Medial elbow pain combined with a sense of instability during overhead activities or after elbow trauma may indicate posterior medial rotatory instability, a less common but important form of elbow instability that benefits from specialist assessment and, in significant cases, surgical reconstruction.
What is Posterior Medial Rotatory Instability (PMRI)?
PMRI involves instability of the medial aspect of the elbow, primarily caused by damage to the medial collateral ligament (MCL) complex. It can present following a traumatic dislocation with associated MCL injury, or in overhead athletes who subject the medial elbow to repeated valgus stress, such as cricketers and baseball pitchers. It is frequently associated with posterior elbow dislocation and coronoid fractures.
Types of Posterior Medial Rotatory Instability (PMRI)
Causes
High-energy elbow trauma, including dislocations and complex fracture-dislocations, are the primary traumatic causes. Repetitive valgus loading in throwing athletes can cause chronic MCL insufficiency and progressive medial instability.
- Pain on the medial (inner) side of the elbow with overhead or throwing activities
- A feeling of looseness or instability in the elbow joint
- Reduced confidence in the elbow during overhead athletic activities
- May be associated with ulnar nerve symptoms including tingling in the ring and little fingers
Diagnosis
The moving valgus stress test, performed with the elbow in full flexion moving to extension while a valgus force is applied, reproduces the characteristic medial elbow pain in patients with MCL insufficiency. The milking manoeuvre also applies valgus stress and tests MCL integrity.
Plain X-rays may show medial joint space widening on valgus stress views, confirming instability. MRI or MRI arthrogram is the primary imaging investigation, demonstrating partial or complete MCL tears, areas of tendon degeneration, and associated pathologies such as loose bodies and posteromedial osteophytes.
Treatment
Elbow Ligament Reconstruction (MCL Reconstruction)
For significant MCL insufficiency causing functional instability, Dr. Kushalappa performs MCL reconstruction using a tendon graft, recreating the medial restraint of the elbow and restoring stability for overhead athletic activities.
Why Choose Dr. Kushalappa Subbiah in Bangalore?
Dr. Kushalappa Subbiah completed a Fellowship in Shoulder Surgery at the Sydney Shoulder Research Institute, where he trained in advanced arthroscopic shoulder procedures including labral repair and reconstruction. He holds the International Olympic Committee (IOC) Diploma in Sports Medicine, and has direct clinical experience managing shoulder injuries in Indian athletes across cricket, swimming, tennis, and contact sports. He is appointed as a Consultant Shoulder Surgeon at NH Hospital, Bangalore.