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 The Annular Ligament
Ross Hauser, M.D.
The annular
ligament
wraps around the radial head and attaches to the
ulna, which stabilizes the radius bone when a
patient 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
cortisone shots
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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