Title: MCL Injuries of the Knee
1MCL Injuries of the Knee
- Kristopher Aalderink, MD
- Orthopaedic Surgery, Sports Fellow
- August 14, 2008
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3Presentation Objectives
- Anatomy Function of the MCL
- Biomechanics of MCL
- Physical Exam Techniques
- Diagnostic Studies
- Types of Injuries
- Treatment Options
- Nonsurgical
- Surgical
4Medial Collateral Ligament (MCL)
- One of the most commonly injured ligaments about
the knee. - Common in sports involving valgus knee loading
(football, ice hockey, skiing)
5Anatomy of the MCL
- Composed of both static dynamic parts.
- Static components
- Superficial MCL (primary stabilizer)
- Deep MCL, a thickening of the medial capsule
- Posterior oblique ligament
- Dynamic components semimembranosis, vastus
medialis, and pes anserinus.
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7Anatomy cont
- Three-layer concept described by Warren
Marshall - Layer I
- Deep fascia, Sartorius
- Layer II
- Superficial MCL
- Layer III
- Deep MCL
- Posterior oblique ligament- confluence of layers
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8MCL Function
- Main function is to resist valgus and external
rotation forces of the tibia in relation to the
femur. - Primary stabilizer to valgus force.
- Secondary stabilizer to anterior translation.
9Basic Biomechanics
- Anterior parallel fibers in constant tension
throughout flexion, whereas posterior fibers were
oblique and slackened in flexion . - MCL is tight in external rotation.
- With knee flexion gt 90 degrees,
the tibia internally rotates,
relaxing the anterior
fibers. - MCL has 1.5cm of excursion
during knee
flexion/extension.
10Biomechanics
- The ultimate strength of the human MCL has been
shown to be approximately equal to that of the
anterior cruciate ligament (ACL). - The location of maximum strain of the MCL from
cadaver studies was found to be near the femoral
insertion with the knee in full extension. - In contrast to the ACL, the MCL has shown
excellent healing capability in both animal and
clinical studies.
11History Physical Examination
- Mechanism of injury and the position of the knee
when it was injured. - Vast majority from direct blow to lateral
leg/thigh - Hughston and colleagues found that 76 of
athletes with grade III injuries could walk into
the office unaided by external support.
12Physical Examination cont
- Patellar tenderness, apprehension, and medial
retinacular tenderness are sought because
patellar dislocation is associated with valgus
injuries. - Hunter and colleagues found a 9 to 21 incidence
of damage to the extensor mechanism (vastus
medialis tearing) with medial ligament injury.
13MCL Physical Examination
- The gold standard for medial instability is a
valgus stress test performed at 30 degrees of
knee flexion. - If medial opening at 0 degrees, suspect a
combined ligamentous injury. - Always compare to
contralateral limb!
14MCL
- Concomitant ligamentous injuries
- 20 of grade I
- 52 of grade II
- 78 of grade III
- ACL most commonly associated combined ligament
tear
15MCL Physical Examination
- Proximal MCL tears at the femoral insertion are
more common than at the distal tibial insertion. - In general, femoral side injuries tend to heal
better than tibial side or midsubstance injuries.
16Diagnostic Studies
- A-P, Lateral, Merchant (if indicated)
- Stress views
- MRI r/o associated
injuries
17Diagnostic Studies
Pellegrini-Stieda lesion Chronic MCL injury
characterized by a bony avulsion with
calcification of femoral insertion of MCL
Physeal injury
18MCL Grading System(Hughston)
Grade Description
I involves a few fibers resulting in localized tenderness but no instability
II disruption of more fibers, with more generalized tenderness but still no instability
III complete disruption of the ligament, with resultant instability
1 3-5 mm
2 6-10 mm
3 gt 10 mm
Laxity determined with knee in 30 degrees of
flexion
19MCL Grading(Fetto Marsh)
Grade Description
1 Stable to valgus stress at 0 30 degrees of knee flexion
2 Laxity at 30 degrees of flexion, stable at 0.
3 Valgus laxity at both 0 30 degrees flexion
20Treatment of Isolated MCL Injury
- Stable to valgus stress in extension
- Non-Surgical Treatment
- Crutches until pain subsides, WBAT
- Quad isometrics and ROM
- Hinged-knee brace
- Edema Control - Ice, Compression, Massage
- /- NSAIDs
21MCL Surgical Indications
Acute Repair Presence of intraarticular ligamentous entrapment A large bony avulsion Associated tibial plateau fracture MRI finding of complete tibial side avulsion in athletes Presence of AMRI Presence of valgus instability in 0 degrees of flexion w/ valgus knee alignment
Delayed repair Combined with anterior cruciate or other ligament reconstruction if the examination under anesthesia shows valgus laxity in 0 degrees of flexion
Augmentation Combined with any repair if local tissue is deficient
Reconstruction Symptomatic chronic valgus laxity
Distal Femoral Osteotomy Chronic valgus laxity with valgus bony alignment
22Entrapped MCL
23Acute Repair Surgical Technique(within 7-10
days)
- Femoral avulsion - ligament can be approximated
using suture anchors, staples, or a screw and
washer. - most problems with postoperative motion because
of capsular adhesions and dysfunction of the
extensor mechanism - Tibial avulsion (superficial and deep components)
repair can be performed using either suture
anchors or staples, restore tension - Mid-substance may require augmentation or
allograft reconstruction.
24Chronic MCL Repair(gt 3 months)
- Focus mainly on reconstruction of the superficial
MCL - Numerous options quadriceps tendon autograft,
hamstring autograft, hamstring allograft, or
Achilles allograft - Associated valgus deformity of the knee
- distal femur varus-producing osteotomy
25Combined ACL MCL Injury
- Problems with loss of motion with early
reconstruction of both the ACL and MCL - Many authors recommend ACL reconstruction after a
period of rehabilitation to allow the MCL to heal - Delay until full ROM, adequate strength,
resolution of knee effusion - Residual valgus laxity post ACL reconstruction ?
reconstruct MCL
26References
- DeLee DeLee and Drez's Orthopaedic Sports
Medicine, 2nd ed. - Derscheid et al, Medial collateral ligament
injuries in football. Nonoperative management of
grade I and grade II sprains Am J Sports Med.
1981 Nov-Dec 9(6) 365-8. - Hughston JC, Barrett GR Acute anteromedial
rotatory instability. Long-term results of
surgical repair. J Bone Joint Surg Am 1983 65
145-153. - Hunter SC, Marascalco R, Hughston JC Disruption
of the vastus medialis obliquus with medial knee
ligament injuries. Am J Sports Med 1983 11
427-431. - Indelicato, Isolated Medial Collateral Ligament
Injuries in the Knee, J Am Acad Orthop Surg 1995
3 9-14.
27References
- Iowa Orthopaedic Journal, MCL injuries of the
knee Current concepts review, Vol. 26, pp 77-90. - Master Techniques in Orthopaedic Surgery
Reconstructive Knee Surgery, LWW2nd ed, 2003. - O'Donoghue DH Reconstruction for medial
instability of the knee. J Bone Joint Surg Am
1973 55941-954. - O'Donoghue DH Treatment of acute ligamentous
injuries of the knee. Orthop Clin North Am
1973 4617-645. - Shelburne et al, ACL-MCL injury nonoperative
management of MCL tears with ACL reconstruction.
A preliminary report. Am J Sports Med
20283-286, 1992. - Sports Medicine, Core Knowledge in Orthopaedics,
Miller, Sekiya, 2006.
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