Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study

The purpose of this study was to determine the relative contribution of muscle activity and the effect of forearm position on the stability of the medial collateral ligament (MCL)-deficient elbow. Simulated active and passive elbow flexion with the forearm in both supination and pronation was performed using a custom elbow testing apparatus. Testing was first performed on intact specimens, then on MCL-deficient specimens. Elbow instability was quantified using an electromagnetic tracking device by measuring internal-external rotation and varus-valgus laxity of the ulna relative to the humerus. Compared with the intact elbow, transection of the MCL, with the arm in a vertical orientation, caused a significant increase in internal-external rotation during passive elbow flexion with the forearm in pronation, but forearm supination reduced this instability. Overall, following MCL transection the elbow was more stable with the forearm in supination than pronation during passive flexion. In the pronated forearm position simulated active flexion also reduced the instability detected during passive flexion, with the arm in a varus and valgus gravity-loaded orientation. The maximum varus-valgus laxity was significantly increased with MCL transection regardless of forearm position during passive flexion. We concluded that active mobilization of the elbow with the arm in vertical orientation during rehabilitation is safe in the setting of an MCL-deficient elbow with the forearm in a fully supinated and pronated position. Splinting and passive mobilization of the MCL-deficient elbow with the forearm in supination should minimize instability and valgus elbow stresses should be avoided throughout the rehabilitation period.