The Annular Ligament
The mighty annular ligament wraps around the radial head and attaches to the ulna, which stabilizes the radius bone when an athlete does any twisting or rotating movement of the elbow. Any kind of throwing motion, whether in javelin, baseball (especially the curve ball), bowling, or even lesser-known sports like hurling, puts tremendous force on this ligament. The team physician or athletic trainer rarely examines this ligament, so its injury is never diagnosed. The annular ligament is responsible for the majority of lateral elbow pain that continues for more than a couple of months. In our experience, nearly every patient that comes to our office with this condition has been told they have tennis elbow.
The annular ligament is located approximately three-quarters of an inch distal to (away from) the lateral epicondyle (the "tennis elbow" spot). Its job is to attach the radius bone to the ulnar bone. It is this ligament that enables the hand to rotate, as in turning a key or a screwdriver. It allows a bowler to crank out those big hooks, or the tennis player to hit a big forehand topspin smash. Because of the tremendous demands placed on the fingers and hands to perform repetitive tasks during everyday living (typing) and during athletic events, the annular ligaments becomes lax and a source of chronic elbow pain.
The lateral epicondyle of the humerus bone is very superficial (near the skin), so it is much more inviting to the dreaded cortisone-filled needle than is the deeper annular ligament. The needle must go down 1 to 1.5 inches to reach this ligament in some athletes. One of the reasons why this area is slow to heal with traditional physiotherapy is because it is so deep. The other reason is that it is a ligament, not a muscle. Ligament physiology is not changed much with ultrasound, massage, heat, or exercise.
Athletes are typically tender over the lateral epicondyle, but do not elicit positive "jump signs" in that area. Only palpation over the annular ligament elicits the positive "jump sign." The annular ligament also has a distinct referral pain pattern. It refers pain to the thumb, index, and middle fingers. This is the same pain pattern exhibited in Carpal Tunnel Syndrome.
Unfortunately, many people with elbow and hand pain have been misdiagnosed with Carpal Tunnel Syndrome. Carpal Tunnel Syndrome refers to the entrapment of the median nerve as it travels through the wrist into the hand. The nerve supplies sensation to the skin over the thumb, index, and middle fingers. A typical Carpal Tunnel Syndrome patient will experience pain and numbness in this distribution in the hand. Because most physicians do not know the referral pain patterns of ligaments, they do not realize that cervical vertebrae ligaments, C4 and C5, and the annular ligament can refer pain to the thumb, index, and middle fingers. Ligament laxity anywhere in the body can cause numbness and pain. Most orthopedic surgeons and athletic trainers do not know that numbness can be a sign of ligament weakness or injury. Cervical and annular ligament laxity should always be evaluated prior to making the diagnosis of Carpal Tunnel Syndrome. Surgery for Carpal Tunnel Syndrome should not be done until a physician who understands the referral patterns of ligaments and is experienced in Prolotherapy performs an evaluation.
Seldom do patients and athletes find relief from the "Carpal Tunnel" complaints of pain in the hand and elbow with physical therapy and surgery because the diagnosis is so often wrong. The most common reason for pain in the elbow, referring to the hand, is weakness in the annular ligament, not from Carpal Tunnel Syndrome. Several sessions of Prolotherapy will easily strengthen the annular ligament and relieve chronic elbow pain.
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