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MCL Injury

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Other Names

  • Medial Collateral Ligament Injury
  • Medial Collateral Ligament Tear
  • MCL Tear
  • MCL Bursitis
  • Voshell's bursitis
  • Tibial Collateral Ligament tear
  • Pellegrini-Stieda Syndrome
  • MCL Sprain

Background

  • This page refers to injuries to the Medial Collateral Ligament (MCL)
    • Includes both acute and chronic tears
    • Includes MCL bursopathy, a phenomenon poorly described in the literature

History

  • MCL Bursitis
    • First described by doctors Brantigan and Voshell in 1943[1]
    • First reported as a clinical diagnosis by Kerlan and Glousman[2]

Epidemiology

  • MCL Bursitis
    • Uncommon cause of knee pain poorly described in the literature
  • MCL Tear
    • Most common ligamentous injury, roughly 40% (need citation)
    • In one 10 year observational study, accounted for 7.9% of all knee injuries[3]
    • Likely higher than reported, mild cases are probably missed or underreported
    • Males > females

Pathophysiology

MCL Tear

  • General
    • Occurs due to excessive valgus stress on the knee
  • Contact injury
    • Most common mechanism of injury
    • Lateral aspect of the knee is usually the most exposed during sport
    • Often the result of a valgus stress applied to a stationary or planted knee
    • More often results in high grade or multiligament injuries
  • Noncontact injury
    • Less common overall
    • More commonly seen in skiing
    • Occurs with pivoting or cutting with valgus and external rotation force
    • More often results in low grade injury

MCL Bursitis

  • See: Bursopathies (Main)
  • Tenderness of the medial collateral ligament at the level of the medial joint line[4]
  • Patients also should not have a history of knee buckling or locking

Associated Pathology

Pathoanatomy

  • Medial Collateral Ligament
    • Primary static stabilizer of the medial side of the knee
    • Provides support against valgus stress, rotational forces, anterior translational forces on the tibia
  • MCL Bursa (Voshell's Bursa)
    • Found between the superficial and deep portions of the medial collateral ligament
    • Anterior margin: adjacent to the anterior border of the superficial portion of the MCL
    • Posterior margin: outlined by the junction of the superficial, deep portions
    • Tibial component and femoral component (70% of cases)[5]

Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • Typically presents with acute trauma
    • Patient may describe buckling or the knee giving out
    • "pop" at time of injury is often reported
    • In the setting of bursitis, more likely insidious or subacute
  • Physical Exam: Physical Exam Knee
    • The patient will be tender during palpation of the MCL
    • The proximal component is often the most tender
    • Effusion may be present
  • Special Tests
    • Valgus Stress Test (Knee): One hand on tibia, other on lateral knee, apply a valgus force at 0° and 30°
      • Note laxity at 30° may suggest isolated MCL injury, laxity at 0° suggests other structural or ligamentous pathology
    • Important to perform thorough structural knee exam on LCL, ACL, PCL, posterolateral corner, etc

Evaluation

Radiographs

  • Standard Radiographs Knee
  • Screening tool, typically normal
  • Findings can include
    • Effusion
    • Avulsion fracture
  • Pellegrini-Stieda Syndrome or Lesion
    • thought to involve calcification of a posttraumatic hematoma
    • On radiographs, AP view will show calcification of the MCL and superiorly to the medial femoral condyle

MRI

  • General
    • Often unnecessary
    • Typically only performed if suspected multi-ligament injury[7]
  • MCL Bursa
    • Only 0.1% of knee MRI report bursitis[8]
    • Findings:
      • Fluid distention in the bursa
      • Additionally intact MCL, absence of medial meniscal tear

Ultrasound

  • Advantages over MRI
    • Low-cost
    • Dynamic scanning
  • MCL Bursa
    • Can identify fluid distended bursa along medial knee

Arthroscopy

  • Diagnostic gold standard which is rarely performed

Classification

Hughston's Classification System

  • Based on history, physical exam
  • Grade 1 (mild)
    • Involve a few fibers of the MCL
    • Exam: localized tenderness to the medial knee and no instability
    • Firm endpoint, no laxity
  • Grade 2 (moderate)
    • Involve disruption of more fibers, commonly fibers of the superficial MCL with preservation of the deep MCL
    • Exam: more generalized tenderness to palpation, and no instability
    • +/- laxity with firm endpoint
  • Grade 3 (severe)
    • Represents a complete tear of the MCL, both deep and superficial portions
    • Exam: instability of the knee, significant laxity on valgus stress
    • Increased laxity with no end point
    • Further subdivided by laxity: 1+ (3–5 mm), 2+ (5–10 mm), 3+ (>10 mm)

Management

Prognosis

  • Derscheid et al study of high school football players with nonoperative management of grade 1, 2 tears[9]
    • Grade 1 tears returned to sport an average of 10.6 days post-injury
    • Grade 2 tears returned an average of 19.5 days post-injury

Prevention

  • Functional bracing may reduce MCL injury in football players, particularly interior linemen

MCL Bursitis

  • Corticosteroid Injection under ultrasound guidance
    • The MCL bursa is found between the second and third layers of the medial knee[10]
    • Knee in slight flexion, probe at the level of the medial knee, an injection is performed in the coronal plane[11]

Nonoperative

  • Indications
    • Grade 1, grade 2 injuries
    • Grade 3 tears in isolation
  • Physical Therapy
  • Hinged Knee Brace
    • Indications: Grade II, III
    • Goal is to prevent further valgus injury
  • Weight bearing as tolerated
    • Advance as patient is pain free, able to walk without an antalgic gait
  • NSAIDS

Operative

  • Indications
    • Grade 3 with other ligament injuries
    • Chronic MCL tears
  • Technique
    • Ligament repair
    • Ligament reconstruction

Rehab and Return to Play

Rehabilitation

  • General
    • Early rehabilitation
    • Range of motion, however prolonged immobilization can lead to weaker ligament healing, worse outcomes in animal models[12]
    • Progressive strengthening
  • Physical Therapy (early)
    • Quad sets, straight leg raises, hip adduction
    • Cycling
    • Progressive resistance training

Return to Play

  • General rule for isolated MCL injuries
    • Grade 1: 5-7 days
    • Grade 2: 2-4 weeks
    • Grade 3: 4-8 weeks

Complications

  • Instability/ Laxity
    • More common after grade 2, 3 tears
  • Persistent pain
  • Recurrence of injury
    • In a group of patients with isolated grade 3 MCL injuries, the recurrence of MCL injury was 23%[13]
  • Saphenous Nerve Injury
  • Loss of range of motion

See Also


References

  1. Brantigan OC, Voshell AF: The tibial collateral ligament: Its function, its bursae, and its relation to the medial meniscus. J Bone Joint Surg 25:121-131, 1943
  2. Kerlan, RK, Glousman, RE: Tibial collateral ligament bursitis. Am J Sports Med 1988;16:344–346.
  3. Majewski M., Susanne H., Klaus S. Epidemiology of athletic knee injuries: a 10-year study. Knee. 2006;13(3):184–188.
  4. Glousman, R. K. (1988). Tibial Collateral Ligament Bursitis. The American Journal of Sports Medicine, 344-346.
  5. De Maeseneer M, Shahabpour M, Van Roy F, Goossens A, De Ridder F, Clarijs J, Osteaux M. MR imaging of the medial collateral ligament bursa: findings in patients and anatomic data derived from cadavers. (2001) AJR. American journal of roentgenology. 177 (4): 911-7.
  6. Hakan Nur, A. A. (2018). Medial collateral ligament bursitis in a patient with knee osteoarthritis. Journal of Back and Musculoskeletal Rehabilitation, 589-591.
  7. Phisitkul P., James S.L., Wolf B.R., Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J. 2006;26:77–90.
  8. De Maeseneer, M, Shahabpour, M, Van Roy, F: MR imaging of the medial collateral ligament bursa: findings in patients and anatomic data derived from cadavers. Am J Roentgenol 2001;177:911–917.
  9. Derscheid G.L., Garrick J.G. Medial collateral ligament injuries in football: nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9:365–368.
  10. Vincenzo Ricci, L. O. (2019). Ultrasound‐Guided Treatment of Extrusive Medial Meniscopathy: A 3‐Step Protocol. Journal of Ultrasound in Medicine.
  11. Jean Jose, E. S. (2011). Sonographically Guided Therapeutic Injection for Primary Medial (Tibial) Collateral Bursitis. The Journal of Clinical Ultrasound, 257-261.
  12. Creighton R.A., Spang J.T., Dahners L.E. Basic science of ligament healing. Sports Med Arthrosc Rev. 2005;13(3):145–150.
  13. Reider B., Sathy M.R., Talkington J., Blyznak N., Kollias S. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. Am J Sports Med. 1994;22(4):470–477.
Created by:
John Kiel on 7 July 2019 05:43:50
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Last edited:
4 October 2022 15:50:02
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