchers. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.04.017

[129] Fracture Dislocations of the Elbow in Athletes. Clinics in Sports Medicine. 2001. DOI: 10.1016/s0278-5919(05)70247-7

[130] Surgical Treatment of Posterolateral Rotatory Instability of the Elbow. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.02.029

[131] Medial elbow torque during baseball hitting: considerations for return to play. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.001

[132] Distal Biceps Tendon Ruptures: A Quick And Reliable Physical Examination Strategy. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.062

[133] Complex Elbow Instability. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2007.11.010

[135] Elbow Torque Is Reduced in Asymptomatic College Pitchers With Elbow Laxity: A Dynamic Ultrasound Study. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.12.208

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[138] Isolated Clinically Diagnosed Grade I-II Lateral Collateral Ligament Injuries in Elite Athletes Do Not Require Surgery. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967126s00022

[141] Chapter 80 Elbow Stiffness. 2019.

[144] Surgical management of lateral epicondylitis combined with ligament insufficiency. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.06.011

[146] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[147] Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.12.033

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[153] Return-to-play outcomes in high school baseball players after ulnar collateral ligament injuries: dynamic contributions of flexor digitorum superficialis function. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.022

[154] Ulnar Collateral Ligament Injuries in Overhead Athletes: Diagnosis, Management, and Clinical Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00392

[155] Elbow Lateral Collateral Ligament Injuries. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.030

[156] Emerging Applications of Stem Cell and Regenerative Medicine to Sports Injuries. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967113519935

[157] Outcomes of Non-Operatively Treated Elbow Ulnar Collateral Ligament Injuries in Professional Baseball Players by Magnetic Resonance Imaging Tear Grade and Location. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00311

[160] Management of ulnar collateral ligament injury in throwing athletes: a survey of the American Shoulder and Elbow Surgeons. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.08.005

[161] Treatment of Medial Collateral Ligament Injuries of the Elbow with Use of the “Tommy John” Operation: Indications and Results. JBJS Reviews. 2014. DOI: 10.2106/jbjs.rvw.m.00057

[162] What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.01.001

[163] Partial ACL injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2007. DOI: 10.1007/s00167-007-0384-y

[165] Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.11.026

[166] Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517699832

[167] Ulnar Collateral Ligament Injuries in Pediatric and Adolescent Throwing Athletes. JBJS Reviews. 2025. DOI: 10.2106/jbjs.rvw.25.00060

[170] Ulnar Collateral Ligament Injuries in the Throwing Athlete. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-05-315

[171] Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair. Arthroscopy, Sports Medicine, and Rehabilitation. 2024. DOI: 10.1016/j.asmr.2023.100828

[172] Complex fracture-dislocations of the proximal ulna and radius in adults: a comprehensive classification. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.06.003

[173] Poster 208. Evaluating Outcomes and Return to Sport of Ulnar Collateral Ligament Injuries in Wrestlers. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00505

[174] Intraoperative arthroscopic classification tool for posterolateral elbow instability. JSES International. 2023. DOI: 10.1016/j.jseint.2023.02.016

[175] Return to Play after Nonsurgical Treatment of Elbow Ulnar Collateral Ligament Injuries in Professional Baseball Players. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00021

[176] Avoiding Tommy John Surgery: What Are the Alternatives?. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517692548

[178] Myotendinous junction tears of the pectoralis major are occurring more frequently and discrepancies exist between intraoperative and radiographic assessments. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.019

[181] Distal biceps tendon repair: comparison of clinical and radiological outcome between bioabsorbable and nonabsorbable screws. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.007

[183] Arthroscopic Foveal Repair of Triangular Fibrocartilage Complex Peripheral Lesion With Distal Radioulnar Joint Instability. Techniques in Hand & Upper Extremity Surgery. 2008. DOI: 10.1097/bth.0b013e3181901b1

[184] Magnetic Resonance Imaging Signal Abnormalities in Enthesopathy of the Extensor Carpi Radialis Longus Origin. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.02.023

[185] Lateral collateral ligament injuries of the elbow – chronic posterolateral rotatory instability (PLRI). EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.160033

[186] Magnetic resonance imaging–based classification for ulnar collateral ligament injuries of the elbow. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.05.006

[187] Medial Epicondylitis. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/JAAOS-D-14-00145

[188] Phrenic Nerve Transfer for Elbow Flexion and Intercostal Nerve Transfer for Elbow Extension. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.006

[189] Rehabilitation of the painful elbow. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.034

[190] Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221120654

[191] Lateral elbow ligament reconstruction for posterolateral rotatory instability: 10 years follow-up in 32 patients. JSES International. 2023. DOI: 10.1016/j.jseint.2022.12.009

[192] MRI Predictors of Failure in Non-operative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00169

[195] The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.03.025

[196] Subtle elbow instability associated with lateral epicondylitis. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2069-8

[198] Valgus extension overload syndrome in adolescent baseball players: clinical characteristics and surgical outcomes. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.09.007

[200] Comprehensive ultrasound assessment of thumb metacarpophalangeal collateral ligament injuries reveals frequent concomitant abnormalities. Archives of Orthopaedic and Trauma Surgery. 2026. DOI: 10.1007/s00402-026-06430-0

[201] Paper 39: Can the Flexed Elbow Valgus External Rotation (FEVER) View MRI Eliminate the Need for an MR Arthrogram or Dynamic Stress Ultrasound in Athletes with Ulnar Collateral Ligament Injuries of the Elbow? A Prospective Study of Professional and Varsity Athletes. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00096

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[206] Adolescent Baseball Pitchers With Ulnar Collateral Ligament Tears Exhibit a High Proportion of Partial Tears. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221094326

[207] Predicting the need for collateral ligament repair in transolecranon fractures of the elbow: a traffic light model. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.06.006

[209] Elbow joint stability following experimental osteoligamentous injury and reconstruction. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1016/s1058-2746(03)00062-4

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[212] Fractures concomitantes du radius et du scaphoïde associées à une luxation du coude. Chirurgie de la Main. 2008. DOI: 10.1016/j.main.2008.07.006

[214] Magnetic resonance imaging of injury to the medial collateral ligament of the elbow: A cadaver model. Journal of Shoulder and Elbow Surgery. 2000. DOI: 10.1067/mse.2000.107392

[217] Enthesopathy of the Extensor Carpi Radialis Brevis Origin. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00233

[219] Repair of the Acutely Unstable Elbow. Techniques in Hand & Upper Extremity Surgery. 2012. DOI: 10.1097/bth.0b013e31826cef1c

[220] The Internal Joint Stabilizer in Lateral Ulnar Collateral Ligament Injuries: A Biomechanical Study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.04.058

[222] Elbow Trauma in the Athlete. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.07.002

[223] Elbow Ulnar Collateral Ligament Reconstruction in Javelin Throwers at a Minimum 2-Year Follow-up. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511422350

[224] Major League pitching workload after primary ulnar collateral ligament reconstruction and risk for revision surgery. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.11.008

[225] Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.09.030

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Ligament Injuries

Overview¶

Anatomy & Pathophysiology¶

General Ligament Biology¶

Knee Ligaments¶

Elbow Bony Anatomy¶

Elbow Ligaments¶

Elbow Muscles¶

Elbow Kinematics and Biomechanics¶

Elbow Pathomechanics and Injury Patterns¶

Classification¶

Elbow Ulnar Collateral Ligament (UCL)¶

Thumb Metacarpophalangeal Joint (MCP) Collateral Ligaments¶

Distal Interphalangeal Joint (DIP) Collateral Ligaments¶

Knee Ligaments¶

Elbow Fracture-Dislocations and Instability¶

Other Ligament and Tendon Classifications¶

Clinical Presentation¶

General Assessment and Diagnosis¶

Imaging Modalities¶

Specific Injury Patterns and Mechanisms¶

Investigations¶

Treatment¶

Non-Operative Management¶

Operative Management¶

Indications and Decision Making¶

Biologic Agents and Adjuncts¶

Rehabilitation and Postoperative Care¶

Evidence Quality and Limitations¶

Complications¶

Recovery¶

Key Evidence¶

See Also¶

References¶