This article has been inspired by both my experience as a physical therapist, as well as a patient of fabulous orthopedic surgeons and rehabilitation colleagues. The difficulty in obtaining related case studies, especially regarding annular ligament repairs in the adult population, exhibited the need for additional case studies and information.
The primary purpose is to document this case, in the hopes that it may stimulate questions and research when faced with confusing symptoms in elbow patients. This experience may in fact be rare; however, due to it's improbability, it may be overlooked in the clinical diagnosis. Annular ligament tears do, in fact, occur in adults. The exact mechanism of injury, full rehabilitation understandings, or even an accurate prognosis are yet to be established. The persistence of both my symptoms as well as the professionals treating me led to diagnosis. It is possible that we do not know enough, and that previous cases are not recorded due to limitations of insurance, knowledge, and perseverance for treatment by the patient.
A Literature Review
A review of available literature on annular ligament tears/repair in the adult population without ulnar fracture was very limited. Two cases of posterior dislocation only were presented at the university of Zimbabwe Medical School. Diagnosis was not made until five and six weeks respectively after injury. In one case, open reduction with annular ligament reconstruction yielded a poor result. After excision of the radial head in the second case a good range of motion was restored. There was no availability of related studies in the United States or Canada.
In the pediatric population, nursemaid's elbow is caused by a sudden pulling on an extended, pronated arm, wherein the radial head slips partially under the annular ligament, the proximal portion of which displaces into the radiocapitellar joint. There is no tear in the soft tissue (probably due to the pliability of young connective tissues).
Monteggia's fracture also causes the radial head to dislocate, although it is associated with fracture of the ulna—the annular ligament may or may not be torn. Again, radial head displacement is frequently missed on x-ray, but easier identified with this particular lesion (as the examiner is assisted in diagnosis by the ulnar involvement).
Isolated radial head dislocation is a rare lesion, and is directly correlated with capsulotendinous disruption especially of the annular ligament. Reduction is achieved by forceful supination of the forearm. Displacement is usually anterior or lateral, occasionally posterior.
Painful Annular Ligament, inflammation or fibrosis, as described by Bosworth, is the cause of tennis elbow, and the trauma to the annular ligament is caused by repetitive rotation of an asymmetrical radial head.
Compression neuropathies, especially of the radial nerve, when associated with radial tunnel syndrome, can occur under proximal supinator, radial recurrent vessels, the arcade of Frohse, or the ECRB origin. There are no motor of sensory deficits, pain is localized to 5cm. distal to the lateral epicondyle and is aggravated by resisted extension of the third digit. It is important to note the various levels at which the median, radial and ulnar nerves may become entrapped, and produce symptoms of this region.
Anatomic Assessment of Annular Ligament and Related Regions
It has been well documented that the body does not function in isolated patterns of movement. There is not a joint, muscle, or anatomical structure that acts truly as an isolated stucture in functional activity. Therefore the entire upper quadrant must be thoroughly evaluated in the initial assessment. Even distinct lesions of a particular area will affect both the proximal and distal structures within the body. This section is not intended as an anatomy review, but as a quick highlight of structures related to the upper extremity assessment. This assists in differential diagnosis, as well as formulation of secondary problem lists. It is well understood that limitations of time are a reality; however, thorough assessment can eliminate unnecessary treatment, and assist in the development of effective treatment planning.
The annular ligament originates at the radial notch on the lateral side of the coronoid process of the ulna, encompasses the radial head, and inserts again onto the ulna. This ring-like ligament, which is bands of fibrous tissue, assists in holding the extensor tendons of the wrist in place, and also prevents the radial head from displacing during movement, especially during pronation and supination of the forearm.
The Cervical Spine
Compression at this level can cause radiation of symptoms to the upper extremity; including paresthesias and myotomal weakness (which must be distinguished from specific muscle weakness). Decreased mobility at the cervical level can also cause a patient to move the entire quadrant in a guarded manner. It is the muscular components of this region that a patient may use to compensate for or initiate improper movement patterns (e.g.; trapezii, anterior and middle scalenes). Thoracic Outlet Syndrome should also be tested for and ruled out.
The Scapula and Scapulohumeral Rhythm
Decreased fluidity of movement, and muscular imbalances at the scapular level on either side can impair mobility at a distal level. The scapulohumeral rhythm gives the clinician insight into whether the proximal foundation of upper extremity mobility is strong, or whether it may be contributing to the patient presentation.
The Glenohumeral Joint
Altered mobility at this articulation may affect the length/tension relation of two joint muscles, e.g.; long head of biceps and triceps, directly impacting elbow mobility and strength. Palpation of the bony landmarks also assists in determining proper alignment of the upper extremity as a whole unit.
The Axilla/Brachial Plexus
It is important to screen the patient for any involvement of the brachial plexus, and to rule out peripheral neural impairment that may originate from this. The axillary muscular triangle of latissimus, pectoralis major, and teres major should also be assessed for flexibility and strength.
The Elbow (lateral portion)
The lateral epicondyle is the easiest bony landmark to identify. Distally, the trochlea articulates with the ulna. Lateral to the trochlea, the capitulum articulates with the head of the radius. The superior radioulnar joint is made up of the radial notch (ulna), articulating with the radial head. It is this articulation that is most notably disrupted with annular ligament tears.
The Wrist and Hand
The distal radioulnar joint, and its articulations with the proximal carpal row is obviously important and can have a direct effect on pronation and supination of the forearm. Strength of the hand, as well as sensation, can be impaired by proximal disruptions of tissue. Also essential is evaluation of the integrity of the triangular fibrocartilaginous complex on the ulnar portion of the wrist. The TFCC originates on the ulnar portion of the wrist joint, and acts as disc/cushion to prevent the ulna from directly impacting the proximal carpal row.
In order to reduce bias, this information is documented in the most objective manner possible, utilizing treatment records and tests to demonstrate the findings. Subjective information is also incorporated, given the advantage of patient perspective. The diagnoses important to this article are tears of triangular cartilage complex, and the annular ligament.
On Oct. 5, 1997, I was involved in a motor vehicle accident, wherein the medial border of my right upper extremity hit the windshield, sustaining direct as well as axial compression forces. Upon impact, my shoulder was positioned at approximately 110 degrees forward elevation, 45 degrees internal rotation, 90 degrees elbow flexion, neutral forearm rotation, wrist extension and radial deviation. Biomechanically, it is possible that my radius moved in a cranio-caudal direction, causing damage at the proximal and distal soft tissue, or simply that the direct force on the ulna was the mechanism of injury at both the wrist and elbow levels. Lacerations occurred on my left shoulder, right forearm and hand. Initial diagnostic studies revealed the following: cervical disc bulging at c2, 3,4,6, central herniation at C5, facial and kidney contusions, sacro-iliac (R on R posterior torsion) and right fifth metacarpal (boxer's) fracture.
30 year old, healthy female, physical therapist. Dancer/dance instructor for 27 years. Presents with mild-moderate hypermobility, with a relatively strong musculoskeletal structure. Past surgical history is not relevant.
Clinical Findings (One month post MVA)
Persistent lack of right shoulder elevation, snapping and locking right elbow, with palpable radial head instability (more apparent with active pronation and supination combined with elbow flexion greater than 90 degrees), tenderness, lateral epicondyle, over radial head and throughout the extensor tendons, limitation of radioulnar rotation with discomfort in the area of the interosseous membrane, decreased pronation (40 degrees active), difficulty with weightbearing through the right upper extremity secondary to pain in the lunate, triquetrum, hamate, and pisiform areas, parasthesias right medial forearm and hand. All symptoms in the elbow, forearm and wrist were intensified with active and resistive activities, with elbow flexion greater than 95 degrees and with weightbearing through the extremity.
RADIOLOGICAL FINDINGS (Within one year post MVA)
MRI RIGHT WRIST-triangular fibrocartilage complex tear.
MRI RIGHT ELBOW-small effusion, not extending to annular ligament level.
MRI RIGHT SHOULDER-partial supraspinatous tear off anterior humeral surface.
MRI CERVICAL SPINE-central herniation C5, bulges throughout, flattened curvature.
MRI LUMBAR SPINE-bulging L5.
X RAYS-boxers fracture right hand.
CT ATHROGRAM RIGHT ELBOW-negative for tears and loose bodies.
It is my theory that the difficulty in obtaining a diagnosis at the elbow level in this case was in part due to the involvement of the wrist, as well as the negative diagnostic testing as previously listed. R/O diagnoses prior to surgical intervention of the elbow were: torn capitulum, loose bodies, lateral epicondylitis or Annular ligament disruption.
PRE-OPERATIVE RANGE AND STRENGTH ASSESSMENT RIGHT UPPER EXTREMITY AT TWO WEEKS POST MVA
|Movement||Range of Motion (degrees)||Manual Muscle Test (0-5)||Related Symptoms and Findings|
|Shoulder ext/flex||30-0-175||4+(both)||Positive impingement sign|
|Shoulder add/abd||20-0-175||4+with pain||Pain with initial scapular setting|
|Shoulder int/ext rotation||90-0-80||4+with pain||Pain increased with resisted ext. rot.|
|Elbow flex/ext||115-0-(-8)||5-flex 4-ext||Hyperextension noted|
|Forearm pronation/supination||50-0-90||3+pro 4+sup||Palpable popping radial head with pronation|
|Wrist flexion/extension||80-0-55||5-flex 3-ext||Pain with ext and with pressure onto hand (Weightbearing)|
|Hand (general)||5th MCP abd -5||5th digit 3 All other movements 5||Fracture 5th MC (immobilized)|
Initial immobilization of right MC fracture, cessation of work and excessive activity, with the exception of physical therapy, further investigation of symptoms including hematuria, left hip pain with weightbearing, and neural symptoms lasted approximately four months, followed by a return to part-time work (six hours per day), the initiation of chiropractic intervention, and injections to the right wrist and elbow.
The combination of chiropractic mobilization and physical therapy for maintenance of alignment via strengthening produced the most effective results for spinal and sacroiliac conditions. Persistence of right arm pain, progressive lack of range, and the inability to perform repetitive manual techniques resulted in MRI of the shoulder, and TFCC repair with a wafer resection of the ulna six months later, followed by postoperative occupational therapy with a CHT. However, after returning to part time employment after eight weeks, symptoms comtinued specifically in the elbow. Therapy and injections were attempted, and further testing was initiated on the elbow.
Radiological findings were essentially negative, however the symptoms of pronation loss, radial head "popping", extensor tendon irritation, and jamar grip weakness did not resolve. Two months after the last return to work, with continued treatment, a surgical exploration of the elbow was indicated. It was at this time that the annular ligament tear could be visualized and properly repaired. A review of the surgical reports follows, with the range of motion findings at 18 months post-op. Again, this was followed by rehabilitation with a certified hand therapist.
Operative Report Summaries
9 Months Post MVA
Pre-operative Diagnosis—torn TFCC right wrist with distal radio-ulnar synovitis
Operation—Debridement of triangular fibrocartilage; synovectomy distal r-u joint; reconstruction TFCC complex; wafer excision ulnar head; removal of synovial cyst from distal r-u joint.
Summary of findings—large amount of hypertrophic and bulging synovium; large synovial cyst; hole in the central portion of the TFCC-the edges irregular/erythematous; distal ulna impinged on the TFCC; reconstruction via previously created tissue flaps and Vicryl.sutures.EDM and ECU tendons were protected; ECU not dislodged.
Post op immobilization via volar plaster casting for six weeks.
Post op diagnosis-same
1 Year Post MVA
Pre-operative Diagnosis—Dynamic Instability Right Elbow
Operation—Exploration of right elbow with arthrotomy; reconstruction of elbow arthroplasty with repair of annular ligament, application posterior molded splint
Summary of findings—local anesthesia with intravenous sedation; incision over lateral aspect of elbow and centered at the radial capitular joint, which preoperatively was determined as the site of snapping which was visible, palpable, and audible with pronation and supination. This was increased with active movement by the patient; with deeper dissection, it was noted that the snapping was under the interval between ECU, ECR, ECRL and ECRB. Once the lateral capsule was opened, and the patient again rotated the forearm, subluxation of the radial head was noted- (rotating the arm in flexion).
The ligament was also noted to be thickened and scarred, interposing the radial capitular joint. The radial head was noted to be without its normal round contour, but it articulated well with the humerus. Repair was completed by mobilizing the scarred/interposed ligament and flipping and suturing it back over the radial head. A relaxing incision was also made where the ligament had scarred into the joint, thus reducing tension on the ligament. Vicryl and Monocril sutures were used to close the wounds at all levels. Post-op immobization posterior molded splint applied in long arm fashion for six weeks.
Post-Operative Assessment Range and Strength (At 18 months postop elbow)
|Movement||ROM IN DEG.||MMT (0-5)||Related Information|
|Shoulder elevation||Full 0-0-180||5 -|
|Shoulder abduction||Full 0-0-180||5 -|
|Shoulder int/ext rot||85-0-95||5-; 5 -||Pain with RROM Ext Rot||Elbow flex/exten.||130- (-) 3||5; 5 with pain t/o ROM||Flex limited -capsular endfeel |
|Forearm pro/sup||60-0-85||5-in avail ROM||Interosseus membrane tightness, wrist pain with rotation|
|Wrist flex/ext||90-0-70||5-: 4+ t/o ext.||Pain with wt. bearing|
|Hand||Full all movements||75# left 65# right (Jamar Grip)||none|
Contra-Indications and Concerns for the Therapist Treating the Post-operative Elbow
It should be noted that vigorous manipulation of the elbow too soon post operatively, might be harmful to the articulation. Stretching is contra-indicated secondary to the high possibility of hyper osseous formation, most notably in the elbow. Progression of range restoration must be slow, to avoid secondary tendonitis of either the ulnar or radial extensors. Optimally, there is gradual loading of the soft tissue fibres, using modalities to minimize secondary inflammatory processes. Post-operative supination is additionally contra-indicated as this causes a direct pull on the repair site.
In this particular case, following TFCC repair AAROM began three weeks post-op with continued immobilization via removable posterior casting. This was limited to the degree of flexion and extension, without forearm rotation until 4-6 weeks. Passive stretching (of pronation) following the elbow reconstruction was prolonged until approximately 12 weeks.
A case specific determination is, as always, requires consideration of a patient's age, activity level, and ability to adapt the environment. In this case, full functional return with intermittent pain/popping and locking was acquired at the elbow, with chronic ulnar paresthesias and symptoms of radial tunnel syndrome. Repetitive motion, especially forearm rotation, and weight bearing through the wrist increased intra and extra-articular irritation, as well as interroseous membrane region hypo mobility. Prognosis is fair, although cannot be accurately predicted due to the limited amount of literature and case studies. However, it may be postulated by deriving assimilation with other elbow surgeries. The probability of achieving full elbow flexion and extension following post operative procedures to this joint is high, although the process itself can be deterred secondary to high incidence of calcific and hyper osseous formation seen in this joint.
The probability of attaining full forearm rotation is good, however that was not the case in this study. Limitation of free, full radial head rotation (due to shortening of the annular tissue which required excision), adherence of the interosseous membrane and limitation at the distal radioulnar articulation all may have contributed to this result. The prognosis for full functional return in this case was good; however, frequent pain in the lateral elbow, forearm and medial wrist occasionally inhibit function. The lack of forearm rotation also presents a problem with some ADL, as does weight bearing through the wrist. Specific functional impairments include difficulty with opening doors or jars, holding the arm in an ergonomically efficient manner at the computer or with writing, activities requiring pronation (such as pouring), and demonstrating the repetitive manual techniques performed as a manual physical therapist. (craniosacral, massage, MFR among others). Potential interventions to reduce chronic inflammatory changes, achieve further range and reduce pain are resumption of treatment, injections of the wrist and elbow, and potentially radial head excision.
It is my hope that by writing this directive that clinicians will be made aware of the possibility of annular ligament tears in their adult elbow patients. The persistence of symptoms, and the treating orthopedist, did lead to proper diagnosis. However, this is not a well-documented finding nor was it supported by radiological testing. The use of cinematographic analysis would have assisted in this diagnosis, given its dynamic presentation. More research is needed in evaluation and treatment of such tears in the elbow, so that it is not excluded from differential diagnoses and patients can receive accurate and timely intervention.
Melinda Chios received her BSc PT from University of Alberta, Canada, and is presently working on her advanced masters in orthopedic physical therapy at Touro in New York. She has worked in a variety of PT settings, and currently is teaching in the dance community on injury prevention and treatment of dance injury.