Medial Collateral LigamentEdward Silverman PGY VFebruary 17, 2015

GoalsAnatomyInjuryExamImagingTreatmentNon-operativeOperative

Medial Collateral Ligament

Medial Knee Anatomy Layer I Fascia, Sartorius Layer II Superficial MCL, Posterior oblique

ligament, Medial patellofemoralligament, Semimembranosus attachments

Layer III Knee capsule, Deep MCL

(Warren and Marshall, 1979)

Medial Knee Ligaments Superficial MCL Deep MCL Posterior Oblique Ligament

Superficial MCL Largest structure on the medial side of

the knee One femoral attachment 3.2 mm proximal, 4.8 mm posterior to

medial epicondyle Two tibial attachments Proximal insertion Soft tissue – semimembranosus 12.2 mm distal to joint line Distal insertion Bone – 4.5 - 6 cm distal to joint line Just anterior to posteromedial crest

sMCL primary restraint to valgus stress at 25 deg flex, resists external rotation

Hartshorn et. al. AJSM 2013

Deep MCL Thickened medial joint capsule Meniscofemoral 12.6 mm distal/deep to sMCL

Meniscotibial 3.2 mm distal to joint line Just distal to articular surface

Secondary valgus stablilizer Resists external rotation btw 30-90

degrees

Posterior Oblique Ligament Fibrous extension of distal

semimembranosus Blends with and reinforces post-medial

capsule Previously thought to be part of sMCL rotation and valgus stabilizer btw 0-30

degrees flexion Extension

Medial Knee Anatomy

LaPrade 2009 JBJS Posterior cortex

reference line Line 2 – most posterior

aspect of Blumensaatline POL – Most posterior,

posterior to line 1 sMCL – distal and

posterior to medial epicondyle MPFL – btw adductor

tubercle and medial epicondyle

Injury Valgus stress to a flexed knee External rotation / pivoting injury Blow to anterolateral knee Most commonly injured ligament 0.24 per 1000 (US incidence)

7.3 per 1000 per year (West Point Cadets)

Exam Suspicion based on

mechanism Complete exam – 78% rate of

associated injuries (grade III) Intra-articular effusion –

concern for ACL MCL extra-articular

Valgus stress with knee 30 degrees flexed Grade 1 <5 mm opening Grade 2 5-10 mm opening Grade 3 >10 mm opening

Degree 1st degree – tendernes without

instability 2nd degree – valgus laxity but

firm endpoint 3rd degree – no endpoint

Exam Valgus stress at 0 Posterior oblique ligament If laxity at 0, likely concominant ACL

tear or complete injury to posteromedial capsule

Valgus stress at 30 degrees Long fibers of sMCL

Saphenous nerve neuropraxia Medial meniscus (5% of sMCL

injuries)

Imaging Xray Medial joint space widening (Grade III) Avulsions Stress Xray, physeal injuries Pellegrini-Stieda lesion Chronic, femoral origin

MRI

Best study for diagnosisSite of injury (femoral/tibial

avulsion vs intrasubstance)Associated injuries Medial meniscus (5%) ACL (20%, 52%, 78%)

MCL Healing Extra-articular, good blood supply Hemorrhage, inflammation, repair, remodeling Repair with type 1 collagen Grade III with gapping – ↑ type 3 collagen Creighton et. al. ‘05

Immobilization hinders the healing,↓ load to failure Thornton et. al. ‘05

Adjuvants Ultrasound, PRP, Stem cells etc. Promising early results Pending publication UM Sports!

Grade 1 and 2 MCL Injury First 2-3 days Relative rest, ice, compression, elevation

When swelling is controlled ROM, partial weight bearing, +/- NSAIDs Hinged knee brace

When full ROM, 80% strength Jogging, proprioceptive exercises

75% speed running Start figure 8 drills, cutting drills Return to sport (10 day avg grade 1)

Grade 3 MCL Injuries 80% incidence of concomitant ligament

injuries Need to treat according to other injuries Isolated MCL Early repair vs late reconstruction Based on location of tear

Giannotti et. al. 2006

7.3 per 1000 per year (West Point Cadets) 73% grade 1, 27% grade 2/3 All non-operatively treated Grade 1 – lost 13.5 days, High grade – lost

29 days

Surgical Indications Persistent instability preventing normal activities or return to

sport Failed Non-operative treatment

Multi-ligamentous knee injuries MCL management Early primary repair vs non-operative management Bony avulsions – ORIF Reconstruct cruciates, non-op MCL

Tibial sided avulsions

Tibial avulsion

Taketomi et. al. Knee 2013

Stener like lesion• Tibial side avulsions• Rare, associated with

ACL tear• 9/12 type 2 or 3, poor

healing potential • Stener like lesion• Early repair

2011 CORR Italy 36 patients, chronic valgus laxity

(combined ACL) Medial reefing Reefing of medial capsule from

epicondyle Anterodistally, distally and

posterodistally Decreased laxity and improved

functional scores postop

2005 AJSM Japan Autograft hamstring Good results in small

case series n=24 Aim for anatomic

reconstruction of sMCL

2014 China Double bundle

reconstruction technique sMCL and POL

Better restoration of rotational stability Don’t sacrifice medial

hamstrings Dynamic stability

Prophylactic Bracing 1990 AJSM USMA West Point 1396 cadets Intramural, tackle football. RCT, Prophylactic brace vs no brace Decreased # of MCL injuries, significant

difference for defensive players.

1994 Big Ten Study Nonsignificant trend towards decreased

MCL injuries in braced linemen Similar nonsignificant increase in injury

rate for brace skill players Very low risk at baseline

2003 AAOS position statement “Prophylactic knee braces may provide

limited protection against injuries to the MCL in football players. Scientific studies have not demonstrated similar protection to other knee ligaments, menisci, or articular cartilage.”

Summary Non-operative treatment Surgery Reserved for valgus instability, failed non-operative tx Tibial side avulsions Associated with Multiligamentous injury