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MCL Injuries Dr. David Vasconcellos Sports Fellow University of Iowa Sports Medicine Center The Latest and Greatest Evidence Based Case 17 y/o male tackled at his left knee from the outside while playing intramural football. Knee buckled inward.

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mcl injuries

MCL Injuries

Dr. David Vasconcellos

Sports Fellow

University of Iowa Sports Medicine Center

slide4
Case
  • 17 y/o male tackled at his left knee from the outside while playing intramural football.
  • Knee buckled inward.
  • Felt a pop in his knee, limped off the playing field.
slide5
Case
  • PE
    • Stiff Knee Gait
    • Mild Effusion
    • No Joint Line TTP
    • +TTP over femoral insertion of the MCL
    • Negative Lachman, Negative Anterior and Posterior Drawer.
    • Negative McMurrays
    • Varus and Valgus stable in extension.
    • Moderate laxity in 30 degrees of flexion with valgus stress with firm endpoint.
slide6
Case
  • XR: Negative
slide7
Case
  • Diagnosis?
slide8
Case
  • Grade II MCL Tear
slide9
Case
  • Treatment
    • Conservative Treatment.
      • Crutches
      • Anti-inflammatories
      • ROM Brace
      • Rehab
    • Outcome
      • RTP in 4 weeks, weaned as tolerated from brace.
anatomy
Anatomy
  • Layer I
    • Deep fascia, Sartorius
  • Layer II
    • Superficial MCL
  • Layer III
    • Deep MCL
    • Posteromedial Capsule
mcl function
MCL Function
  • Primary stabilizer to valgus force.
  • Secondary stabilizer to Anterior translation.
  • Resist external rotation.
  • MCL and ACL have a codependent relationship.
diagnosis
Diagnosis
  • History
    • Classic Mechanism: Isolated Valgus moment to knee.
  • PE
    • Complete Knee Exam
    • Examine MCL with the knee both in full extension and at 30 degrees of flexion.
    • Valgus Stress with knee at 30 degrees of flexion causes pain or instability of medial knee.
mcl grading system
MCL Grading System
  • I - Stretching of fibers. Localized TTP. No instability.
  • II - Disruption of Fibers. Mild to moderate instability.
  • III - Complete disruption of ligament. Gross instability.
imaging
Imaging
  • XR
    • May demonstrate avulsions.
  • MRI
    • Confirms Diagnosis
    • Evals other ligaments, cartilage.
treatment
Treatment
  • The injured MCL heals predictably without repair regardless of its grade.
  • Non-op management of all MCL tears is considered standard practice.
treatment of isolated mcl injury
Treatment of Isolated MCL Injury
  • Grade I and II Injuries
    • Non-Surgical Treatment
      • Crutches until symptoms improve, WBAT, ROM.
      • Edema Control - Ice, Compression, Massage.
      • NSAIDS
      • Hinged knee brace
    • Speeding Recovery
      • Good control of swelling can decrease the amount of time for full recovery of motion and strength.
treatment of isolated mcl injury19
Treatment of Isolated MCL Injury
  • Grade III MCL
    • Non-Surgical Rehab
    • Brief period of immobilization
    • Start ROM when initial swelling subsides.
    • May need a longer period of protected weight bearing.
  • Persistant valgus instability
    • May consider for early surgical reconstruction.
tibial sided vs femoral sided mcl injury
Tibial Sided vs. Femoral Sided MCL injury
  • Proximal MCL tears at the femoral insertion more common than at the distal tibial insertion.
  • In general, femoral side injuries tend to heal better than tibial side or midsubstance injuries.
acl mcl
ACL + MCL
  • Usually do not require MCL reconstruction
  • Rehab the medial side and achieve full ROM then do ACL reconstruction.
  • However, if valgus instability persists after rehab then reconstruction of ACL and MCL should be considered.
pcl mcl
PCL + MCL
  • If significant posterior subluxation is present following injury, both ligaments should be reconstructed acutely.
  • If the Joint is well reduced, can treat MCL nonsurgically with bracing. PCL can be reconstructed when full ROM is achieved and valgus stability is restored.
  • If valgus instability persists, reconstruct PCL and MCL.
chronic mcl injury
Chronic MCL Injury
  • Chronic injury results when the MCL complex loses its potential for spontaneous healing.
  • Usually occurs 3 to 4 months following the initial injury.
  • Can develop secondary ligamentous instabilities or secondary limb malalignment.
chronic mcl injury24
Chronic MCL Injury
  • Valgus deformity of limb secondary to chronic MCL
    • Osteotomy may be required at time of MCL reconstruction.
  • Surgical Options
    • POL Advancement
    • Proximal Capsular Advancement
    • Distal Capsular Advancement
    • Semimembranosis advancement
    • Allograft
child with medial knee injury
Child with Medial Knee Injury
  • Don’t forget to rule out physeal injury!
prevention
Prevention
  • Prophylactic and Functional Bracing for MCL Protection
    • Controversial
latest research
Latest Research
  • Animal Studies suggest that Anti-Inflammatory medications do not impede ligament healing in early and intermediate healing phases
  • Sports Med. 1999; 27; 738. Claude T. Moorman, III, Udita Kukreti, David C. Fenton and Stephen M. Belkoff. The Early Effect of Ibuprofen on the Mechanical Properties of Healing Medial Collateral Ligament
acl mcl28
ACL + MCL
  • Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture Were Not Different in Combined Medial Collateral and Anterior Cruciate Ligament Rupture.
    • ACL + Grade 3 MCL
    • Surgery at 4 - 23 days after injury.
    • No difference in results at 2 years.
  • Review
    • Surgery took place before MCL healing.
    • Low Demand Patients
    • Treated with continuous hinged knee brace
    • Conclusion: Patients with combined ACL + MCL injuries who undergo early surgery after injury may do well without surgical treatment of the MCL, but they should be treated in a hinged knee brace. Caution should be used in a different patient population such as high demand athletes.
  • Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture with Early Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study. Am J Sports Med. 2006 Jul;34:1134-40.