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Lateral Ulnar Collateral Ligament Injury

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Other Names

  • Lateral Ulnar Collateral Ligament Injury
  • PLRI
  • Posterolateral Rotatory Instability of the elbow
  • Posterolateral Rotatory Instability
  • LUCL Injury
  • Lateral Ulnar Collateral Ligament Tear
  • Posterolateral Rotatory Instability (PLRI) of the Elbow
  • Lateral Elbow Instability
  • Lateral Collateral Ligament Complex Injury (Elbow)

Background

  • This page refers to injuries to the Lateral Collateral Ligament Complex of the Elbow
    • This represents a spectrum of disease from 'strains' of the lateral ligament structures to complete ruptures and posterolateral rotatory instability (PLRI)

History

  • Posterolateral Rotatory Instability (PLRI) first described by O'Driscoll in 1991[1]
  • In a subsequent paper by O'Driscoll, recognized as a spectrum of instability[2]
  • In 2016, Fedorka and Oh confirmed LUCL injuries central to instability[3]

Epidemiology

  • Not well described in the literature
  • Most common cause of chronic elbow instability[4]

Pathophysiology

Illustration of the lateral collateral ligament complex[5]
Typical mechanism of injury[6]
The lateral collateral ligament complex[7]

General

  • Involve disruption of the lateral capsuloligamentous structures that stabilize the ulnohumeral and radiocapitellar joints
  • The LCL complex includes radial collateral, lateral ulnar collateral (LUCL), annular, and accessory lateral collateral ligaments
  • Patients typically present with mechanical symptoms such as click, locking and instability
  • Diagnosis requires a high index of suspicion, detailed history, focused physical exam augmented by imaging
  • Management depends on the degree of instability; low grade isolated injuries may be managed conservatively while the rest require surgical intervention

Etiology

  • Trauma, most commonly is the most common cause
    • In one study, 67/71 patients with PLRI described a traumatic event[8]
    • Can be as a result of elbow dislocation or significant valgus stress with axial load
  • Iatrogenic as a result of surgical procedure, for example tenotomy for Lateral Epicondylitis
    • Other iatrogenic causes include radial head resection, prior distal humeral fracture repair
  • Chronic attenuation
    • Due to chronic cubitus varus

Posterolateral rotatory instability (PLRI)

  • Characterized by abnormal external rotation, posterior subluxation of the ulna and radius relative to the distal humerus
    • Primarily, this occurs due to injury to the lateral ulnar collateral ligament (LUCL)[9]
    • PLRI can be thought of as the end spectrum of LUCL injuries
  • The instability allows the forearm bones to rotate externally and subluxate away from the humeral trochlea
  • This presents as painful clicking, snapping, locking or even frank dislocation when the elbow is loaded in supination and extension[10]
    • PLRI presents similar to isolated LUCL tears, but is characterized by subluxation or dislocation
  • Management requires surgical intervention

Anatomy of the Lateral Collateral Ligament Complex of the Elbow

Associated Conditions

Risk Factors

  • History of elbow dislocation
  • Trauma with hyperextension/ supination
  • Iatrogenic
  • Repetitive overuse
  • Heavy labor
  • Multiple corticosteroid injections for lateral epicondylitis

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

Demonstration of the Elbow Varus Stress Test

History

  • Most patients will endorse either an acute or chronic, repetitive trauma
  • Will complain of pain, clicking, catching, locking, snapping
  • They may even endorse recurrent dislocations
  • Worse with supination extension and valgus forces, e.g. carrying a bag

Physical: Physical Exam Forearm

  • Tenderness over LCL
  • Instability with varus stress

Special Tests

Evaluation

MRI of patients with atraumatic LUCL insufficiency (right elbow): a partial lesion of LUCL and extensor tendons (blue arrows) after multiple steroid injections and b complete LUCL and extensor tendon avulsion (blue arrow) following surgery[12]
A) Coronal section of the elbow at the level of the lateral ulnar collateral ligament. The white dotted square marks the corresponding area of the ultrasound image on B) acquired in an oblique long axis direction at the posterolateral elbow at the level of the radial head[13]

Radiographs

  • Standard Radiographs Elbow
    • Useful to evaluate other causes of pain, especially in the setting of trauma
    • No confirmatory findings for Elbow LCL
  • Stress radiography can confirm instability
    • AP stress view can show show slight malalignment of the ulnohumeral joint, overlap of the radial head and capitellum[14]
  • Can see "permanent defect or crater in the postero-lateral margin of the capitulum occurs, and, with repeated dislocation, the edge of the radial head can become similarly damaged, sometimes with a crater or ‘shovel-like’ defect”[15]
    • Sometimes referred to as 'Osborne-Cotterill Lesion'[16]

MRI

  • Helpful to better evaluate soft tissue injuries
  • LCL difficult to visualize due to oblique course
  • Pathology identified in 50% of patients (need citation)

Ultrasound

  • Teixeira et al: Able to identify RCL, LUCL and annular ligament 10/10 normal subjects and 8/10 cadaveric elbows[17]
  • Future studies needed for dynamic evaluation and clarification of pathological findings

Classification

O'Driscoll Classification

  • Timing: acute, chronic, recurrent
  • Articulations Involved: ulnohumeral, radiohumeral, proximal radioulnar or both
  • Direction of Displacement: posterolateral, anterior, valgus, and varus
  • Degree of Displacement: Refers to degree of displacement to posterolateral rotary instability
    • Stage 1: elbow subluxates in a posterolateral rotatory direction, patient has positive lateral pivot-shift test.
    • Stage 2: elbow has an incomplete dislocation so the coronoid is perched under the trochlea.
    • Stage 3: complete elbow dislocation so that the coronoid is behind the humerus.
    • Stage 3a: anterior band of the medial collateral ligament (MCL) is intact, and after reduction, the elbow is stable to valgus stress.
    • Stage 3b: anterior MCL is disrupted and the elbow is unstable to valgus stress after reduction.
    • Stage 3c: complete soft tissue stripping of the elbow and it is grossly unstable even after the application of a splint or cast.
  • Presence of Fractures: present or absent

Management

Lateral view of the elbow demonstrating the grasping sutures placed in the lateral ulnar collateral ligament and advanced through drill holes in the centre of rotation through to the posterior lateral condyle.[18]
Case 3: a 38-year-old man treated by repair of lateral collateral ligament (LCL) complex alone. (A) Initial radiograph showing dislocation on left elbow. (B) After closed reduction, the elbow was not congruent on lateral view. (C) Magnetic resonance imaging scan showing injuries of LCL complex and sprain of medial collateral ligament. (D, E) Radiographs at postoperative 3 months showing stable elbow. (F, G) Photographs at postoperative 3 months.[19]

Nonoperative

  • If acute elbow dislocation
  • If subacute, can manage nonoperatively in mild instability or low demand patients
    • Elbow Brace, what type?
    • Physical Therapy with emphasis on extensor strengthening
    • Activity modification

Operative

  • Acute Indications[20]
    • OCD or soft tissue in joint space preventing reduction
    • Complex
    • Instability
  • Technique
    • ORIF with LCL repair
  • Chronic Indications
    • Chronic symptoms refractory to conservative management

Rehab and Return to Play

Rehabilitation

  • No comparative studies on postoperative protocols exist
  • Publishes cases series support several weeks of immobilization at 90° flexion and pronated forearm
  • Followed by 4-6 weeks in Hinged Elbow Brace
  • Followed by prolonged strengthening protocol

Proposed Rehab Program

  • Phase 1 (protection and early motion, weeks 0-3)
    • Goals: Protect healing ligament, control pain and inflammation, initiate protected range of motion, prevent elbow stiffness
    • Immobilization: hinged elbow brace locked at 30-90° flexion (1-2 weeks), gradually increase extension as tolerated, maintain forearm in pronation during exercises
    • Range of Motion: Weeks 0-1: Passive ROM exercises with arm overhead (weeks 0-1), progress to active-assisted ROM with forearm pronated (1-3 weeks), 3-4 times daily
    • Avoid: Varus stress, forearm supination, combined extension-supination
    • Pain Management: Acetaminophen, NSAIDs as needed, Ice 15-20 minutes, 3-4 times daily, (avoid corticosteroid injections)
    • Precautions: No lifting, pushing, or pulling activities, avoid varus arm positioning, sleep with elbow supported in flexion
  • Phase 2 (intermediate rehabilitation, weeks 3-6)
    • Goals: restore full ROM, initiate strengthening program, improve neuromuscular control
    • Bracing: continue hinged elbow brace during activities, may discontinue at night if comfortable, wean from brace by week 6 based on stability
    • Range of Motion: progress to full active ROM in all planes, continue overhead positioning for exercises when possible, maintain forearm pronation emphasis
    • Strengthening (Begin Week 6): flexion, extension, pronation, supination (isometric), light resistance exercises with forearm pronated, Wrist flexor/extensor, grip
    • Neuromuscular Training: proprioceptive exercises, joint position sense training, rhythmic stabilization drills
  • Phase 3 (advanced strengthening, weeks 6-12)
    • Goals: restore full strength, progress functional activities, prepare for sport-specific training
    • Strengthening: isotonic strengthening, ccentric exercises for elbow flexors/extensors, shoulder girdle and scapular stabilization, core strength, kinetic chain rehab
    • Functional Activities: gradual return to activities of daily living, light recreational activities by week 8-12, sport-specific movements without resistance
    • Criteria to Progress: full pain-free ROM, strength >70% of contralateral side, no pain with resisted activities, negative provocative testing for instability

Lateral Ulnar Collateral Ligament Injury Rehab Exercises PDF

Return to Play

  • Goals:
    • Return to full sport participation
    • Prevent re-injury
  • Sport-Specific Training:
    • Progressive sport-specific drills
    • Interval training programs
    • Gradual increase in intensity and duration
    • Throwing athletes: structured throwing program over 8-12 weeks
  • Return to Play Criteria:
    • Full pain-free ROM (within 5° of contralateral side)
    • Strength ≥90% of contralateral side (isokinetic testing)
    • Negative clinical instability tests
    • Successful completion of sport-specific training without symptoms
    • Psychological readiness
  • Timeline Expectations:
    • Conservative treatment: 3-4 months for light sports, 4-6 months for full return
    • Post-surgical repair: 4-6 months for return to sport
    • Post-surgical reconstruction: 6-8 months for return to sport

Prognosis and Complications

Post traumatic arthritis show in the Broberg and Morrey classification. (A) Grade 1: slight joint space narrowing with minimal osteophyte formation (B) Grade 2: moderate joint space narrowing with moderate osteophyte formation (C) Grade 3: severe degenerative change with gross destruction of the joint.[21]

Prognosis

  • General
    • Generally favorable when managed appropriately
    • This is especially true with surgical management of unstable or chronic problem
  • Surgical
    • Most patients who undergo LUCL repair have good to excellent functional outcomes[22]
    • Elbow ability can be restored with a high rate of return to ADL and sports[23]
    • Functional range of motion is regained in over 90% of patients
    • Patient satisfaction is high, most report minimal pain and disability at mid- and long- term follow up[24]

Complications

  • Posterolateral Rotatory Instability
  • Recurrent elbow dislocation or subluxation[25]
  • Chronic Pain
  • Traumatic Arthritis
  • Stiffness and loss of range of motion
  • Recurrent instability
  • Postoperative
    • Infection
    • Cutaneus nerve injury
    • Loss of ROM

See Also

Internal

External

References

  1. ↑ O’Driscoll S, Bell D, Morrey BF. Posterolateral instability of the elbow. J Bone Joint Surg. 1991;73:440–446.
  2. ↑ O'DRISCOLL, SHAWN W., et al. "Elbow Subluxation and Dislocation: A Spectrum of Instability." Clinical Orthopaedics and Related Research (1976-2007) 280 (1992): 186-197.
  3. ↑ Fedorka, Catherine J., and Luke S. Oh. "Posterolateral rotatory instability of the elbow." Current reviews in musculoskeletal medicine 9.2 (2016): 240-246.
  4. ↑ Shemesh, Shai, et al. "Posterolateral rotatory instability of the elbow." Harefuah 153.5 (2014): 261-5.
  5. ↑ Bain GI, Mehta JA. Anatomy of the elbow joint and surgical approaches. In: Baker CL Jr, Plancher KD, eds. Operative Treatment of Elbow Injuries. New York, NY: Springer-Verlag;2001:1 e 27.
  6. ↑ Camp, Christopher L., Jay Smith, and Shawn W. O'Driscoll. "Posterolateral rotatory instability of the elbow: part I. Mechanism of injury and the posterolateral rotatory drawer test." Arthroscopy techniques 6.2 (2017): e401-e405.
  7. ↑ Hayter, Catherine L., and Bruno M. Giuffre. "Overuse and traumatic injuries of the elbow." Magnetic Resonance Imaging Clinics 17.4 (2009): 617-638.
  8. ↑ Anakwenze OA, Kwon D, O’Donnell E, Levine WN, Ahmad CS. Surgical treatment of posterolateral rotatory instability of the elbow. Arthrosc - J Arthrosc Relat Surg. 2014;30(7):866–871. doi: 10.1016/j.arthro.2014.02.029.
  9. ↑ Kotsapas, Michail, et al. "Anatomical considerations, diagnosis, and treatment of medial and posterolateral elbow rotatory instability in athletes: an arthroscopic perspective and literature review." International Orthopaedics (2025): 1-12.
  10. ↑ Anakwenze, Oke A., et al. "Posterolateral rotatory instability of the elbow." The American journal of sports medicine 42.2 (2014): 485-491.
  11. ↑ Goldin, Amanda N., et al. "A simple and versatile test for elbow posterolateral rotatory instability." Hand 20.1 (2025): 37-42.
  12. ↑ Geyer, Stephanie, et al. "LUCL reconstruction of the elbow: clinical midterm results based on the underlying pathogenesis." Archives of Orthopaedic and Trauma Surgery 142.8 (2022): 1809-1816.
  13. ↑ Gondim Teixeira, Pedro Augusto, et al. "Ultrasound assessment of the lateral collateral ligamentous complex of the elbow: imaging aspects in cadavers and normal volunteers." European radiology 21.7 (2011): 1492-1498.
  14. ↑ O’Driscoll S. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res. 2000;(370):34–43.
  15. ↑ Osborne G, Cotterill P. Recurrent dislocation of the elbow. J Bone Joint Surg Br. 1966;48(2):340–346.
  16. ↑ . Jeon IH, Micic ID, Yamamoto N, Morrey BF. Osborne-Cotterill lesion: an osseous defect of the capitellum associated with instability of the elbow. AJR Am J Roentgenol. 2008;191(3):727–729.
  17. ↑ Teixeira PAG, Omoumi P, Trudell DJ, et al. Ultrasound assessment of the lateral collateral ligamentous complex of the elbow: imaging aspects in cadavers and normal volunteers. Eur Radiol. 2011;21(7): 1492–1498
  18. ↑ Marinelli, Alessandro, et al. "Treatment of elbow instability: state of the art." Journal of ISAKOS 6.2 (2021): 102-115.
  19. ↑ Heo, Youn Moo, et al. "Unstable simple elbow dislocation treated with the repair of lateral collateral ligament complex." Clinics in orthopedic surgery 7.2 (2015): 241-247.
  20. ↑ https://www.orthobullets.com/shoulder-and-elbow/3129/lateral-ulnar-collateral-ligament-injury-plri
  21. ↑ Kwak, J-M., et al. "Intraobserver and interobserver reliability of the computed tomography-based radiographic classification of primary elbow osteoarthritis: comparison with plain radiograph-based classification and clinical assessment." Osteoarthritis and Cartilage 27.7 (2019): 1057-1063.
  22. ↑ Daluiski, Aaron, et al. "Direct repair for managing acute and chronic lateral ulnar collateral ligament disruptions." The Journal of hand surgery 39.6 (2014): 1125-1129.
  23. ↑ Kim, Jeong Woo, et al. "Arthroscopic lateral collateral ligament repair." JBJS 98.15 (2016): 1268-1276.
  24. ↑ Geyer, Stephanie, et al. "LUCL reconstruction of the elbow: clinical midterm results based on the underlying pathogenesis." Archives of Orthopaedic and Trauma Surgery 142.8 (2022): 1809-1816.
  25. ↑ Cohen, Mark S., and I. I. Hill Hastings. "Rotatory instability of the elbow. The anatomy and role of the lateral stabilizers." JBJS 79.2 (1997): 225-33.
Created by:
John Kiel on 18 June 2019 01:54:07
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Last edited:
29 May 2026 12:33:33
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