An elbow that feels unstable — or gives way — during pushups, pressing, or weight-bearing on outstretched arms is describing posterolateral rotatory instability. Most LUCL injuries resolve without surgery. When they don't, Dr. R. David Graham at Jacksonville Orthopaedic Institute performs a direct ligament repair using a knotless anchor technique — or reconstruction when the tissue demands it.
PLRI is one of the more frequently missed causes of lateral elbow pain — often attributed to lateral epicondylitis before the instability component is identified. The pivot shift test is the key examination finding.
Understanding the Condition
The lateral ulnar collateral ligament (LUCL) is the primary stabilizer of the lateral elbow against posterolateral rotatory forces. It originates at the lateral epicondyle of the humerus and inserts on the supinator crest of the ulna, forming the deep layer of the lateral collateral ligament complex — distinct from the radial collateral ligament that lies superficial to it.
The LUCL's specific function is to prevent the forearm from rotating posterolaterally away from the humerus when the elbow is extended and the forearm supinated. Under normal loading conditions, the intact LUCL keeps the ulna and radius coupled to the humerus during pushups, pressing movements, and activities requiring weight-bearing through an outstretched arm. When the LUCL is torn or attenuated, this coupling fails and the forearm subluxes posterolaterally — producing the characteristic symptom pattern of posterolateral rotatory instability (PLRI).
LUCL tears most commonly occur from elbow dislocations — when the elbow dislocates, the lateral soft tissue envelope fails in a predictable sequence starting with the LUCL. They can also develop after repeated corticosteroid injections to the lateral epicondyle (which weaken the lateral ligament complex), from iatrogenic injury during elbow surgery, or from chronic overuse in patients with recurrent valgus-varus loading. Many patients present without a clear single injury event — their PLRI has developed insidiously or was never diagnosed at the time of an old elbow dislocation.
In Dr. Graham's experience, PLRI is underdiagnosed — patients often present having been treated for lateral epicondylitis for months without improvement, because the lateral elbow pain from ligament insufficiency mimics epicondylitis clinically until the instability component is specifically tested. The lateral pivot shift test, performed with the patient supine and the elbow extended under valgus stress with forearm supination, demonstrates the characteristic posterolateral subluxation and is the key examination finding.
The LUCL (orange) runs from the lateral epicondyle to the supinator crest of the ulna. The red oval marks the typical tear zone. The purple arrow shows the posterolateral subluxation direction of PLRI. The green anchor represents Dr. Graham's knotless anchor repair technique at the lateral epicondyle.
Unlike UCL tears — which typically occur at the medial elbow in throwers — LUCL tears are more commonly associated with elbow dislocations, repeated lateral epicondyle injections, or iatrogenic injury.
The Instability Pattern
PLRI is the clinical syndrome that results from LUCL insufficiency. Understanding the mechanics explains why pushups specifically provoke the symptoms and why the pivot shift test is the diagnostic key.
The pushup position loads the elbow in extension with the forearm supinated and the hand fixed to the ground. As the elbow extends toward full extension, gravity and the body's weight create a posterolateral rotatory force on the forearm — exactly the direction the LUCL resists. When the LUCL is intact, this force is absorbed and the elbow remains stable. When the LUCL is torn or attenuated, the ulna and radius rotate posterolaterally away from the lateral condyle as the elbow extends.
Patients experience this as pain, apprehension, or a giving-way sensation specifically during the descending phase of a pushup — the phase where the elbow extends under load. Some feel a click or clunk as the joint subluxes and reduces. Many patients subconsciously begin performing pushups with the forearms pronated (knuckle pushups) to avoid the provocative supinated position — an instinctive compensation that hints at the diagnosis before the examination.
Other provocative activities include pressing weight overhead with the hands outside shoulder-width, pushing open heavy doors, and any task requiring pushing force through an outstretched supinated arm. Chair rising — pushing up from a chair armrest — can also reproduce the instability in more severe cases.
Performed supine with the arm overhead, elbow extended, forearm supinated. Valgus stress and axial compression applied while flexing the elbow. A positive test produces visible or palpable posterolateral subluxation of the radial head — and often an apprehension response from the patient before any subluxation is observed. Often best confirmed under anesthesia.
The patient pushes up from a chair with forearms supinated, or performs a pushup with palms flat. Pain, apprehension, or instability reproduced in this position — particularly near full elbow extension — is a positive pushup sign consistent with PLRI. A more specific functional confirmation of the laboratory pivot shift finding.
MRI characterizes the LUCL tear — location, completeness, tissue quality — and assesses the surrounding lateral collateral ligament complex. Dynamic fluoroscopy or stress radiographs can demonstrate the posterolateral subluxation under provocative loading. MRI also identifies any associated radial head or posterior interosseous nerve pathology.
Recognizing LUCL Injury
PLRI from a LUCL tear has a distinctive symptom pattern. The key is the positional specificity — symptoms are provoked by extension under load with the forearm supinated, not by general elbow use.
The most characteristic symptom — the elbow feels like it is going to give out, or actually does give way, during the extending phase of a pushup or pressing movement. Some patients describe a click or clunk. Many patients begin avoiding pushups entirely or compensate with pronated forearms without consciously realizing why. This specific, position-dependent instability distinguishes PLRI from lateral epicondylitis, which is activity-related pain without instability.
Pain on the lateral side of the elbow — over the lateral epicondyle and just distal to it along the lateral joint line. This location overlaps precisely with lateral epicondylitis (tennis elbow), which is why PLRI is frequently missed and misdiagnosed. The key distinguishing feature is the instability component: epicondylitis produces pain with resisted wrist extension; LUCL tear produces apprehension and instability with elbow extension under load.
Beyond pushups, any activity requiring weight-bearing through an outstretched arm — getting up from a chair, pushing open a heavy door, overhead pressing — can provoke apprehension. Some patients notice the elbow feels "loose" or "unreliable" with any forceful pushing task. Apprehension (the patient's anxiety about the elbow giving way) can be present even in the absence of frank instability during daily activities.
As the radial head and ulna sublux posterolaterally and then spontaneously reduce, a click or clunk may be felt and sometimes heard. This is the mechanical hallmark of joint subluxation — distinct from the grinding of arthritis or the snapping of a tendon. The click is typically reproducible in a specific arc of elbow motion with the forearm supinated.
A prior elbow dislocation — even one that was reduced promptly and seemed to heal uneventfully — is the most common cause of LUCL tear. The LUCL is the first structure to fail during the lateral-to-medial ligament disruption sequence of elbow dislocation. If the dislocation was not followed by adequate immobilization and rehabilitation, the LUCL may have healed in an attenuated or lengthened position that provides insufficient stability.
Repeated corticosteroid injections to the lateral epicondyle can weaken the lateral collateral ligament complex over time — a well-recognized iatrogenic cause of LUCL insufficiency. Patients who have received multiple lateral epicondyle injections for presumed tennis elbow and notice progressive instability, rather than persistent pain alone, should be assessed for PLRI. This presentation highlights the importance of the pivot shift test in any lateral elbow evaluation.
When Is Surgery Indicated?
Most LUCL injuries are managed non-operatively. Surgery is indicated in two specific circumstances — each with clear clinical criteria.
When a patient has completed a course of conservative management — activity modification, avoidance of provocative loading positions, physical therapy strengthening of the lateral elbow musculature — and continues to have functional instability with a positive pivot shift test, surgery is indicated. The pivot shift test must remain positive, confirming that the LUCL has not healed sufficiently to restore stability. Patients in this category experience ongoing limitations with pushups, pressing, and weight-bearing activities that are no longer acceptable to them.
When a LUCL tear accompanies an elbow fracture that itself requires operative fixation — most commonly an olecranon fracture or a radial head fracture — the LUCL is repaired at the same surgical setting. Since the patient is already undergoing surgery for the fracture, repairing the LUCL simultaneously eliminates a second operation and addresses both the bony and ligamentous injuries in one procedure. Dr. Graham assesses the LUCL intraoperatively after fracture fixation and repairs it when instability is confirmed.
Regenerative Treatment
PRP is used for elbow LUCL injuries in the same two roles as for UCL tears — non-operatively during conservative management, and as surgical augmentation at the time of repair or reconstruction. The biological rationale is consistent: ligament healing in a structurally disrupted tissue benefits from concentrated growth factors that accelerate cell proliferation, collagen synthesis, and vascular ingrowth at the tear site.
Non-operative PRP: For patients with confirmed LUCL tears pursuing conservative management, PRP injection into the lateral collateral ligament complex delivers growth factors directly to the tear zone. This is most biologically meaningful for partial tears and acute injuries where ligament continuity is maintained and the healing scaffold is intact. For patients who want to maximize the likelihood of avoiding surgery — or for those whose instability is mild and functional — PRP during the conservative window is a rational intervention.
Surgical PRP augmentation: At the time of LUCL repair or reconstruction, PRP is applied to the repair site and, for reconstruction, to the graft-tunnel interfaces. This promotes early healing of the repaired ligament and incorporation of the reconstruction graft, supporting the biological component of a recovery that the internal brace or graft weave alone cannot provide.
Surgical Treatment
Repair for acute injuries and first-time surgery. Reconstruction when the native tissue cannot support a reliable repair — failed prior repair or chronic laxity with poor tissue quality.
Dr. Graham's standard approach for acute LUCL injuries and first-time surgical repair. A locking stitch is run up and down the LUCL, capturing the ligament in a secure whipstitch pattern along its length. The construct is then "dunked" into a knotless suture anchor placed at the lateral epicondyle footprint — tensioning the ligament back to its anatomical origin without the bulk and potential irritation of exposed knots at the bone surface.
This technique preserves the native LUCL tissue entirely — nothing is replaced, no graft is harvested. The locking stitch distributes the repair tension across the ligament length rather than concentrating it at a single anchor point. PRP is applied to the repair site before closure to promote healing.
→ Acute LUCL tears, first-time surgical repair, fracture-dislocation setting. Native ligament preserved. Recovery: 3–4 months to functional activities.
When the native LUCL tissue is too attenuated, degenerative, or insufficient for reliable repair — whether from a chronic injury or a failed prior repair — reconstruction replaces the ligament with a graft. The graft is woven through bone tunnels at the lateral epicondyle and supinator crest of the ulna, recreating the LUCL's anatomic course. PRP is applied to the graft tunnels to support incorporation.
Reconstruction provides a structurally robust new ligament when the native tissue cannot. Recovery is longer than repair due to graft maturation — 6 to 9 months to full activities, compared to 3 to 4 months for repair.
→ Failed prior LUCL repair, chronic laxity with poor tissue quality. Recovery: 6–9 months to full activities.
Performed at Baptist Beaches Hospital or Horizon Surgery Center as a same-day outpatient procedure. Regional block with or without sedation, or general anesthesia. Tourniquet on the upper arm. The patient is positioned supine with the arm across the chest or on a hand table to allow lateral elbow access. When performed at the same setting as fracture fixation, positioning accommodates both procedures.
A longitudinal incision over the lateral epicondyle exposes the lateral collateral ligament complex. The posterior interosseous nerve (PIN) — the deep branch of the radial nerve — is in the vicinity and is carefully protected throughout. The lateral epicondyle origin of the LUCL is identified and the tear is exposed. The quality of the native LUCL tissue is assessed directly, confirming the repair versus reconstruction decision made preoperatively.
A locking stitch — a Krackow or modified locking whipstitch — is run up and down the length of the LUCL, capturing the ligament securely in a braid-like pattern. This distributes the tension of the repair along the ligament's full length rather than concentrating force at a single suture-to-bone interface. The ends of the suture are left long for anchor insertion.
A knotless suture anchor is prepared at the anatomic LUCL footprint on the lateral epicondyle. The free ends of the locking stitch are loaded into the knotless anchor. The LUCL is tensioned to its appropriate length and the anchor is deployed — driving the anchor into the bone and simultaneously locking the suture tension. The ligament is "dunked" into the footprint, creating a flush, knotless repair at the bone surface with no hardware prominence. Elbow stability is assessed through a full arc of motion under fluoroscopy.
PRP is applied to the LUCL repair site before closure — concentrated growth factors delivered directly to the repaired ligament to promote biological healing. The wound is closed in layers. A posterior elbow splint is applied at 90° of flexion with the forearm in neutral rotation or slight pronation — the position that reduces tension on the LUCL during healing. The patient goes home the same day.
Recovery
LUCL repair recovery is straightforward — a period of protected healing followed by progressive return to pushing and weight-bearing activities.
Posterior elbow splint at 90° in neutral or slight pronation. No forearm supination against resistance — the position that stresses the repair. Gentle finger and wrist motion encouraged. Edema management with ice and elevation.
Splint discontinued. Hinged elbow brace for activity. Progressive elbow range of motion and forearm rotation through formal therapy. Strengthening of the lateral elbow musculature — anconeus and extensor mass — begins to provide dynamic lateral stability.
Brace discontinued for most activities. Progressive introduction of pushing activities — initially with forearm pronated, then advancing to supinated positions as strength and confidence allow. Pivot shift testing performed to confirm restored stability.
In Dr. Graham's experience, most patients return to full weight-bearing activities — including pushups, bench press, and overhead pressing — by 3 to 4 months after LUCL repair. The pivot shift test should be negative and the patient should be able to perform pushups without apprehension.
"I had been treated for tennis elbow for almost a year with no improvement. Dr. Graham did a specific exam test and immediately identified that my elbow was actually unstable — not just painful. One surgery later, I'm doing pushups again without any apprehension for the first time in years."
Verified Patient · Elbow LUCL / PLRI · Google Review ★ 5/5
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