Medial Collateral Ligament Strain Of The Knee

Description1,2

The medial collateral ligament (MCL) is the most frequently injured structure of the knee. Its primary function is as a static stabilizer of the medial aspect of the knee. It resists valgus forces and prevents severe medial gaping of the femur with the tibia. It can also act as a secondary restraint to anterior translation of the tibia when the anterior cruciate ligament (ACL) is injured. When strong valgus forces are directed at the knee the MCL can be stretched, and with a strong enough force will eventually tear. Both conservative and surgical management of MCL injuries have shown to be successful, depending on the severity of the tear and whether other ligaments and structures of the knee were damaged in the injury.


Anatomy1,3

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The MCL is a broad and flat ligament made up both a superficial and a deep layer. The superficial layer has both anterior and posterior fibers that differ in orientation. The vertically oriented anterior fibers, originate on the medial epicondyle of the femur approximately 1 cm distal to the adductor tubercle. These fibers insert on the medial tibial condyle about 4-5 cm distal to the joint line of the knee, and deep to the pes anserinus tendons (sartorius, gracilis, semitendinosus). The anterior superficial fibers are taut during flexion and lax during extension. The posterior superficial fibers run obliquely to the medial corner of the knee and can be referred to as the posterior oblique ligament. A bursa is located between the superficial and deep layers of the MCL. The Deep fibers (referred to as the medial capsular ligament) blend with the posteriomedial capsule of the knee and attach to the medial meniscus of the knee. The ligament proximal to the meniscus attachment is the mensicofemoral ligament. The ligament distal to the meniscus attachment is the meniscotibial ligament. A rupture of the deep layer will not occur in isolation; the superficial layer will also rupture.

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Classification2,4,5

There are numerous systems used to classify the degree of MCL sprains:

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1. American Medical Association
Grade I: <5mm of medial joint line opening
Grade II: 5 to 10mm of medial joint line opening
Grade III: >10mm of medial joint line opening

2. The Hughston MCL injury classification
Grade I: involves a few fibers, localized tenderness, no instability
Grade II: disruption of more fibers, generalized tenderness, no instability
Grade III: a complete disruption of the ligament with instability
*with grade 3 tears they are further divided based on amount of laxity found in the valgus stress test in 300 of knee flexion
+1: 3-5mm
+2: 6-10mm
+3: 10mm or more

3. Fetto and Marshall
Grade I: No valgus laxity in either 0 or 30 degrees of knee flexion
Grade II: No valgus laxity in 0 degrees of knee flexion, valgus laxity in 30 degrees of knee flexion
Grade III: Valgus laxity in both 0 and 30 degrees of knee flexion

4. O'Donoghue classification
Grade I: Few torn fibers, structurally intact
Grade II: Incomplete ligament tear, no valgus laxity
Grade III: Complete ligament tear, valgus laxity


Incidence/Prevalence5

Currently there is no consensus on the number of MCL injuries that occur, since there is great variability in the severity of the injury and not all injuries require medical intervention. Injuries to the MCL do not always occur in isolation; associated injuries can also occur. The anterior cruciate ligament (ACL) is injured in an estimated 20% of grade I MCL injuries and up to 78% of grade III MCL injuries. The incidence of medial meniscus injury occurs in 5-25% of MCL injuries. The vastus medialis obliquus and the extensor retinaculum can be injured in 9-21% of MCl injuries.


Clinical Presentation5

Signs and Symptoms of an MCL injury include:

  • Pain over the area of the ligament
  • Swelling
  • Bruising
  • Point tenderness along the medial aspect of the knee
  • A feeling of giving way during ambulation (more likely in more severe injuries)
  • A positive valgus stress test

Potential Etiologies

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The cause of MCL injuries are either by a direct valgus forces aimed at the knee, non-contact, or overuse injuries. Non-contact injuries usually occur by cutting maneuvers, where the person has their foot planted on the ground and then forcefully shifts directions causing a valgus force at the knee. Contact and non-contact injuries most often occur in athletes involved in ice hockey, football, or skiing. Overuse injuries generally involve swimmers when performing a whip-kick which continuously applies valgus loads to the knee.


Diagnostic Tests6

The gold standard for diagnosing an MCL injury is through diagnostic arthroscopy and surgical exploration. Surgery is not always warranted for MCL injuries, therefore x-rays, MRI's, and clinical tests can be used as diagnostic tools. X-Rays should be taken to rule out any fracture of either the femur or tibia, and any bony avulsions or osteochondral fragments that could have occurred. An MRI can be taken to visualize any tears of the ligaments or other soft tissues.

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Evaluation/Special Orthopedic Tests1,7

The abduction valgus stress test is used to assess medial instability by gaping the tibia with the femur on the medial aspect of the knee.This test should be performed in both full knee extension and 30o of knee flexion. The examiner should be looking for laxity and pain at the medial aspect of the knee. It is recommended that testing is done immediately after the injury has occurred if trainers or physicians are available on the sidelines. This allows for greater accuracy before pain, swelling, and muscle spasm has set in.

Since MCL injuries can often occur with ACL, and medial meniscus injuries it is important to rule out other possible injuries to the knee.2
Tests for ACL injury include:
1. Anterior Drawer Test
2. Lachman Test
3. Pivot Shift Test

Testing for integrity of the meniscus:
McMurray Test

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Physical Therapy Management of a Medial Collateral Ligament Strain of the Knee

Conservative Treatment1,8

Grade I and Grade II MCL injuries can often be treated successfully with conservative management. Grade III tears will usually be treated conservatively before surgical interventions are applied.
Acute phase (first 72 hours): decrease pain and swelling of the knee

  • Rest, Ice, Compression, Elevation (RICE)
  • NSAIDs
  • Hinged knee braces may be used in weight bearing, in order to avoid any valgus stresses

Protocol followed by Edson 2006
Treatment of grade I injuries:
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Treatment of Grade II injuries:
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Treatment of Grade III injuries:
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The use of prophylactic knee bracing when returning to sport has been a controversial issue. The use of a brace has been found to decrease recurrence of MCL injuries, and provide added stability to the knee. Many players believe it hinders their athletic performance by leading to greater muscle fatigue by increasing blood lactate levels, reducing running speed, and increasing oxygen consumption. The players perception of the benefits or disadvantages to brace wear can alter compliance to brace use.

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Surgery & post-op Treatment9,10,11

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Surgical Treatment is considered for patients with grade III injuries, that have continuous laxity effecting their activities of daily living (ADLs). Surgical fixation is performed with semitendinosus autografts, gracilis autografts, or allograft tissue. If surgery is required, the knee will first be examined under anesthesia to assess the degree of laxity in the knee. Then 6-7cm incisions will be made at the proximal (medial femoral epicondyle) and distal insertions of the MCL. The tendons are then harvested and made into single or doubled stranded grafts. Proper length of the graft is determined in order to allow for proper knee range of motion. Tunnels are reamed into both the femur and the tibia and screws are used to attach the graft to the bone. Sutures are used to close up all incisions. Sterile strips and dressing are applied and the knee is placed in hinged braced locked in full extension.

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Post-operative Rehab Protocol from Galland and Kirby12:
POST-OP DAYS 1 – 14
Dressing:
– POD 1: Debulk dressing, TED Hose in place
– POD 2: Change dressing, keep wound covered, continue TED Hose
– POD 7-10: Sutures out, D/C TED Hose when effusion resolved
Brace x 8 weeks – Locked in extension for ambulation
Crutches – Partial weight bearing (PWB) in brace (no more than 50% of body weight)
Patellar mobilization (teach patient)
Calf pumping
AAROM, AROM 0-90 degrees
Passive extension with heel on bolster or prone hangs
Electrical stimulation in full extension with quad sets and SLR
Quad sets, Co-contractions quads/hams
Straight leg raise (SLR) x 3 on mat in brace – No ADD
Short arc quads
No stationary bike x 6 weeks
Ice pack with knee in full extension after exercise
GOALS
Pain/effusion control
Good quad control

Weeks 2 - 4
Brace x 8 weeks – Open to 0-45 degrees
Crutches – PWB in brace
Continue appropriate previous exercises
Scar massage when incision healed
AAROM, AROM 0-90 degrees only
Total Gym for ROM (level 1-3)
– Passive flexion to 90 degrees (push up with opposite leg)
SLR x 3 on mat, no brace if good quad control – No ADD
Double leg heel raises
No stationary bike x 6 weeks
Stretches – Hamstring, Hip Flexors, ITB
GOALS
ROM 0-90 degrees
No extensor lag

WEEKS 4 - 6
Brace x 8 weeks – Open to 0-90 degrees
Crutches – PWB in brace
Continue appropriate previous exercises
AAROM, AROM 0-120 degrees
Standing SLR x 3 with light Theraband bilaterally
– May begin Hip ADD with Theraband if good LE control in full extension
Total Gym (level 3-5)– Mini squats 0-45 degrees
– Passive flexion to 90 degrees (push up with opposite leg)
Leg press 0-45 degrees with resistance up to ¼ body weight
Hamstring curls 0-45 degrees – Carpet drags or rolling stool (closed chain)
No stationary bike x 6 weeks
GOALS
ROM 0-120 degrees
No effusion

WEEKS 6 - 8
Brace – Open to full range
Crutches – Weight bearing as tolerated(WBAT), D/C crutch when gait is normal
Continue appropriate previous exercises
PROM, AAROM, AROM to regain full motion
Standing SLR x 4 with light Theraband bilaterally
Wall squats 0-45 degrees
Leg press 0-60 degrees with resistance up to ½ body weight
Hamstring curls through full range – Carpet drags or rolling stool
Forward, lateral and retro step downs in parallel bars
– No knee flexion past 45 degrees (small step)
Proprioceptive training – Single leg standing in parallel bars
– Double leg BAPS for weight shift
Single leg heel raises
Treadmill – Forwards and backwards walking
Stationary bike – Progressive resistance and time
Elliptical trainer
GOAL
Full ROM

WEEKS 8 - 12
D/C Brace
Continue appropriate previous exercises with progressive resistance
Leg press 0-90 degrees with resistance as tolerated
Hamstring curls on weight machine
Knee extension weight machine
Forward, lateral and retro step downs (medium to large step)
Proprioceptive training – Single leg BAPS, ball toss and body blade, Grid exercises
Treadmill – Walking progression program
Stairmaster – Small steps
Pool therapy
GOAL
Walk 2 miles at 15 min/mile pace

MONTHS 3 - 4
Continue appropriate previous exercises
Slide board
Functional activities – Figure 8s, gentle loops, large zigzags
Treadmill – Running progression program
Pool therapy – Swimming laps
Quad stretches
GOAL
Run 2 miles at easy pace

MONTHS 4 - 6
Continue appropriate previous exercises
Agility drills / Plyometrics
Sit-up progression
Running progression to track
Transition to home / gym program
GOAL
Return to all activities

*NO CONTACT SPORTS UNTIL 6 MONTHS POST-OP*


Additional Web Based Resources

http://www.nlm.nih.gov/medlineplus/ency/article/001076.htm
http://www.cedars-sinai.edu/Patients/Health-Conditions/Medial-Collateral-Ligament-MCL-Tears.aspx
http://www.wheelessonline.com/ortho/medial_collateral_ligament
http://orthoinfo.aaos.org/topic.cfm?topic=A00550

Bibliography
1. Chen L, Kim PD, Ahmad CS, Levine WN. Medial collateral ligament injuries of the knee: Current treatment concepts. Curr Rev Musculoskelet Med. 2008;1(2):108-113.
2. Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: Current concepts review. Iowa Orthop J. 2006;26:77-90.
3. Drake RL., Vogl A. W., and Mitchell A.W.M. Regional anatomy: Thigh. In: Schmitt W., and Gruliow R., ed. Gray's anatomy for students. 2nd ed. Philadelphia: Elsevier; 2010:575-587.
4. American Medical Association: Committee on the Medical Aspects of Sports: Standard Nomenclature of Athletic Injuries. Chicago, IL: American Medical Association, 1966.
5. DeBerardino TM. Medial collateral knee ligament injury clinical presentation. Medscape Reference: Drugs, Diseases, and Procedures Web site. http://emedicine.medscape.com/article/89890-clinical#a0217. Published January 2010. Updated 2010. Accessed Nov 27, 2011.
6. Rasenberg EI, Lemmens JA, van Kampen A, et al. Grading medial collateral ligament injury: Comparison of MR imaging and instrumented valgus-varus laxity test-device. A prospective double-blind patient study. Eur J Radiol. 1995;21(1):18-24.
7. Magee DJ. Orthopedic physical assessment. St. Louis, Miss.: Saunders Elsevier; 2008.
8. Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament. Sports Med Arthrosc. 2006;14(2):105-110.
9. Miyamoto RG, Bosco JA, Sherman OH. Treatment of medial collateral ligament injuries. J Am Acad Orthop Surg. 2009;17(3):152-161.
10. Borden PS, Kantaras AT, Caborn DN. Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy. 2002;18(4):E19.
11. Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: Technique and results in initial cases. Am J Sports Med. 2005;33(9):1380-1385
12. Galland M. KK. Galland/Kirby medial collateral ligament Repair/Reconstruction post-surgical rehabilitation protocol. Physcial Therapy-Postoperative Rehabilitation Protocols Web site. http://www.orthonc.com/sites/default/files/forms/kirby/MCL_Reconstruction.pdf. Updated 2011. Accessed Nov 29, 2011.
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