medial collateral ligament sprains – a case study

Medial Collateral Medial Collateral Ligament Sprains – A Ligament Sprains – A

Case StudyCase Study

Eric SmoyerEric Smoyer

Nebraska Wesleyan UniversityNebraska Wesleyan University

AnatomyAnatomy Not just one bundle but twoNot just one bundle but two

– SuperficialSuperficial– Deep (Medial Meniscus)Deep (Medial Meniscus)

Originates Medial Epicondyle of Originates Medial Epicondyle of FemurFemur

InsertsInserts– Superficial to medial side of tibiaSuperficial to medial side of tibia– Deep to tibial plateau and medial Deep to tibial plateau and medial

meniscusmeniscus Prevent Valgus ForcePrevent Valgus Force Stabilize Medial KneeStabilize Medial Knee

Anatomy – Cont’dAnatomy – Cont’d

In full Ext. both prevent In full Ext. both prevent hyperextensionhyperextension

Always has tension to prevent medial Always has tension to prevent medial tibial translation.tibial translation.

Helps limit external rotation of tibiaHelps limit external rotation of tibia Actually only protects from valgus Actually only protects from valgus

forces in slight flexionforces in slight flexion

MCL InjuryMCL Injury

Very common in contact sports Very common in contact sports Foot planted, Knee flexed, and Foot planted, Knee flexed, and

valgus force applied, sometimes valgus force applied, sometimes rotationrotation

No medical predispositionNo medical predisposition

Case ReportCase Report

20 year old20 year old CaucasianCaucasian MaleMale Football playerFootball player During Regular Season gameDuring Regular Season game

Case Report – HistoryCase Report – History

Healthy and Acclimated physical Healthy and Acclimated physical statestate

No previous injury reportedNo previous injury reported Reported valgus force while knee Reported valgus force while knee

flexed and foot plantedflexed and foot planted Heard a snap in his kneeHeard a snap in his knee Sharp pain that quickly became a Sharp pain that quickly became a

dull ache on Medial Kneedull ache on Medial Knee

Case Report – EvaluationCase Report – Evaluation PPT over MCL both Superior and InferiorPPT over MCL both Superior and Inferior Positive TestPositive Test

– Valgus Stress at 30 degreesValgus Stress at 30 degrees Negative TestsNegative Tests

– Valgus Stress at zero degreesValgus Stress at zero degrees– Varus both zero and 30Varus both zero and 30– Lachman'sLachman's– Anterior/Posterior DrawerAnterior/Posterior Drawer– Posterior SagPosterior Sag– Pivot/ShiftPivot/Shift– McMurray’sMcMurray’s

Case Report – AssessmentCase Report – Assessment

Grade II MCL SprainGrade II MCL Sprain MRI MRI Doctor also concluded Grade II-III Doctor also concluded Grade II-III

MCL SpainMCL Spain Doctor also did not see any damage Doctor also did not see any damage

to other ligamentsto other ligaments

Case Report - TreatmentCase Report - Treatment

First Reduce Swelling and PainFirst Reduce Swelling and Pain– Interferential StimulationInterferential Stimulation– High VoltHigh Volt– IceIce

Approx. 10 Days post injuryApprox. 10 Days post injury– Passive ROM exercises performedPassive ROM exercises performed– Active ROMActive ROM– Reduce stiffness and restore ROMReduce stiffness and restore ROM

Once ROM was met Bike was usedOnce ROM was met Bike was used


Three weeks post injuryThree weeks post injury– Muscle Strengthening ExercisesMuscle Strengthening Exercises

Knee Ext/FlexKnee Ext/Flex Hip Ext/Flex Add/AbdHip Ext/Flex Add/Abd Lower Leg Inv/Ev Plant/DorsiLower Leg Inv/Ev Plant/Dorsi Single and Double Leg raisesSingle and Double Leg raises


Once Strength and Reduced Pain AchievedOnce Strength and Reduced Pain Achieved– One legged balance exercisesOne legged balance exercises

Flat GroundFlat Ground AirEx PadAirEx Pad BOSU BOSU

Four to Five Weeks Post InjuryFour to Five Weeks Post Injury– Functional Testing – DonJoy MCL BraceFunctional Testing – DonJoy MCL Brace

Running Running Running StoppingRunning Stopping CuttingCutting Side StridesSide Strides CariocaCarioca


Six Weeks post injurySix Weeks post injury– Athlete was cleared by doctorAthlete was cleared by doctor– Full Contact Full Contact – Return to playReturn to play– MCL BraceMCL Brace

Case Report – OutcomeCase Report – Outcome

Approximately six weeksApproximately six weeks Competed in rest of regular seasonCompeted in rest of regular season MCL BraceMCL Brace No further complaintsNo further complaints

– Dull PainDull Pain– Continued to ice for mild swellingContinued to ice for mild swelling

DiscussionDiscussion

When injured there are many optionsWhen injured there are many options– RehabilitationRehabilitation– RepairRepair

In the past usually used surgeryIn the past usually used surgery Today Non-invasive treatment is best choiceToday Non-invasive treatment is best choice Non-operative has yielded excellent resultsNon-operative has yielded excellent results Grade IIIGrade III

– Surgery best optionSurgery best option

Discussion - ResearchDiscussion - Research

Rat studyRat study Three GroupsThree Groups

– Rats with surgery and no MCL ruptureRats with surgery and no MCL rupture– Rats with surgery MCL rupture ambulatedRats with surgery MCL rupture ambulated– Rats with surgery MCL rupture and non Rats with surgery MCL rupture and non

weight bearing weight bearing Two Sub-GroupsTwo Sub-Groups

– Rats with three weeks to healRats with three weeks to heal– Rats with seven weeks to healRats with seven weeks to heal


Control no differenceControl no difference Ambulated showed most Ambulated showed most

improvementimprovement Non-Weight showed very littleNon-Weight showed very little Shows importance of slight weight-Shows importance of slight weight-

bearing in the realignment of bearing in the realignment of collagen fiberscollagen fibers

Realignment means more strengthRealignment means more strength


Surgery has a lot of controversySurgery has a lot of controversy The MCL has been found to heal The MCL has been found to heal

better than once thoughtbetter than once thought Leads to MCL injuries to be treated Leads to MCL injuries to be treated

more conservativelymore conservatively Surgery is recommended when:Surgery is recommended when:

– Instability with excessive medial joint Instability with excessive medial joint openingopening

– Instability with no firm endpoint on valgus Instability with no firm endpoint on valgus stress teststress test

Discussion - ResearchDiscussion - Research When surgery is recommended there are many When surgery is recommended there are many

waysways A new way uses parts of the Gracilis and A new way uses parts of the Gracilis and

SemitendinosusSemitendinosus– Grafted togetherGrafted together– Secured at same origin and insertionSecured at same origin and insertion– Utilizes smaller incisionsUtilizes smaller incisions

The study showed after several monthsThe study showed after several months– 88% graded normal on instability tests88% graded normal on instability tests– Pre-Surgery avg. medial joint opening was 3-6mmPre-Surgery avg. medial joint opening was 3-6mm– Post-Surgery avg. medial joint opening was <2mmPost-Surgery avg. medial joint opening was <2mm

Only replaces superficial portion but still Only replaces superficial portion but still improves stabilityimproves stability

Discussion - ResearchDiscussion - Research BracingBracing

– After injury most likely to wear braceAfter injury most likely to wear brace– Used since the inception of footballUsed since the inception of football– Huge debate on effectivenessHuge debate on effectiveness

TestingTesting– CadaverCadaver– ModelsModels

Tests showed small increase in strength Tests showed small increase in strength about 30%about 30%

May hinder athletic performanceMay hinder athletic performance– Few studies done, still inconclusiveFew studies done, still inconclusive

PerformancePerformance– One study showed a slight decrease in high One study showed a slight decrease in high

speed runningspeed running Several FactorsSeveral Factors

– TightnessTightness– ContoursContours– WeightWeight– Overall ComfortOverall Comfort

Effectiveness based on placementEffectiveness based on placement Tests still inconclusiveTests still inconclusive

ConclusionConclusion

Athlete in study did what was best for himAthlete in study did what was best for him Differs with athlete and degree of injuryDiffers with athlete and degree of injury Further complicationsFurther complications Study showed weight bearing is an Study showed weight bearing is an

important role in restoring ligament important role in restoring ligament strengthstrength

Braces may help increase resistance to Braces may help increase resistance to valgus forces but still inconclusivevalgus forces but still inconclusive

MCL can be easily damaged but today can MCL can be easily damaged but today can be rehabilitated more quicklybe rehabilitated more quickly

ReferencesReferences Hoppenfeld S. Hoppenfeld S. Physical Examination of the Spine and Extremities.Physical Examination of the Spine and Extremities. London: Prentice- London: Prentice-

Hall; 1976Hall; 1976 Otto, Voshell. The tibial collateral ligament: its function, its bursae, and its relation to Otto, Voshell. The tibial collateral ligament: its function, its bursae, and its relation to

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Prentice W. Principles of athletic training. Boston: McGraw Hill; 2006.Prentice W. Principles of athletic training. Boston: McGraw Hill; 2006. Schweitzer M.E., Tran D., Deely D.M., Hume E.L. Medial collateral ligament injuries: Schweitzer M.E., Tran D., Deely D.M., Hume E.L. Medial collateral ligament injuries:

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Nakamura N, Horibe S, Toritsuka Y, Mitsuoka T, Yoshikawa H and Shino K. Acute Grade Nakamura N, Horibe S, Toritsuka Y, Mitsuoka T, Yoshikawa H and Shino K. Acute Grade III Medial Collateral Ligament Injury of the Knee Associated with Anterior Cruciate III Medial Collateral Ligament Injury of the Knee Associated with Anterior Cruciate Ligament Tear. Ligament Tear. Am. J. Sports Med. Am. J. Sports Med. 2003; 31; 261. Available at: 2003; 31; 261. Available at: http://ajs.sagepub.com/cgi/reprint/31/2/261. Accessed October 9, 2007http://ajs.sagepub.com/cgi/reprint/31/2/261. Accessed October 9, 2007

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Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M, Medial Collateral ligament Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M, Medial Collateral ligament reconstruction using autogenous hamstring tendons. reconstruction using autogenous hamstring tendons. Am. J. Sports Med.Am. J. Sports Med. 2005; 2005; 33:1380. Available at: http://ajs.sagepub.com/cgi/content/abstract/33/9/1380. 33:1380. Available at: http://ajs.sagepub.com/cgi/content/abstract/33/9/1380. Accessed October 9, 2007 Accessed October 9, 2007

Najibi S. The Use of Knee Braces, Part 1: Prophylactic knee braces in contact sports. Najibi S. The Use of Knee Braces, Part 1: Prophylactic knee braces in contact sports. Am J Sports Med. Am J Sports Med. 2005;33:602-611. Available at: 2005;33:602-611. Available at: http://ajs.sagepub.com/cgi/reprint/33/4/602. Accessed October 9, 2007 http://ajs.sagepub.com/cgi/reprint/33/4/602. Accessed October 9, 2007

medial collateral ligament sprains – a case study

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