They can be isolated or occur with a combination of ligament and/or meniscal injuries. It is very unusual for a pure MCL sprain to produce a knee effusion.

MCL injuries are invariably treated non-operatively with good to excellent results. Primary repair of even Grade 3 MCL injuries occurring with a combination of ACL rupture is not recommended and good long-term results can be achieved by reconstruction of the ACL and treating the MCL non-operatively.

Epidemiology

Medial Collateral Ligament injuries (MCL) are extremely common and account for 60% of all knee injuries during skiing. Both contact and non-contact injuries with valgus force to the knee can cause MCL tears. They also occur with over use injuries as in swimming (breast stroke or eggbeater kick).
In rugby players MCL injuries are responsible for 25% of missed playing days due to injury. The MCL is involved in 17.6% of athletic injuries. The superficial MCL is the primary resistance both to valgus load and to external rotation of the tibia. Medial knee pain is common in Breaststroke swimmers and is often due to MCL sprains.
Facts about Superficial MCL, Deep MCL and Posteromedial corner

  • sMCL is the primary restraint to tibial valgus moments across the arc of knee flexion
  • sMCL is the primary restraint on the medial aspect of the knee to tibial external rotation and that the dMCL also provided some restraint when the knee was flexed beyond 30°.
  • dMCL is a short ligament, so tibial rotations tighten it more rapidly than they do the longer sMCL fibers. This observation may explain why the dMCL is often damaged in association with the ACL in injuries with a tibial rotation mechanism
  • dMCL provides significant restraint to anterior drawer of the flexed and externally rotated tibia,(Basis of Slocum test)
  • PMC is an important structure for controlling tibial posterior translation with the knee in extension (resisting 28-42% of posterior translation load)

Diagnosis

History- Mechanism of injury

Medial tenderness on the superficial MCL attachments or along its mid substance

Tenderness more posteromedially can be due to Posterior Oblique Ligament(POL) injury as happens with valgus rotational force.

Valgus Stress test at 30 degrees knee flexion

Valgus stress in extension usually positive if POL is also ruptured

Anteromedial laxity testing by Slocum test

MRI

Acute MCL tears demonstrate a variable degree of intermediate T1-weighted and high T2-weighted signals indicative of surrounding edema. Depending on the grade of the tear, disruption or thickening of the MCL fibres and surrounding haemorrhage can be seen.

Natural history of healing of MCL tears

A tear in the MCL has good potential to repair whether isolated or occurring with other ligament injuries. Healing happens in the usual stages- short phase of hemorrhage and inflammation, an intermediate phase of proliferation, and a prolonged phase of remodelling. Bridging scar tissue forms in the first 6 weeks but the recovery of the mechanical properties of the MCL substance is slow and not complete, even at 48 weeks. Prolonged immobilisation has deleterious effects on MCL healing.

Non-operative Treatment
Grade 1 injuries

Treated by early mobilisation and physiotherapy without bracing and early return to sport (2-3 months)

Grade 2 and 3 injuries

  • Treated by initially protecting the knee in a rehabilitative knee brace either temporarily in full extension or in a ROM brace from 20-90 degrees
  • Weight bearing is allowed depending on pain and additional injuries
  • Gradually increasing controlled mobilisation is allowed in the brace to avoid the deleterious effects of immobilisation to cartilage, bone, muscles, tendons and ligaments, and to enhance the orientation of collagen fibres to the stress lines of the healing ligament.
  • After 4 to 8 weeks the goal for rehabilitation is rapid and full recovery to work and sports. A functional knee brace may be used at this phase to give extra protection remodelling of the injured ligament.
  • During mobilisation and muscle training various techniques can be used for strengthening the hamstring and quadriceps muscles, including isometric, isotonic, isokinetic and eccentric exercises with or without resistive
  • equipments. In addition, electrical stimulation may help prevent muscle wasting due to immobilisation
    Normally, jogging is allowed approximately 3 months after the injury, and an athlete is generally able to return to full activity and competitive sports after adequate individual response to treatment.

Technique of MCL and POL repair

The technique is well described by Hughston. The leg is positioned with the knee flexed 60 degrees with side support and foot support. A medial curvilinear incision is made. The deeper plane is identified along the anterior border of sartorius.

  • Step 1- Repair femoral avulsion of MCL using suture anchors. Midsubstance tears of the MCL can also be repaired.
  • Step 2- The slack posterior oblique ligament is pulled anteriorly and proximally on to the femur and repaired to periosteum on to the area between medial epicondyle and adductor tubercle.
  • Step 3- The anterior part of the torn POL is also sutured to MCL
  • Step 4- Reefing of semimembranosus to tighten posteromedial corner

MCL with combined ligament injuries

The combination of MCL injury with ACL injury is extremely common. There is no doubt that MCL tears have good healing potential and hence the grade 1 and 2 injuries with ACL rupture can be treated with early or delayed ACL reconstruction and accelerated rehabilitation.

The presence of a Grade 3 MCL combined with an ACL rupture has raised some controversies. Acute ACL reconstruction with both nonoperative and operative treatment of the MCL gives good results. In a prospective study on 47 patients with such injuries, Halinen (AJSM 2006) showed no significant difference in Lysholm, activity level or IKDC at 2 years follow-up.

Numerous authors support nonoperative treatment of the MCL with early ACL reconstruction. (Noyes, Hillard-Sembell, Shelbourne, Millet, Ballmer, Halinen)

Noyes (AJSM 1995) noticed higher complications due to stiffness in the operatively treated MCL group compared to nonoperative treatment when combined with early ACL reconstruction.

Peterson (Arch Orthop Trauma Surg 1999) in a retrospective study on 37 patients compared early vs late ACL reconstruction with nonoperative treatment of grade 3 MCL injury and found less problems with stiffness with late reconstruction. The question is whether an early ACL reconstruction would reduce valgus laxity and this has not been answered as yet.

Hughston is a proponent of MCL repair with repair of Posterior oblique ligament along with ACL reconstruction. Injury to the POL causes anteromedial rotatory instability. In his series he treated the knees postoperatively in a plaster at 60 degrees flexion for 6 weeks. Sims (AJSM 2004) and Jacobson suggest that patients with posteromedial corner injuries are different from isolated Superficial MCL injuries. These patients may benefit from posteromedial repair.

Management of Chronic MCL laxity

The indications for addressing MCL laxity are –

  • valgus instability in a multiligament injured knee or
  • valgus laxity in the presence of severe lateral compartment osteoarthritis.

The techniques available to address valgus laxity are –

  • repair or reattachment of the capsular structures including the posteromedial corner,
  • transfer or tightening of the pes anserinus,
  • reestablishment of the influence of the semi-membranosus complex to the posteromedial corner, and
    advancement of the insertion of the MCL
  • MCL Reconstruction with hamstring graft

There is limited literature in the management of such laxity. Repair or reefing of posteromedial structures is difficult and has poor success in chronic laxity.

Proximal or distal advancement can be used for minimal laxity. Distal advancement can be done as a sleeve of medial capsule with superficial MCL as described by Krackow. Proximal advancement can be done either as a bone block or as a soft tissue sleeve and repaired with screw-washer or suture anchors.

Reconstruction of the MCL can be done using autograft or allograft. The aim is to reconstruct superficial MCL and also reconstruct the posteromedial corner by repairing one limb of the graft to semimembranosis.

 

Pelligrini-Stieda Disease

This is a posttraumatic calcification at the femoral attachment of MCL that can produce refractory pain following MCL injuries. Xrays can show calcification and sometimes MRI scans can be useful.

For unresolving cases, corticosteroid injection or very occasionally surgical excision and repair of MCL may be indicated.

 

References
Epidemiology

Pressman A, Johnson DH: A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments. Arthroscopy 19:194, 2003.

Grood ES, Noyes FR, Butler DL, et al: Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. J Bone Joint Surg Am 63:1257, 1981.

Robinson JR, Bull AMJ, Rhidian R. deW. Thomas, and Andrew A. Amis. The Role of the Medial Collateral Ligament and Posteromedial Capsule in Controlling Knee Laxity. Am. J. Sports Med., Nov 2006; 34: 1815 – 1823.

Healing

Woo SL, Inoue M, McGurk-Burleson E, Gomez MA.Treatment of the medial collateral ligament injury. II: Structure and function of canine knees in response to differing treatment regimens.Am J Sports Med. 1987 Jan-Feb;15(1):22-9.

Frank C, Woo SL-Y, Amiel D, et al: Medial collateral ligament healing: A multi-disciplinary assessment in rabbits. Am J Sports Med 11:379, 1983

Anderson DR, Weiss JA, Takai S, Ohland KJ, Woo SL. Healing of the medial collateral ligament following a triad injury: a biomechanical and histological study of the knee in rabbits. J Orthop Res. 1992 Jul;10(4):485-95.

Non-operative treatment

Indelicato PA, Hermansdorfer J, Huegel M: Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop 256:191, 1990

Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65:323-329.

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 Jul;34(7):1134-40.

Kannus P, Järvinen M. Nonoperative treatment of acute knee ligament injuries. A review with special reference to indications and methods.Sports Med. 1990 Apr;9(4):244-60. Review

Lundberg M, Messner K: Long-term prognosis of isolated partial medial collateral ligament ruptures. Am J Sports Med 24:160, 1996

Repair and combined injuries

Hughston JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament: results of long-term follow-up. J Bone Joint Surg Am. 1994;76:1328-1344

Shelbourne KD, Porter DA.Anterior cruciate ligament-medial collateral ligament injury: nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction. A preliminary report. Am J Sports Med. 1992 May-Jun;20(3):283-6.

Hara K, Niga S, Ikeda H, Cho S, Muneta T.Isolated anterior cruciate ligament reconstruction in patients with chronic anterior cruciate ligament insufficiency combined with grade II valgus laxity.Am J Sports Med. 2008 Feb;36(2):333-9.

Hillard-Sembell D, Daniel DM, Stone ML, et al: Combined injuries to the anterior cruciate and medial collateral ligaments of the knee. J Bone Joint Surg Am 78:169, 1996.

Millett PJ, Pennock AT, Sterett WI, Steadman JR.Early ACL reconstruction in combined ACL-MCL injuries. J Knee Surg. 2004 Apr;17(2):94-8

Petersen W, Laprell H. Combined injuries of the medial collateral ligament and the anterior cruciate ligament.Early ACL reconstruction versus late ACL reconstruction. Arch Orthop Trauma Surg. 1999;119(5-6):258-62.

Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004 Mar;32(2):337-45.

LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007 Sep;89(9):2000-10

Repair/reconstruction

Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. 2005; 33:1380-1385

Lonergan KT, Taylor DC. Medial collateral ligament injuries of the knee: an evolution of surgical reconstruction. Tech Knee Surg. 2002; 1:137-145.

Borden PS, Kantaras AT, Caborn DN. Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy. 2002 Apr;18(4):E19

Slocum DB, Larson RL, James SL. Late reconstruction of ligamentous injuries of the medial compartment of the knee. Clin Orthop Relat Res. 1974;100:23-55.

Healy WL, Iorio R, Lemos DW. Medial reconstruction during total knee arthroplasty for severe valgus deformity. Clin Orthop. 1998;356:161-169.

Krackow KA. Deformity. In the Technique of Total Knee Arthroplasty. Pp. 249-372. St. Louis, Mo: CV Mosby; 1990.
MCL with ACL

Shelbourne KD, Porter DA.Anterior cruciate ligament-medial collateral ligament injury: nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction. A preliminary report. Am J Sports Med. 1992 May-Jun;20(3):283-6.

Hara K, Niga S, Ikeda H, Cho S, Muneta T.Isolated anterior cruciate ligament reconstruction in patients with chronic anterior cruciate ligament insufficiency combined with grade II valgus laxity.Am J Sports Med. 2008 Feb;36(2):333-9.

Hillard-Sembell D, Daniel DM, Stone ML, et al: Combined injuries to the anterior cruciate and medial collateral ligaments of the knee. J Bone Joint Surg Am 78:169, 1996.

Millett PJ, Pennock AT, Sterett WI, Steadman JR.Early ACL reconstruction in combined ACL-MCL injuries. J Knee Surg. 2004 Apr;17(2):94-8

Repair/reconstruction

Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. 2005; 33:1380-1385

Lonergan KT, Taylor DC. Medial collateral ligament injuries of the knee: an evolution of surgical reconstruction. Tech Knee Surg. 2002; 1:137-145.