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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 l.jpg

MCL Injuries

Dr. David Vasconcellos

Sports Fellow

University of Iowa Sports Medicine Center




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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.


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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.


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Case

  • XR: Negative


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Case

  • Diagnosis?


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Case

  • Grade II MCL Tear


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Case

  • Treatment

    • Conservative Treatment.

      • Crutches

      • Anti-inflammatories

      • ROM Brace

      • Rehab

    • Outcome

      • RTP in 4 weeks, weaned as tolerated from brace.


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Anatomy

  • Layer I

    • Deep fascia, Sartorius

  • Layer II

    • Superficial MCL

  • Layer III

    • Deep MCL

    • Posteromedial Capsule



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MCL Function

  • Primary stabilizer to valgus force.

  • Secondary stabilizer to Anterior translation.

  • Resist external rotation.

  • MCL and ACL have a codependent relationship.


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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.



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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.


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Imaging

  • XR

    • May demonstrate avulsions.

  • MRI

    • Confirms Diagnosis

    • Evals other ligaments, cartilage.


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Treatment

  • The injured MCL heals predictably without repair regardless of its grade.

  • Non-op management of all MCL tears is considered standard practice.


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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.


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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.


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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.


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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.


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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.


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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.


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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


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Child with Medial Knee Injury

  • Don’t forget to rule out physeal injury!


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Prevention

  • Prophylactic and Functional Bracing for MCL Protection

    • Controversial


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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


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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.



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