MCL Injuries Dr. David Vasconcellos Sports Fellow University of Iowa Sports Medicine Center
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.
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.
Case • XR: Negative
Case • Diagnosis?
Case • Grade II MCL Tear
Case • Treatment • Conservative Treatment. • Crutches • Anti-inflammatories • ROM Brace • Rehab • Outcome • RTP in 4 weeks, weaned as tolerated from brace.
Anatomy • Layer I • Deep fascia, Sartorius • Layer II • Superficial MCL • Layer III • Deep MCL • Posteromedial Capsule
MCL Function • Primary stabilizer to valgus force. • Secondary stabilizer to Anterior translation. • Resist external rotation. • MCL and ACL have a codependent relationship.
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 • I - Stretching of fibers. Localized TTP. No instability. • II - Disruption of Fibers. Mild to moderate instability. • III - Complete disruption of ligament. Gross instability.
Imaging • XR • May demonstrate avulsions. • MRI • Confirms Diagnosis • Evals other ligaments, cartilage.
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 • 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 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 • 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 • 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 • 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 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 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 • Don’t forget to rule out physeal injury!
Prevention • Prophylactic and Functional Bracing for MCL Protection • Controversial
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 + 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.