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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

Epidemiology: MCL Tear

  • General
    • 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[4]
  • Incidence
    • Among high school football players, seen in 24.2 per 100,000 athletes[5]
    • Represents 26% of all knee injuries in high school athletes[6]
    • About 10% are bony avulsions rather than purely ligamentous
  • Other
    • 78% of patients who have a grade III MCL injury have an injury to another associated structure (need citation)
    • Football and soccer tend to be higher grade, skiing and wrestling tend to be lower grade

Introduction

Relationship of the MPFL (medial patellofemoral ligament), VMO (vastus medialis obliquus muscle), SM (semimembranosus), MGT (medial gastrocnemius tendon), POL (posterior oblique ligament) and sMCL (superficial medial collateral ligament).[7]

MCL Tear

  • General
    • Occurs due to excessive valgus stress on the knee, typically from direct contact
    • Most MCL injuries involve the superficial component at the proximal insertion on the femur[8]
  • 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/ foot
    • 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[9]
  • Patients also should not have a history of knee buckling or locking

Associated Pathology

Anatomy of the MCL

  • 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)[10]

Risk Factors

  • Risk factors for developing bursitis[11]
  • Sports
    • Skiinng
    • Football
    • Soccer
    • Rugby
    • Wrestling
    • Ice Hockey

Differential Diagnosis

Differential Diagnosis Knee Pain

Clinical Features

Avulsion fracture of the posterolateral medial femoral condyle consistent with underlying MCL injury.

History

  • Typically presents with acute trauma from direct contact
  • Patient may describe buckling or the knee giving out
  • A "pop" at time of injury is often reported
  • In the setting of bursitis, more likely insidious or subacute
  • Pain pinpoints to the medial aspect of the knee
  • The patient can describe trouble weight bearing, loss of knee motion or sensation of collapse or wobble

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

High T2 signal is seen surrounding the MCL which demonstrates loss of continuity in keeping with a complete tear (grade 3).[12]
Ultrasound image of proximal MCL tear (arrow), noting ligament tissue disruption with retraction. Both the distal femur (F) and proximal tibia (T) are depicted with the adjoining MCL.[13]

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[14]
  • Findings:
    • Fluid distention in the bursa
    • Additionally intact MCL, absence of medial meniscal tear
  • MCL Bursa
    • Only 0.1% of knee MRI report bursitis[15]

Ultrasound

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

CT

  • Can be used to evaluate for:
    • Bony ligament avulsion injuries
    • Fractures
    • Osteochondral lesions

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

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[16]
    • Knee in slight flexion, probe at the level of the medial knee, an injection is performed in the coronal plane[17]

Nonoperative management of MCL Tear

  • Indications
    • Grade 1, grade 2 injuries
    • Some grade 3 tears in isolation
  • Physical Therapy
  • Hinged Knee Brace
    • Indications: Grade I, 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 management of MCL Tear

  • Indications
    • Grade 3 with other ligament injuries
    • Grade 3 injuries at the tibial insertion
    • 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[18]
    • Progressive strengthening
  • Physical Therapy (early)
    • Quad sets, straight leg raises, hip adduction
    • Cycling
    • Progressive resistance training

3 Phases of Therapy Goals

  • Phase 1
    • Protect the injury in hinged knee brace, rest
    • Treat inflammation via swelling, ice, etc
    • Other modalities: electrical simulation, ultrasound, other compression
    • Work on knee motion, strength of surrounding muscles, normalize gait
  • Phase 2
    • Increasing strength
    • Initiate regional therapy including core, hip abductors, external rotators, biomechanics
    • Start aerobic activity, e.g. jogging in a straight line
  • Phase 3
    • Functional progression (running, agility, plyometrics, sports specific movements)

Return to Play/Work

  • General rule for isolated MCL injuries
    • Grade 1: 1-2 weeks
    • Grade 2: 2-6 weeks
    • Grade 3: 6-8 weeks

Prognosis and Complications

Prognosis

  • Outcomes for grade I, II
    • Typically good to excellent
    • These athletes can return to previous level of activity
  • Outcomes for grade III managed nonoperatively
    • Some studies show good results, others show chronic laxity and early arthritis
    • MCL injuries at tibial insertion tend to due worse than those of femoral origin
  • Derscheid et al study of high school football players with nonoperative management of grade 1, 2 tears[19]
    • 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

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%[20]
  • Saphenous Nerve Injury
  • Loss of range of motion

See Also

Internal

External

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. ↑ Kim, Christopher, Patrick M. Chasse, and Dean C. Taylor. "Return to play after medial collateral ligament injury." Clinics in sports medicine 35.4 (2016): 679-696.
  5. ↑ Encinas-Ullán, Carlos A., and E. Carlos Rodríguez-Merchán. "Isolated medial collateral ligament tears: an update on management." EFORT open reviews 3.7 (2018): 398.
  6. ↑ Kramer, Dennis E., et al. "Collateral ligament knee injuries in pediatric and adolescent athletes." Journal of Pediatric Orthopaedics 40.2 (2020): 71-77.
  7. ↑ Memarzadeh, Arman, and Joel TK Melton. "Medial collateral ligament of the knee: Anatomy, management and surgical techniques for reconstruction." Orthopaedics and Trauma 33.2 (2019): 91-99.
  8. ↑ Craft, Jason A., and Peter R. Kurzweil. "Physical examination and imaging of medial collateral ligament and posteromedial corner of the knee." Sports Medicine and Arthroscopy Review 23.2 (2015): e1-e6.
  9. ↑ Glousman, R. K. (1988). Tibial Collateral Ligament Bursitis. The American Journal of Sports Medicine, 344-346.
  10. ↑ 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.
  11. ↑ Hakan Nur, A. A. (2018). Medial collateral ligament bursitis in a patient with knee osteoarthritis. Journal of Back and Musculoskeletal Rehabilitation, 589-591.
  12. ↑ Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 5650
  13. ↑ Ghosh, N., et al. "Comparing point-of-care-ultrasound (POCUS) to MRI for the diagnosis of medial compartment knee injuries." Journal of medical ultrasound 25.3 (2017): 167-172.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ Vincenzo Ricci, L. O. (2019). Ultrasound‐Guided Treatment of Extrusive Medial Meniscopathy: A 3‐Step Protocol. Journal of Ultrasound in Medicine.
  17. ↑ Jean Jose, E. S. (2011). Sonographically Guided Therapeutic Injection for Primary Medial (Tibial) Collateral Bursitis. The Journal of Clinical Ultrasound, 257-261.
  18. ↑ Creighton R.A., Spang J.T., Dahners L.E. Basic science of ligament healing. Sports Med Arthrosc Rev. 2005;13(3):145–150.
  19. ↑ 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.
  20. ↑ 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:
23 March 2023 06:17:59
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