MCL Injuries Dr. David Vasconcellos Sports Fellow University

1
MCL Injuries

• Dr. David Vasconcellos
• Sports Fellow

University of Iowa Sports Medicine Center
2
The Latest and Greatest
3
Evidence Based
4
Case

• 17 y/o male tackled at his left knee from the
  outside while playing intramural football.
• Knee buckled inward.
• Felt a pop in his knee, limped off the playing
  field.

5
Case

• PE
• Stiff Knee Gait
• Mild Effusion
• No Joint Line TTP
• TTP over femoral insertion of the MCL
• Negative Lachman, Negative Anterior and Posterior
  Drawer.
• Negative McMurrays
• Varus and Valgus stable in extension.
• Moderate laxity in 30 degrees of flexion with
  valgus stress with firm endpoint.

6
Case

• XR Negative

7
Case

• Diagnosis?

8
Case

• Grade II MCL Tear

9
Case

• Treatment
• Conservative Treatment.
• Crutches
• Anti-inflammatories
• ROM Brace
• Rehab
• Outcome
• RTP in 4 weeks, weaned as tolerated from brace.

10
Anatomy

• Layer I
• Deep fascia, Sartorius
• Layer II
• Superficial MCL
• Layer III
• Deep MCL
• Posteromedial Capsule

11
Medial Knee Anatomy
12
MCL Function

• Primary stabilizer to valgus force.
• Secondary stabilizer to Anterior translation.
• Resist external rotation.
• MCL and ACL have a codependent relationship.

13
Diagnosis

• History
• Classic Mechanism Isolated Valgus moment to
  knee.
• PE
• Complete Knee Exam
• Examine MCL with the knee both in full extension
  and at 30 degrees of flexion.
• Valgus Stress with knee at 30 degrees of flexion
  causes pain or instability of medial knee.

14
MCL Injury Model
15
MCL Grading System

• I - Stretching of fibers. Localized TTP. No
  instability.
• II - Disruption of Fibers. Mild to moderate
  instability.
• III - Complete disruption of ligament. Gross
  instability.

16
Imaging

• XR
• May demonstrate avulsions.
• MRI
• Confirms Diagnosis
• Evals other ligaments, cartilage.

17
Treatment

• The injured MCL heals predictably without repair
  regardless of its grade.
• Non-op management of all MCL tears is considered
  standard practice.

18
Treatment of Isolated MCL Injury

• Grade I and II Injuries
• Non-Surgical Treatment
• Crutches until symptoms improve, WBAT, ROM.
• Edema Control - Ice, Compression, Massage.
• NSAIDS
• Hinged knee brace
• Speeding Recovery
• Good control of swelling can decrease the amount
  of time for full recovery of motion and strength.

19
Treatment of Isolated MCL Injury

• Grade III MCL
• Non-Surgical Rehab
• Brief period of immobilization
• Start ROM when initial swelling subsides.
• May need a longer period of protected weight
  bearing.
• Persistant valgus instability
• May consider for early surgical reconstruction.

20
Tibial Sided vs. Femoral Sided MCL injury

• Proximal MCL tears at the femoral insertion more
  common than at the distal tibial insertion.
• In general, femoral side injuries tend to heal
  better than tibial side or midsubstance injuries.

21
ACL MCL

• Usually do not require MCL reconstruction
• Rehab the medial side and achieve full ROM then
  do ACL reconstruction.
• However, if valgus instability persists after
  rehab then reconstruction of ACL and MCL should
  be considered.

22
PCL MCL

• If significant posterior subluxation is present
  following injury, both ligaments should be
  reconstructed acutely.
• If the Joint is well reduced, can treat MCL
  nonsurgically with bracing. PCL can be
  reconstructed when full ROM is achieved and
  valgus stability is restored.
• If valgus instability persists, reconstruct PCL
  and MCL.

23
Chronic MCL Injury

• Chronic injury results when the MCL complex loses
  its potential for spontaneous healing.
• Usually occurs 3 to 4 months following the
  initial injury.
• Can develop secondary ligamentous instabilities
  or secondary limb malalignment.

24
Chronic MCL Injury

• Valgus deformity of limb secondary to chronic MCL
• Osteotomy may be required at time of MCL
  reconstruction.
• Surgical Options
• POL Advancement
• Proximal Capsular Advancement
• Distal Capsular Advancement
• Semimembranosis advancement
• Allograft

25
Child with Medial Knee Injury

• Dont forget to rule out physeal injury!

26
Prevention

• Prophylactic and Functional Bracing for MCL
  Protection
• Controversial

27
Latest Research

• Animal Studies suggest that Anti-Inflammatory
  medications do not impede ligament healing in
  early and intermediate healing phases
• Sports Med. 1999 27 738. Claude T. Moorman,
  III, Udita Kukreti, David C. Fenton and Stephen
  M. Belkoff. The Early Effect of Ibuprofen on the
  Mechanical Properties of Healing Medial
  Collateral Ligament

28
ACL MCL

• Operative and Nonoperative Treatments of Medial
  Collateral Ligament Rupture Were Not Different in
  Combined Medial Collateral and Anterior Cruciate
  Ligament Rupture.
• ACL Grade 3 MCL
• Surgery at 4 - 23 days after injury.
• No difference in results at 2 years.
• Review
• Surgery took place before MCL healing.
• Low Demand Patients
• Treated with continuous hinged knee brace
• Conclusion Patients with combined ACL MCL
  injuries who undergo early surgery after injury
  may do well without surgical treatment of the
  MCL, but they should be treated in a hinged knee
  brace. Caution should be used in a different
  patient population such as high demand athletes.
• Halinen J, Lindahl J, Hirvensalo E, Santavirta S.
  Operative and Nonoperative Treatments of Medial
  Collateral Ligament Rupture with Early Anterior
  Cruciate Ligament Reconstruction A Prospective
  Randomized Study. Am J Sports Med. 2006
  Jul341134-40.

29

• Questions?