Javelin Thrower's Elbow / Medial Collateral Ligament Sprain
By Laurence Schubert APAM
Medial Collateral (Ulnar) Ligament Sprain of the Elbow
Javelin throwers elbow is an injury to the medial collateral ligament, often caused by overuse. This injury is common in throwing athletes who participate in baseball, water polo, handball, tennis, cricket and javelin. You will begin to experience this injury if the force placed on the MCL is greater than the tensile properties of the ligament. Increased load on the MCL is often caused by poor throwing technique, for example it is likely the injured athlete is positioning their arm with 90° - 100° of abduction when ideally 120° - 130° should be achieved.
The Medial Collateral Ligament (MCL) is seen in both the knee and the elbow. As the name suggests, the ligament lies on the medial (inside) aspect of the elbow, and resists valgus forces. Much like the MCL of the knee, this ligament is easily susceptible to injury. The elbow joint connects the humerus to the bones of the forearm; radius and ulna. A separate joint within the same joint capsule is the proximal radio-ulnar joint, which allow supination and pronation (rotation) of the forearm. The elbow joint is classified as a hinge joint; therefore, its primary movement is flexion and extension. If the joint is put under valgus or varus forces, it is at risk of injury.
What are the Signs & Symptoms?
As this condition is predominantly an overuse injury, you will begin to experience increased pain and decreased power during or following throwing activities. During the throw your pain can be sharp but as the condition worsens you will experience an ache at rest, typically following a period of throwing. Upon examination there will be marked tenderness over the site of the MCL and adjacent muscles such as your wrist flexors. You may have decreased ROM and increased swelling around the area.
You will also notice pain in your elbow during everyday tasks such as carrying bags or anything that puts the MCL under increased stress. Your practitioner will perform an MCL stress test in order to assist with the diagnosis (the test puts the MCL under valgus stress similar to a throw, but in a more controlled environment).
Various other injuries can appear in the same way as MCL sprain of the elbow, these include:
- Medial epicondylitis (golfer's elbow).
- Medial epicondyle avulsion fracture.
- Ulno-humeral arthritis.
- Nerve entrapment (e.g. ulnar).
In the early stages of recovery, it is essential to follow the RICE principle. Rest, Ice, Compression and Elevation. Additionally, patients may benefit from NSAIDs in order to reduce pain, swelling and inflammation (please discuss medication with your pharmacist).
After the first few days of rest in complete, you will maintain a cessation of throwing and any aggravating tasks. This will include no throwing and any tasks that cause pain the elbow. During this phase you will begin to complete basic isometric strengthening (exercises where you hold weight but don't move) to ensure no muscle dystrophy occurs (muscle wastage). Examples of this may include stress ball squeezes and holding a weight with your elbow bent.
Now it is time to start increasing the load through the elbow once again. It is critical to be patient during the phase as you will often be experiencing very little pain and therefore you may think you are ready to return to throwing. Before you return to throwing you should commence strengthening of your upper limb. This will include shoulder, elbow and wrist. Most importantly you shoulder focus on strength of biceps, triceps, elbow supination/pronation (rotation), wrist flexion and extension. During this time, you will slowly return to throwing but at a reduced INTENSITY & VOLUME.
The leading cause for MCL elbow strain is poor throwing technique. Therefore, it is crucial that you address needed changes to throwing technique. If you are unable to do so, it is almost guaranteed that you will suffer this injury once again.
In rare cases, surgery is required if the injury fails to improve with conservative management. If you sustain a ruptured (fully torn) MCL, then you will likely need surgery. The most common surgeries are a direct repair of the ligament or an elbow reconstruction. You should attempt at least 3 months of conservative treatment before considering surgery.