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Posterolateral Rotatory Instability (PLRI)

Most common cause of chronic elbow instability, related to insufficiency of the lateral ulnar collateral ligament (LUCL). Often sequel of elbow dislocation or lateral surgery. O'Driscoll classification with 3 stages of increasing severity.

Characteristics

Posterolateral rotatory instability (PLRI) is the most common form of chronic recurrent elbow instability [1]. Described by O'Driscoll in 1991, it results from insufficiency of the lateral collateral ligament complex, primarily the lateral ulnar collateral ligament (LUCL), spanning from the lateral epicondyle to the supinator crest of the ulna. The LUCL is the main stabilizer against varus and external rotation of the forearm. Its rupture causes rotatory subluxation of the forearm in supination and valgus, with posterolateral translation of the radial head beneath the capitellum.

The most common etiology is post-traumatic, sequel of an elbow dislocation (non-healed or poorly repaired ligament), potentially leading to recurrent dislocation. Iatrogenic causes include repeated lateral corticosteroid injections and lateral epicondyle release surgery with LUCL damage [2].

Clinical diagnosis relies on the lateral pivot-shift test (O'Driscoll), performed supine under anesthesia if necessary: supination-valgus-axial compression with progressive extension provoking subluxation then reduction click in flexion. The chair sign (apprehension when rising from a chair with forearms in supination) and push-up sign are complementary functional tests. MRI may show the LUCL injury but false negatives are frequent. CT arthrography with contrast injection is more sensitive [3].

  • The lateral collateral ligament complex includes the radial collateral ligament (from epicondyle to annular ligament), the lateral ulnar collateral ligament (LUCL – from epicondyle to supinator crest of ulna), the annular ligament and the accessory lateral collateral ligament. The LUCL is the key structure: its insufficiency allows external rotation of the ulna and posterolateral translation of the radial head.
  • PLRI mechanism: LUCL injury allows the forearm to rotate externally (supination) relative to the humerus, causing posterolateral subluxation of the radial head. The main etiology is post-traumatic (sequel of elbow dislocation), followed by iatrogenic causes (lateral elbow surgery, repeated corticosteroid injections).
  • Risk factors: history of elbow dislocation (main cause), lateral elbow surgery (epicondylitis release, radial head arthroplasty), repeated corticosteroid injections in the lateral epicondyle area, constitutional ligamentous hyperlaxity, repetitive elbow trauma.
  • Complications: recurrent elbow subluxation or dislocation, progressive joint damage from repeated subluxations, post-traumatic arthritis, loss of quality of life and sports disability.

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  1. Stage 1 – Posterolateral rotatory subluxation

    Rotatory subluxation of the radial head with partial external rotation of the ulna. Positive lateral pivot-shift test with apprehension or subluxation without complete dislocation. Positive chair sign. LUCL insufficiency with preserved secondary stabilizers. Clinical symptoms of clicking, catching and apprehension during daily activities. Treatable by LUCL reconstruction.

  2. Stage 2 – Incomplete dislocation (perched)

    More pronounced subluxation with the radial head perched on the capitellum edge. Posterior capsule disruption adding to the LUCL insufficiency. Lateral pivot-shift test shows a definite subluxation without complete posterior dislocation. More significant functional symptoms with recurrent episodes of perceived instability or frank subluxation.

  3. Stage 3 – Complete dislocation

    Complete posterolateral elbow dislocation. Complete disruption of LUCL, posterior capsule and variable medial ligament involvement. Stage 3A: MCL posterior bundle intact (pivoting around intact MCL). Stage 3B: complete MCL disruption except anterior bundle. Stage 3C: complete disruption of all ligamentous structures. Mandatory surgical reconstruction.

Medical and Surgical Management

  • LUCL reconstruction with tendon autograft (palmaris longus, gracilis): reference surgical treatment. Graft anchoring on the lateral epicondyle and supinator crest of the ulna using bone tunnels or interference screws. Taux of 85-90% good to excellent results. Ligament augmentation with Internal Brace is an emerging alternative.
  • Primary LUCL repair: possible in acute injuries (< 3 weeks) with good quality tissue. Reinsertion by suture anchors on the lateral epicondyle. Less reliable than reconstruction if ligament quality is poor.
  • Conservative treatment (mild cases): strengthening of dynamic stabilizers (anconeus, supinator, extensors) to compensate for passive ligament insufficiency. Avoidance of provocative positions (push-ups with forearms in supination). Activity modification. May be attempted before surgery but rarely sufficient in established PLRI.

Physiotherapy treatment

  • Post-reconstruction: hinged elbow brace with adjustable stops for 6 weeks. Initial protected range 30-100° flexion. Avoid forearm supination against resistance and full extension for 6 weeks. Active-assisted flexion-extension mobilization within the allowed range.
  • Strengthening of dynamic elbow stabilizers: anconeus (posterolateral stabilizer), supinator, wrist and finger extensors (common extensor origin on lateral epicondyle). Isometric exercises from week 3, concentric from week 6. Flexor-pronator strengthening as well.
  • Closed-chain proprioceptive work with forearm in pronation (protective position): wall push-ups in pronation, then table, then floor. Avoid supinated push-ups which stress the reconstruction. Progressive dynamic stabilization with perturbation training.
  • Progressive return to functional activities from week 8-12. Open-chain strengthening with progressive loading. Return to non-contact sports at 4-6 months, contact sports at 6-9 months. Avoid provocative movements (push-ups in supination, Turkish get-ups) for at least 6 months.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

6 to 12 months post-reconstruction, return to sports 6-9 months

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