Introduction Overview medial collateral ligament (MCL) injury results from excessive valgus stress on the knee, is often an isolated injury and can be managed nonoperatively in the majority of patients Epidemiology most common ligamentous injury of the knee 40% of knee ligament injuries incidence is likely higher than reported low grade injuries can be missed males > females commonly occur in athletes account of 8% of all athletic knee injuries highest risk in skiing, rugby, football, soccer and ice hockey Pathophysiology valgus stress is the most common mechanism of injury usually with the knee held in slight flexion and external rotation contact injury more common than noncontact direct blow to the lateral knee with valgus force more often result in high grade / complete ligament disruption than noncontact injury rupture usually occurs at the femoral insertion of the MCL proximal MCL tears have greater healing rates distal MCL tears have inferior healing and residual valgus laxity noncontact injury less common than contact but more common in skiing pivoting or cutting activities with valgus and external rotation force more often result in low grade / incomplete ligament injury Associated conditions anterior cruciate ligament (ACL) tear most common associated injury make up ~95% of injuries associated with nonisolated MCL injury combined ACL-MCL is the most common multiligamentous knee injury presence of hemarthrosis is highly suggestive often associated with high grade MCL injuries grade III > grade II > grade I meniscus tear medial > lateral up to 5% of isolated MCL injuries are associated with meniscus tears Pellegrini-Stieda syndrome calcification at the medial femoral insertion site results from chronic MCL deficiency Anatomy Ligaments of the knee Anatomy superficial MCL located in layer II of the medial knee with posteromedial corner ligaments and medial patellofemoral ligament femoral attachment medial epicondyle 1cm anterior and distal to the adductor tubercle tibial attachment proximal tibia periosteum 4.5cm distal to the joint line deep and posterior to the pes anserinus deep MCL located in layer III of the medial knee with the joint capsule composed of meniscofemoral and meniscotibial ligaments Vascular supply superior medial and inferior medial geniculate arteries Function superficial MCL primary stabilizer to valgus stress at all angles of knee flexion greatest stability contribution at 25 degrees knee flexion (78%) secondary stabilizer to tibial external rotation and anterior/posterior tibial translation deep MCL secondary stabilizer to valgus stress greatest stability contribution at full knee extension other stabilizers of the medial knee static stabilizers posterior oblique ligament resists tibial internal rotation at full knee extension secondary restraint to valgus stress oblique popliteal ligament posterior capsule dynamic stabilizers semimembranosus complex consists of 5 attachments vastus medialis medial retinaculum pes anserine muscle group sartorius semitendinosus gracilis Classification American Medical Association (AMA) Classification based on joint laxity alone valgus stress applied with the knee in 30 degrees of flexion graded by amount of medial joint line opening < 3 mm considered physiologic laxity described in 1966 caused confusion and difficulty comparing treatment results Grade I injury 3-5 mm Grade II injury 6-10 mm Grade III injury > 10 mm Hughston Modification of the AMA Classification based on joint laxity and injury severity severity graded by extent of tenderness and quality of the endpoint with valgus stress at 30 degrees of knee flexion often referred to as "degree" of injury revised in 1994 Grade I -- First-degree injury mild localized tenderness firm endpoint no joint laxity stretch injury or few MCL fibers torn no significant loss of ligamentous integrity Grade II -- Second-degree injury moderate more generalized tenderness firm endpoint +/- mild increase in joint laxity incomplete / partial MCL tear some MCL fibers remain intact, generating the firm end point Grade III -- Third-degree injury severe generalized tendernesss no endpoint with valgus stress increased joint laxity third-degree injuries are further subdivided by joint laxity, described by the original AMA system Grade 1+: 3-5 mm Grade 2+: 6-10 mm Grade 3+: > 10 mm complete MCL tear Presentation History "pop" reported at time of injury Symptoms medial joint line pain difficulty ambulating due to pain or instability Physical exam inspection and palpation tenderness along medial aspect of knee ecchymosis knee effusion ROM and stability valgus stress testing at 30° knee flexion isolates the superficial MCL medial gapping as compared to opposite knee indicates grade of injury 1- 4 mm = grade I 5-9 mm = grade II > or equal to 10 mm = grade III valgus stressing at 0° knee extension medial laxity with valgus stress indicates posteromedial capsule or cruciate ligament injury neurovascular exam saphenous nerve exam evaluate for additional injuries ACL PCL patellar dislocation medial meniscal tear Imaging Radiographs recommended AP and lateral optional view stress radiographs in skeletally immature patient may indicate gapping through physeal fracture findings usually normal calcification at the medial femoral insertion site (Pellegrini-Stieda Syndrome) MRI modality of choice for MCL injuries identifies location and extent of injury useful for evaluating other injuries Treatment Nonoperative NSAIDs, rest, therapy indications grade I therapy quad sets, SLRs, and hip adduction above the knee to begin immediately cycling and progressive resistance exercises as tolerated return to play grade I may return to play at 5-7 days bracing, NSAIDs, rest, therapy indications grades II grade III if stable to valgus stress in full extension no associated cruciate injury technique immobilizer for comfort hinged knee brace for ambulation return to play grade II return to play at 2-4 weeks grade III return to play at 4-8 weeks outcomes distal MCL injuries have less healing potential than proximal injuries Operative ligament repair vs. reconstruction relative indications acute repair in grade III injuries in the setting of multi-ligament knee injury displaced distal avulsions with "stener-type" lesion entrapment of the torn end in the medial compartment sub-acute repair in grade III injuries continued instability despite nonoperative treatment >10 mm medial sided opening in full extension reconstruction chronic injury loss of adequate tissue for repair technique diagnostic arthroscopy recommended for all surgical candidates to rule out associated injuries Prevention knee bracing functional bracing may reduce MCL injury in football players, particularly interior linemen Techniques MCL repair approach medial approach to the knee indications acute injuries techniques ligament avulsions should be reattached with suture anchors in 30 degrees of flexion interstitial disruption anterior advancement of the MCL to femoral and tibial origins internal brace thought to minimize tension on repair during healing process MCL reconstruction approach medial approach to the knee indications chronic instability insufficient tissue for repair graft type can use semitendinosus autograft or hamstring, tibialis anterior or Achilles tendon allograft Complications Loss of motion Neurological injury saphenous nerve Laxity associated with distal MCL injuries
QUESTIONS 1 of 3 1 2 3 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ07SM.17) Prophylactic hinged knee bracing for contact athletes has shown a trend towards decreased rates for which types of injuries? Review Topic | Tested Concept QID: 1402 Type & Select Correct Answer 1 ACL tears 5% (158/3380) 2 ACL and MCL tears 18% (599/3380) 3 ACL, MCL and ankle ligament tears 1% (30/3380) 4 MCL and ankle ligament tears 3% (116/3380) 5 MCL tears 73% (2459/3380) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ06.68) All of the following are true regarding grade III medial collateral ligament (MCL) tears of the knee EXCEPT: Review Topic | Tested Concept QID: 179 Type & Select Correct Answer 1 Proximal ruptures have decreased residual valgus laxity following nonoperative treatment than distal ruptures 17% (684/4043) 2 They result in greater than 10 mm of valgus opening 5% (215/4043) 3 They can result in a Stener-type lesion 13% (529/4043) 4 They require operative repair when there is a concomitant anterior cruciate ligament tear 51% (2053/4043) 5 Proximal ruptures have better healing potential with nonoperative treatment than distal ruptures 13% (540/4043) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept
All Videos (7) Podcasts (1) Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery MCL: Conservative? Repair? Reconstruct? Technique and Evidence - Jorge Chahla, MD (CSMS #66, 2018) Jorge Chahla Knee & Sports - MCL Knee Injuries 11/24/2018 752 views (7) Login to View Community Videos Login to View Community Videos MCL & Posteromedial Corner: When & How to Fix? - Christopher Kaeding, MD Knee & Sports - MCL Knee Injuries 8/14/2018 475 views (3) Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine MCL With ACL: What Do We Do Now - Alan Getgood, MD (3.35, 2018 Winter SKS) Knee & Sports - MCL Knee Injuries 8/8/2018 338 views (2) Knee & SportsâMCL Knee Injuries Team Orthobullets 4 Knee & Sports - MCL Knee Injuries Listen Now 15:31 min 10/21/2019 166 plays (1) See More See Less