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MCL Knee Injuries

Topic updated on 12/12/14 2:53pm
Introduction
  • The medial collateral ligament is both a primary and secondary valgus stabilizer of the knee 
    • also known as the tibial collateral ligament
  • Epidemiology
    • most commonly injured ligament of the knee
  • Mechanism of injury
    • valgus and external rotation force to the lateral knee
      • non-contact force results in milder sprains
      • direct blow usually causes complete disruption of MCL
        • rupture usually occurs at femoral insertion of ligament with proximal tears having greater healing rates  
        • distal injuries tend to have excessive valgus laxity
  • Associated conditions
    • ACL tears
      • comprise up to 95% of associated injuries
        • 20% are with grade I MCL injuries
        • 52% are with grade II MCL injuries
        • 78% are with grade III injuries
    • meniscal tears 
      • up to 5% of isolated MCL injuries are associated with meniscal tears
    • Pellegrini-Stieda Syndrome  
      • calcification at the medial femoral insertion site 
      • results from chronic MCL deficiency
Anatomy
  • Ligaments of the knee  
  • Medial capsulo-ligamentous complex of the knee 
    • function
      • resist valgus and external forces at the knee
    • composition
      • it is composed of 3 layers which extend from the anterior midline to the posterior midline
      • it contains both static and dynamic stabilizers
        • static stabilizers
          • superficial MCL
            • primary restraint to valgus stress 
          • deep MCL and posterior oblique ligaments
            • secondary restraints to valgus stress
        • dynamic stabilizers
          • semimembranosus complex
            • consists of 5 attachments 
              • vastus medialis 
              • medial retinaculum
              • pes anserine muscle group
                • sartorius 
                • semitendinosus 
                • gracilis 
  • Blood supply
    • superior medial and inferior medial geniculate arteries 
Classification
  • Classification of MCL Sprains
    • Grade 1
      • mild severity
      • no loss of ligamentous integrity (stretch injury)
      • minimal torn fibers
    • Grade II
      • moderate severity
      • incomplete tearing of MCL (partial tear)
      • increased joint laxity
      • end point found at 30 degrees of flexion with valgus stress
      • fibers remain apposed 
    • Grade III
      • severe
      • complete disruption of ligament (complete tear)
      • gross laxity
      • no end point with valgus stress at 30 degrees of knee flexion
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 & stability
      • valgus stress testing at 30 degrees 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 degrees 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
  • 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

 

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Qbank (2 Questions)

TAG
(SBQ07.17) Prophylactic hinged knee bracing for contact athletes has shown a trend towards decreased rates for which types of injuries? Topic Review Topic

1. ACL tears
2. ACL and MCL tears
3. ACL, MCL and ankle ligament tears
4. MCL and ankle ligament tears
5. MCL tears

PREFERRED RESPONSE ▶
TAG
(OBQ06.68) All of the following are true regarding grade III medial collateral ligament (MCL) tears of the knee EXCEPT: Topic Review Topic

1. Proximal ruptures have decreased residual valgus laxity following nonoperative treatment than distal ruptures
2. They result in greater than 10 mm of valgus opening
3. They can result in a Stener-type lesion
4. They require operative repair when there is a concomitant anterior cruciate ligament tear
5. Proximal ruptures have better healing potential with nonoperative treatment than distal ruptures

PREFERRED RESPONSE ▶




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