Medial Collateral Ligament Tear

Ovid: 5-Minute Sports Medicine Consult, The

Medial Collateral Ligament Tear
Claudia Dal Molin
Delmas J. Bolin
  • Superficial component is primary restraint to valgus stress.
  • Deep portion has tight connection to medial meniscus.
  • Medial collateral ligament (MCL) connects with the posteriomedial corner structures and is a secondary stabilizer in resisting external rotation and anterior-posterior translation of the knee.
  • Tension injury to the MCL occurs most commonly with a valgus stress (ie, a blow to the lateral knee).
  • Grade of injury classified by symptoms and physical exam by degree of joint opening with applied valgus stress at 0° and 30° of knee flexion:
    • Grade I: minimal fiber tearing, localized tenderness, no instability (0–5 mm of laxity)
    • Grade II: greater degree of ligamentous tearing, slight-to-moderate abnormal motion (6–10 mm of laxity)
    • Grade III: complete tear, demonstrable instability (>10 mm of laxity)
MCL is most frequently injured ligament of the knee (1).
General Prevention
Prophylactic knee bracing is controversial; most studies demonstrate bracing protects MCL and increases force required to produce failure. Some studies suggest athletes perceive decreased performance while using brace (1,2).
Commonly Associated Conditions
  • Medial meniscus tear, commonly in the posterior horn
  • Anterior cruciate ligament (ACL) tear
  • Posterior oblique ligament injury; anteromedial rotatory instability
  • Dislocation of the knee (rare)
  • In contact/collision sports, an acute blow to the lateral aspect of the knee when the foot is planted results in a valgus stress:
    • The medial joint line is under tension and can open, producing “buckling” and an injury to the MCL (closed-chain injury).
  • The injury may be seen in soccer players who are struck on the instep while passing the ball (open-chain injury).
  • Skiers can injure MCL by noncontact valgus external rotation injury.
  • Overuse injuries to the MCL have been reported in breaststroke swimmers.
  • History of a “pop” should suggest associated meniscus or ACL injury.
Physical Exam
  • Observe for antalgic gait; inquire about a sense of the knee being “loose.”
  • Inspect the knee for ecchymosis, swelling, effusion, and presence of deformity. Presence suggests greater extent of injury. In pediatric patients, ecchymosis and swelling necessitate evaluation for physeal injury.
  • Palpate for localized tenderness over medial joint line and course of MCL, including adductor tubercle and proximal medial tibia.
  • Assess range of motion for deficit at full extension (MCL) or flexion (MCL and joint effusion).
  • Perform valgus stress at full extension and 30° of knee flexion. Valgus laxity at 30° alone indicates an isolated MCL injury. Laxity at both 0° and 30° indicates injury to the MCL and posterior oblique ligament, knee capsule, and/or anterior cruciate ligaments. Always compare the exam to the unaffected knee.
  • Degree of injury (as opposed to grade) assessed by findings: 1st degree, pain but no laxity; 2nd degree, pain and laxity but firm endpoint present on valgus stress test at 30°; 3rd degree, no end point is present on valgus stress test at 30°.
  • Determine the amount of joint line opening. If >10 mm, coexisting intra-articular pathology (torn ACL or meniscus) will be present 80% of the time.
  • Posterior oblique ligament injury can lead to anteromedial rotatory instability and posterior horn medial meniscus tears. Anterior drawer testing with the foot in external rotation can assess anteromedial translation, but may be difficult to perform in acute injury.
  • Lachman's exam to evaluate a concomitant ACL tear; McMurray's exam to evaluate the menisci for injury
  • Assess neurovascular status of the extremity; popliteal nerve and artery injuries associated with instability can be limb-threatening and should not be missed.
Diagnostic Tests & Interpretation
  • Standard radiographic knee series (45-degree flexion weight-bearing, lateral, and sunrise views) usually normal, but used to identify avulsions or osteochondral fragments
  • Stress radiographs are useful in adolescents to exclude Salter-Harris (physeal) injuries; used when tenderness presents completely around physis.
  • Calcification of the MCL (Pellegrini-Stieda lesion) is seen in chronic MCL injury (3).
  • T2 MRI is gold standard and demonstrates acute intrasubstance edema and fiber discontinuity with acute MCL tears, and identifies associated bone contusions (45% of MCL injuries) and associated injuries, including ACL and meniscal tears (1).
Differential Diagnosis
  • Medial meniscus tear
  • Medial knee contusion
  • Patellar instability, subluxation, or dislocation
  • Fracture of the distal femoral physis
Ongoing Care
  • Grade I injuries:
    • Bracing is preferable for contact-related sports; football lineman at the college and occasionally at the high school levels will wear prophylactic MCL braces (1,5)
    • Return to sport is acceptable when level of strength, agility, and proprioception is equivalent (usually 90% of) to the uninvolved extremity.
    • Grade I injuries may be able to return to play in as little as 10 days to 2 wks.
  • Grade II injuries:
    • Return to play based on functional ability similar to that of grade I injuries; a hinged or custom MCL brace may be used for comfort and confidence of the athlete.
    • Grade II usually return to play in 21–28 days.
  • Grade III: Conservative management:
    • May require more than 28 days to return to full function. Consider surgical consultation for those athletes who fail conservative management or who develop pain with chronic instability.
Follow-Up Recommendations
  • Referral is suggested when there is suspicion of ACL or meniscal injury.
  • Some clinicians have suggested arthroscopy for all complete MCL injuries with more than 6 mm of joint opening.
844.1 Sprain, medial collateral, knee

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