Medial Collateral Ligament Sprains A Case Study
Eric Smoyer Nebraska Wesleyan University
Anatomy
Not just one bundle but two
Superficial Deep (Medial Meniscus)
Originates Medial Epicondyle of Femur Inserts
Prevent Valgus Force Stabilize Medial Knee
Superficial to medial side of tibia Deep to tibial plateau and medial meniscus
Anatomy Contd
In full Ext. both prevent hyperextension Always has tension to prevent medial tibial translation. Helps limit external rotation of tibia Actually only protects from valgus forces in slight flexion
MCL Injury
Very common in contact sports Foot planted, Knee flexed, and valgus force applied, sometimes rotation No medical predisposition
Case Report
20 year old Caucasian Male Football player During Regular Season game
Case Report History
Healthy and Acclimated physical state No previous injury reported Reported valgus force while knee flexed and foot planted Heard a snap in his knee Sharp pain that quickly became a dull ache on Medial Knee
Case Report Evaluation
PPT over MCL both Superior and Inferior Positive Test Negative Tests
Valgus Stress at 30 degrees Valgus Stress at zero degrees Varus both zero and 30 Lachman's Anterior/Posterior Drawer Posterior Sag Pivot/Shift McMurrays
Case Report Assessment
Grade II MCL Sprain MRI Doctor also concluded Grade II-III MCL Spain Doctor also did not see any damage to other ligaments
Case Report - Treatment
First Reduce Swelling and Pain
Interferential Stimulation High Volt Ice
Approx. 10 Days post injury
Passive ROM exercises performed Active ROM Reduce stiffness and restore ROM
Once ROM was met Bike was used
Case Report - Treatment
Three weeks post injury
Muscle Strengthening Exercises
Knee Ext/Flex Hip Ext/Flex Add/Abd Lower Leg Inv/Ev Plant/Dorsi Single and Double Leg raises
Case Report - Treatment
Once Strength and Reduced Pain Achieved
One legged balance exercises
Flat Ground AirEx Pad BOSU
Four to Five Weeks Post Injury
Functional Testing DonJoy MCL Brace
Running Running Stopping Cutting Side Strides Carioca
Case Report - Treatment
Six Weeks post injury
Athlete was cleared by doctor Full Contact Return to play MCL Brace
Case Report Outcome
Approximately six weeks Competed in rest of regular season MCL Brace No further complaints
Dull Pain Continued to ice for mild swelling
Discussion
When injured there are many options
Rehabilitation Repair
In the past usually used surgery Today Non-invasive treatment is best choice Non-operative has yielded excellent results Grade III
Surgery best option
Discussion - Research
Rat study Three Groups
Rats with surgery and no MCL rupture Rats with surgery MCL rupture ambulated Rats with surgery MCL rupture and non weight bearing
Two Sub-Groups
Rats with three weeks to heal Rats with seven weeks to heal
Discussion - Research
Discussion - Research
Control no difference Ambulated showed most improvement Non-Weight showed very little Shows importance of slight weight-bearing in the realignment of collagen fibers Realignment means more strength
Discussion - Research
Surgery has a lot of controversy The MCL has been found to heal better than once thought Leads to MCL injuries to be treated more conservatively Surgery is recommended when:
Instability with excessive medial joint opening Instability with no firm endpoint on valgus stress test
Discussion - Research
When surgery is recommended there are many ways A new way uses parts of the Gracilis and Semitendinosus
Grafted together Secured at same origin and insertion Utilizes smaller incisions
The study showed after several months
88% graded normal on instability tests Pre-Surgery avg. medial joint opening was 3-6mm Post-Surgery avg. medial joint opening was <2mm
Only replaces superficial portion but still improves stability
Discussion - Research
Bracing
Testing
After injury most likely to wear brace Used since the inception of football Huge debate on effectiveness Cadaver Models
Tests showed small increase in strength about 30% May hinder athletic performance
Few studies done, still inconclusive
Performance
One study showed a slight decrease in high speed running
Several Factors
Tightness Contours Weight Overall Comfort
Effectiveness based on placement Tests still inconclusive
Conclusion
Athlete in study did what was best for him Differs with athlete and degree of injury Further complications Study showed weight bearing is an important role in restoring ligament strength Braces may help increase resistance to valgus forces but still inconclusive MCL can be easily damaged but today can be rehabilitated more quickly
References
Hoppenfeld S. Physical Examination of the Spine and Extremities. London: Prentice-Hall; 1976 Otto, Voshell. The tibial collateral ligament: its function, its bursae, and its relation to the medial meniscus. J Bone Joint Surg Am. 1943;25: 121-131. (Rev. and current as of October 11, 2007) 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: evaluation of multiple signs, prevalence and location of associated bone bruises, and assessment with MR imaging. Radiology. 1995;194, 825-829. Available at: http://radiology.rsnajnls.org/cgi/reprint/194/3/825. Accessed October 9, 2007 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 Ligament Tear. Am. J. Sports Med. 2003; 31; 261. Available at: http://ajs.sagepub.com/cgi/reprint/31/2/261. Accessed October 9, 2007 Provenzano P, Martinez D,. Grindeland R, Dwyer K, Turner J, Vailas A, and Vanderby R, Hindlimb unloading alters ligament healing. Journal of Applied Physiology. 2002;94:314-324. Available at: http://jap.physiology.org/cgi/reprint/94/1/314. Accessed October 9, 2007 Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M, Medial Collateral ligament reconstruction using autogenous hamstring tendons. Am. J. Sports Med. 2005; 33:1380. Available at: http://ajs.sagepub.com/cgi/content/abstract/33/9/1380. Accessed October 9, 2007 Najibi S. The Use of Knee Braces, Part 1: Prophylactic knee braces in contact sports. Am J Sports Med. 2005;33:602-611. Available at: http://ajs.sagepub.com/cgi/reprint/33/4/602. Accessed October 9, 2007
