MCL INJURIES

John Hardin, MA, ATC, LAT CSCS

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.• 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

Medial Knee Anatomy

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 Injury Model

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.

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.

• Questions?