Medial Collateral Ligament Injuries

Clinical Background
The anatomy of the medial knee has been divided into three layers, consisting of the deep investing fascia of the thigh, the superficial MCL and the deep MCL, or knee joint capsule. The superficial MCL is the primary restraint to valgus loading, and the deep MCL and posteromedial capsule are secondary valgus restraints at full extension.
Most isolated MCL injuries result from direct trauma to the lateral aspect of the knee creating a valgus force (Fig. 4-40). An indirect or noncontact mechanism, especially involving rotation, typically produces associated injuries, usually involving the cruciate ligaments.

The patient may report a popping or tearing sensation on the medial aspect of the knee. Most injuries occur at the femoral origin or in the midsubstance over the joint line, although tibial avulsions do occur. MCL sprains may be isolated or combined with other knee injuries. Associated injuries may be diagnosed by an alert clinician who looks for clues that appear in the history and examination or while monitoring the clinical progress of the patient.

Physical Examination The physical examination begins with the patient seated. Inspection of the knee may reveal localized edema over the MCL. A visible enlargement of the normal prominence of the medial epicondyle characterizes injuries to the femoral origin. The presence of a large

effusion should alert the clinician to a possible intra-articular injury, such as a fracture, meniscal tear, or crudate ligament injury. Because the MCL is extra-articular, isolated MCL injuries seldom produce large intra-articular swelling. Careful palpation along the course of the MCl from the origin on the femoral epicondyle to the insertion on the proximal medial tibia will reveal maximal tenderness over the injured portion of the ligament. Valgus laxity should be evaluated with the patient supine and relaxed (see Fig. 4-5). The examiner supports the leg with one hand under the heel and, with the other hand, applies a gentle valgus force to the fully extended knee. In a normal knee, the examiner will feel firm resistance with virtually no separation of the femur and tibia. In an abnormal knee, the femur and tibia will be felt to separate in response to the valgus force and to "clunk" back together when the force is relaxed. Increased laxity on valgus stress testing of the MCl in full extension (0 degrees) indicates severe injury to the Mel, the posteromedial capsule, and usually one or both cruciate ligaments. If the valgus stress test is normal with the knee in full extension, the examiner flexes the knee about 30 degrees

and repeats the .test. This flexion relaxes the posterior capsule and ~mits more~olated testing of the MeL: With--the' knee flexed, the examiner again evaluates the firmness of the resistance (the "endpoint") and the amount of joint separation. The opposite knee should be examined to determine normal laxity; generalized ligamentous laxity may be incorrectly identified as abnormal opening to valgus stress. The physical examination findings progress with higher grades of injuries. In a grade 1 sprain, the ligament is tender, but the knee is stable to valgus stress testing in 30 degrees of knee flexion. A grade 2 sprain demonstrates abnormal valgus laxity compared with the contralateral knee, but with a firm endpoint. The firm endpoint may be difficult to appreciate owing to involuntary guarding. Because a grade 3 sprain represents a complete rupture, valgus laxity is abnormal with a soft or indefinite endpoint. Differential Diagnosis The differential diagnosis of an isolated MCl injury includes medial knee contusion, medial meniscal tear, patellar subluxation or dislocation, and physeal fracture (in a skeletally immature patient). A careful physical examination will help to differentiate an MCl sprain from the other diagnostic possibilities. A bone contusion also produces tenderness, but does

not result in abnormal valgus laxity. Tenderness near the adductor tubercle or medial retinaculum adjacent to the patella can be caused by a patellar dislocation or subluxation with VMO avulsion or medial retinaculum tear. A positive patellar apprehension sign aids in distinguishing an episode of patellar instability from MCl injury. Physeal fractures in skeletally immature patients are tender over the growth plate, and the growth plate opens up on gentle stress-testing radiographs. Joint line tenderness may be present in either a medial meniscal tear or an MCl sprain. Opening of the joint line on valgus laxity examination should differentiate between a meniscal tear and a grade 2 or 3 MCl sprain. The differentiation between a grade 1 MCl sprain and a medial meniscal tear is more difficult. An MRI can be obtained, or the patient can be observed for a few weeks. Tenderness usually resolves with a MCl sprain, but persists with a meniscal injury. Radiographic Examination Routine plain radiographs of the knee, including AP, lateral sunrise, and tunnel views, should be obtained to exclude a fracture or osteochondral injury. Bony avulsions of the cruciates or a tibial flake avulsion of the lateral capsule (Segond sign-associated with an ACL injury) may indicate associated injuries.

The Pelligrini-Steida sign does not indicate an avulsion fracture, but rather an ectopic calcification that may develop near the medial epicondyle after a proximal MeL sprain. Its presence on radiographs suggests a previous MCl injury. An MRI is not indicated for evaluation of an isolated MCl injury but may be helpful if the examination is equivocal (Fig. 4-41). Isolated MCl sprains are rarely associated with meniscal tears. Treatment of Isolated and Combined Medial Collateral Ligament Injuries The treatment of all grades of isolated MCl sprains is an aggressive, nonoperative rehabilitation program. Numerous studies have shown that a functional rehabilitation treatment program allows more rapid recovery with results equal or superior to those obtained with surgery or prolonged immobilization. When abnormal MCl laxity is present, a functional hinged brace is used to support and protect the MCl while allowing full knee ROM during rehabilitation. When an associated cruciate ligament injury is present, treatment of the cruciate injury assumes paramount importance, and surgery is usually recommended. For MCl sprains associated with ACl tears, surgical reconstruction of the ACl without direct surgical repair of the

MCl is recommended by most authors. It has been shown that injuries to both ligaments (ACl and MCl) adversely affect the healing of the MCL. Reconstruction of the ACl improved the healing response of the MCL. Some surgeons advocate primary repair of the MCl in association with ACl reconstruction in a knee that opens widely to valgus stress in full extension. Documentation to support this practice is scarce because these cases are relatively infrequent and difficult to compare in a controlled fashion. For combined PCL and MCL injuries, primary repair of the injured medial structures and PCl reconstruction are usually recommended. For isolated MCL sprains, we stress the functional rehabilitation treatment outlined later. The healing MCl is protected with a lightweight hinged brace at all times, and the patient is encouraged to return to full weightbearing and to begin an endurance activity such as cycling or stair climbing as soon as possible. This minimizes secondary muscle atrophy so that the factor limiting the patient's return to sports is the rate of healing of the MCl and not weakness or stiffness owing to imposed restrictions. The paramount feature of this program is that progression of rehabilitation activities and return to sports are based on the attainment of functional goals rather

than arbitrary time periods. When MCl injury occurs with ACl rupture, the athlete is treated with the same brace and rehabilitation program until full weight-bearing and nearly full motion are attained and swelling is minimized. ACl reconstruction usually is then carried out without direct repair of the MCL. Rarely, in a knee with gross increased valgus laxity at full extension, primary repair of injured medial structures is done at the time of ACl reconstruction. In this case, surgery should be done within 7 to 10 days of injury to facilitate primary repair of the medial structures. When the superficial MCl is too compromised to permit a strong repair, it is reinforced with the semitendinosus tendon, which is left attached to the tibia and fixed at the most isometric point on the medial epicondyle. This same technique is also useful for reconstruction of the MCl in the rare case in which it does not heal primarily. Finally, for combined injuries of the PCl and MCl or of the ACl, PCl, and MCl, the medial structures usually are repaired primarily during the cruciate ligament surgery. Rehabilitation after MCL Injury The rehabilitation program is divided into three phases. Successful completion of each phase and progression into the next phase are based on attaining specific goals. The

time in each phase varies. The average time to return to sport varies with both grade and sport. On the average, grade 1 injuries require about 10 days, and grades 2 and 3 need about 3 to 6 weeks. Sports that place more stress on the MCl, such as soccer, may require a longer period of healing before return to play.