MCL Insufficiency

AetiologyTommy John Surgery


Throwing injury

- seen in the throwing athlete

- repetitive microtrauma / valgus stress

- develop laxity


Little leaguer's elbow







- lose velocity / accuracy


Develop medial pain


40% ulna nerve symptoms




Pain on palpation of anterior bundle MCL


CFO muscle bulk covers insertion in full extension

- reveal UCL with flexion


Jobes test


Valgus stress with elbow flexed 25o to unlock olecranon

- forearm pronated to prevent false positives due to lateral side laxity

- problem is shoulder ER



- lie patient prone

- apply valgus stress


Elbow MCL Test ProneElbow MCL Test Prone 2


Milker test

- shoulder ER

- thumb pointing out

- extend arm whilst placing valgus strain


MIlkers Sign 1Milkers Sign 2




Elbow MCL Anatomy




40% calcification MCL


Stress view

- > 3mm difference from opposite side




Nearly all throwing athletes / pitchers will have abnormalities

- don't decide surgery on basis of MRI findings




Non Operative






- may be muscle imbalance in throwers 

- overactivity of EDC and ECRB aggravates valgus

- physio to balance flexors and extensors 

- radial deviators vs Ulna deviators

- if doesn't settle consider reconstruction


Really amounts to 6/12 rest

- problem for professional athletes




Tommy John Surgery


Named after famous American baseball pitcher

- first to have this surgery




1.  Repair

- not often able to be done

- perhaps in acute tear


2.  Reconstruction with free graft

+ / - transpose ulnar nerve anteriorly out of the way

- many techniques described


UCL reconstruction


Tommy John Surgery


Numerus techniques described


Palmaris longus / gracilis graft


Ulna tunnel

- proximal ulna at level coronoid tubercle

- AP


Humeral tunnel

- medial epicondyle

- Y shaped

- no posterior cortical penetration to avoid injury ulna nerve


Figure of 8

- tension at 30o

- suture both limbs together to improve tension




Immobilise for 10/7

ROM brace for 4/52


No throwing for 6/12

No sport for 12/12




Jimmy Andrews et al Am J Sports Med 2010

- modification Jobe technique + subcutaneous ulna nerve transfer

- 942 patients followed up for 2 years minimum

- 83% returned to previous level of sport

- returned to throwing at 4 - 5 months

- return to full sport at 12 months


Posterior Elbow Impingement




Cause posteromedial pain

- probably related to subtle UCL instability


May be protective




Pain posteromedially with full extension




Identify posterior olecranon osteophytes




Arthroscopic Resection


Maximum 2 - 3 mm

- if remove too much arthroscopically

- high incidence of UCL tear

- probably protective