eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Medial Collateral and Lateral Collateral Ligament Injury

Adam B Agranoff, MD, Physiatrist and Partner, Chelsea Back Care, Chelsea Community Hospital
Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center

Updated: Jul 9, 2008

Introduction

Background

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries of the knee are common. In fact, injury to the MCL is the most common ligamentous knee injury.

The MCL and LCL provide restraint to valgus and varus angulation of the knee, respectively. The MCL has superficial and deep components. The superficial MCL fibers attach proximally to the medial femoral epicondyle and distally to the medial aspect of the tibia, approximately 4 cm distal to the joint line. The deep MCL fibers originate from the medial joint capsule and are attached to the medial meniscus.

The LCL is part of a complex of ligaments collectively named the posterolateral corner (PC). The structures in the PC include the LCL, the popliteofibular ligament, the popliteus ligament, the arcuate ligament, the short lateral ligament, and the posterolateral joint capsule. The LCL is separated from the lateral meniscus by a fat pad (see Image 1).^1,2,3,4

Related eMedicine topics:
Collateral Ligament Pathology, Knee
Knee, Collateral Ligament Injuries (MRI)
Lateral Collateral Knee Ligament Injury
Medial Collateral Knee Ligament Injury

Related Medscape topic:
Resource Center Joint Disorders

Pathophysiology

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries are caused primarily by valgus and varus stress (respectively) to the knee joint. Injuries also can occur to both ligaments with excessive lateral rotation of the knee.

Frequency

United States

The annual incidence of acute knee injury in the United States is estimated to be 300 cases per 100,000 population. Collateral ligament injuries account for 25% of patients presenting to emergency rooms with acute knee injury. Peak incidence of collateral ligament injuries occurs in adults aged 20-34 years. The National Collegiate Athletic Association (NCAA) injury surveillance system reported 2.1 medial or lateral collateral injuries per 1000 player exposures in games across all NCAA sports over 1 year.⁵ Even noncontact sports, such as gymnastics and swimming, can lead to collateral ligament injuries.⁶

Mortality/Morbidity

Medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries can in most individuals be treated successfully with conservative methods. Severe injuries may require surgical intervention and tend to have good outcomes.^2,7

Race

There is no known racial predilection for medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries.

Sex

Unlike anterior cruciate ligament (ACL) injuries, which occur at a higher rate in women, medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries occur at equal rates in men and women.^6,8

Related eMedicine articles:
Anterior Cruciate Ligament Pathology
Anterior Cruciate Ligament Injury [Physical Medicine and Rehabilitation]
Anterior Cruciate Ligament Injury [Sports Medicine]
Knee, Anterior Cruciate Ligament Injuries (MRI)

Age

Age patterns for medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries are bimodal, with the highest incidence rates found in individuals aged 20-34 years and in persons aged 55-65 years. Nonetheless, MCL and LCL injuries can occur at any age.

Clinical

History

Listen to the patient's description of the injury event. The force vector of injury to the knee indicates the most likely site of pathology.⁹ For example, a football player who complains of medial knee pain after a valgus stress on the knee is likely to have an injury to the medial collateral ligament (MCL). Have the patient use the uninjured knee to explain precisely what he/she was doing when the incident occurred.

• MCL injury
  • Patients commonly have had recent excessive valgus force applied to a partially flexed knee (eg, a clipping injury in football). A common triad of injury (particularly in athletes) when a valgus force is applied to the knee involves injury to the MCL, the medial meniscus, and the anterior cruciate ligament.
  • Most patients are able to continue ambulating after an acute injury.
  • Pain and stiffness are localized to the medial knee.
  • Erythema may appear after several days.
  • The location of pain and swelling can be good indicators of which structure(s) may be damaged in the knee.
  • Instability or mechanical symptoms (eg, a locking or popping sensation) are uncommon.
• Lateral collateral ligament (LCL) injury
  • The patient commonly reports a history of varus force applied to the knee.
  • Most patients are able to continue ambulating after an acute injury.
  • Pain and stiffness are localized to the lateral knee.
  • Erythema may appear after several days.
  • Swelling is often present.
  • Instability or mechanical symptoms (eg, a locking or popping sensation) are uncommon.

Physical

Recognize that collateral ligament injuries often are seen in association with injury to other knee structures. A comprehensive musculoskeletal knee examination should be completed to direct further diagnostic testing and therapeutic interventions. A systematic review of the available literature revealed no articles that adequately assessed the diagnostic sensitivity and specificity of a physical examination in detecting medial and lateral collateral ligamentous injuries.

• Medial collateral ligament (MCL) injury
  • Palpate with the knee in 25-30 º of flexion.
  • Tenderness may be noted anywhere along the course of the MCL.
  • Isolated tenderness at the proximal or distal insertion sites may indicate an avulsion-type injury.
  • Swelling often is present and should alert the examiner to possible intra-articular injury.
• Lateral collateral ligament (LCL) injury
  • Palpate with the knee in 20 º of flexion.
  • Tenderness may be noted anywhere along the course of the LCL.
  • Isolated tenderness at the proximal or distal insertion sites may indicate an avulsion-type injury.
  • Swelling is common.
• Evocative testing of collateral ligaments
  • Valgus stress testing of the MCL
    • The patient is in the supine position with the knee flexed 25-30 º. The examiner places one hand on the lateral knee and grasps the medial ankle with the other hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or tearing of the MCL.
    • Perform the same technique as above with the knee extended. If excessive knee joint laxity and pain are still noted, injury to the anterior cruciate ligament also may be present.
  • Varus stress testing of the LCL
    • The patient is in the supine position with the knee flexed 20-25 º. The examiner places one hand on the medial knee and grasps the lateral ankle with other hand. The knee is adducted. Pain and excessive laxity indicate injury to the LCL.
    • Then perform the same technique as above with the knee extended. If pain and laxity are still present, injury to the posterior capsule may be present.
• Injury severity
  • Grade I - Less than 5 cm laxity (partial tear)
  • Grade II - 5-10 cm laxity
  • Grade III - More than 10 cm laxity (complete tear)
• Physical examination under general anesthesia may be indicated if the patient is guarding due to pain symptoms.

Causes

• Injury to the medial collateral ligament (MCL) or lateral collateral ligament (LCL) may be caused by the following:
  • Trauma
    • Acute varus or valgus stress on the knee joint
    • Sports related (younger population)
    • Falls (elderly)
    • Other trauma
  • Overuse syndromes (for example, swimmers who use the breaststroke may repetitively stretch the MCL, leading to injury)

Differential Diagnoses

Patellofemoral Syndrome
Pes Anserinus Bursitis
Rheumatoid Arthritis
Tibial Plateau Fractures

Other Problems to Be Considered

Osteochondral fracture
Extensor mechanism rupture
Osteonecrosis of the femoral epicondyle
Osteonecrosis of the tibial condyle
Inflammatory conditions (systemic disease)

Workup

Laboratory Studies

• Laboratory studies usually are not indicated for the diagnosis of a medial collateral ligament (MCL) or lateral collateral ligament (LCL) injury.

Imaging Studies

• Diagnosis of a medial collateral ligament (MCL) or lateral collateral ligament (LCL) injury is usually clinical.^7,10,11
• Plain films in patients with suspected knee ligamentous injuries should include anteroposterior, lateral, intercondylar notch, and sunrise views. Avulsion fractures are often noted in knee ligament injuries. Indications for plain knee radiographs in suspected knee ligamentous injuries (Pittsburgh decision rules) are blunt trauma or a fall with one of the following criterion:
  • The patient is unable to walk 4 weight-bearing steps.
  • The patient is older than 50 years or younger than 12 years.
• Magnetic resonance imaging (MRI) is helpful for ruling out other soft-tissue injuries (eg, anterior or posterior cruciate ligament tears, meniscus injury). MRI is very sensitive in detecting tears of the collateral ligaments. However, it is not reliable for differentiating grades of injury, and use of the modality can lead to underestimation of the degree of injury.^12,13
  • The MCL can usually be visualized in its entirety in the coronal plane. A partial tear of the MCL is seen on T2-weighted MRI scans as an area of increased signal intensity, representing edema. The ligament may irregular. A complete tear of the MCL is marked by edema at the rupture site and retraction of the free ends.
  • The LCL is best visualized on coronal images. It tends to be of low signal intensity and have uniform thickness. Partial tears are characterized by edema. A complete LCL tear may be associated with a small avulsion of the styloid process of the fibular head and with marked edema.

Procedures

• If an effusion is present, arthrocentesis of the knee may be indicated to rule out hemarthrosis.

Treatment

Rehabilitation Program

Physical Therapy

• Grade I - Compression, elevation, and cryotherapy are recommended. Short-term use of crutches may be indicated, with weight-bearing–as–tolerated (WBAT) ambulation. Early ambulation is recommended.
• Grade II - A short-hinged brace that blocks 20º of terminal extension but allows full flexion should be used. The patient may ambulate, WBAT. Closed-chain exercises allow for strengthening of knee musculature without putting stress on the ligaments.
• Grade III - The patient initially should be non–weight-bearing (NWB) on the affected lower extremity. A hinged braced should be used, with gradual progression to full weight-bearing (FWB) over 4 weeks. Grade III injuries may require 8-12 weeks to heal.

All MCL injuries should be treated with early range of motion (ROM) and strengthening of musculature that stabilizes the knee joint. Conservative measures usually are adequate, but, if the patient fails to progress with treatment, a meniscal or cruciate ligament tear is suggested.

Lateral collateral ligament (LCL) injuries heal more slowly than do MCL injuries, due to the difference in collagen density. Recommendations for the treatment of LCL injuries include the following:

• Grades I and II - These injuries are treated according to a regimen similar to that for MCL injuries of the same severity. A hinged brace is used for 4-6 weeks.
• Grade III - Severe LCL injuries typically are treated surgically due to rotational instability, because they usually involve the posterolateral corner of the knee. Patients may require bracing and physical therapy for up to 3 months in order to prevent later instability.

Surgical Intervention

Most patients with a collateral ligament injury can be treated effectively with conservative measures. Grade III lateral collateral ligament (LCL) tears usually involve the posterolateral complex and are associated with instability. These patients do require surgical repair.^15,16 Surgical treatment for isolated injuries of the medial collateral ligament (MCL) or LCL is a controversial topic. The treatment plan should be based partially on the patient's pre-injury level of activity and on motivational factors. For example, a young competitive swimmer may want surgery, followed by a comprehensive rehabilitation program to accelerate the time needed for adequate functional recovery.¹⁷ A technique for repairing severe MCL injuries using autogenous hamstring tendons has been proposed.¹⁸

Consultations

An orthopedic surgery consultation is advised for individuals with severe ligament injury.

Medication

The goal of pharmacotherapy is to reduce morbidity.

Nonsteroidal anti-inflammatory drugs

These have analgesic, anti-inflammatory, and antipyretic activity. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400 mg PO q4-6h prn; not to exceed 2400 mg/d; take with food

Pediatric

4-10 mg/kg PO q6-8h prn; not to exceed 50 mg/kg/d; take with food

Interactions

Co-administration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; history of GI bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Celecoxib (Celebrex)

Primarily inhibits COX-2. COX-2 is considered an inducible iso-enzyme; it is induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 iso-enzyme is not inhibited; thus, incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates pro-inflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent on cytochrome P450 enzymes (a hepatic enzyme) for metabolism.

Dosing

Adult

200 mg/d PO qd; alternatively, 100 mg PO bid

Pediatric

Not recommended

Interactions

CYP450 2C9 substrate; co-administration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; co-administration of celecoxib with rifampin may decrease celecoxib plasma concentrations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or lab results suggest liver dysfunction

Analgesics, miscellaneous

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Tramadol (Ultram)

Inhibits ascending pain pathways by binding to mu-opiate receptors in CNS, thus altering perception of and response to pain. Also inhibits re-uptake of norepinephrine and serotonin.

Dosing

Adult

50 mg/d PO initially; gradually increase by 50 mg/d PO q3d to 50-100 mg PO q4-6h prn; not to exceed 400 mg/d

Pediatric

Not established

Interactions

Significantly decreases carbamazepine effects; cimetidine increases toxicity, risk of serotonin syndrome with co-administration of antidepressants

Contraindications

Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 days; use of SSRIs, TCAs, or opioids; acute alcohol intoxication

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Can cause dizziness, nausea, constipation, sweating, and pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, and hypo-adrenalism; pregnancy and breastfeeding; seizure; and development of tolerance or dependency with extended use

Follow-up

Further Inpatient Care

• Depending on each individual case and on the complexity of a lateral collateral ligament (LCL) injury that requires surgery, patients may or may not need inpatient care. If the patient requires hospitalization, education should be completed prior to dismissal. Physical therapy may be ordered to complete crutch and stair training, thus ensuring the patient's safety upon his/her return home.

Further Outpatient Care

• Patients who undergo surgery for grade III lateral collateral ligament (LCL) injuries are later referred to outpatient PT for rehabilitation. The process of recovery and rehabilitation may take up to 3 months. Less severe injuries of the medial collateral ligament (MCL) and LCL also are commonly referred for outpatient PT treatment (see Physical Therapy).¹⁴

Complications

• Peroneal nerve injuries can occur with lateral collateral ligament (LCL) injuries.

Prognosis

• Most patients have an excellent outcome.⁷

Patient Education

• Depending on their age and activity level, patients may need education and training in the use of the most appropriate assistive device (eg, crutches, walker). Education is important throughout the patient's recovery. Proper treatment strategies and a home exercise program to increase knee joint stability further and avoid recurrence are essential elements of patient education.
• For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Knee Injury and Knee Pain.

Miscellaneous

Medicolegal Pitfalls

• Failure to complete a thorough examination and rule out cruciate ligament and meniscal tears in the presence of a collateral ligament injury is an important medical concern.

Multimedia

Media file 1: The medial and lateral collateral ligaments of the knee. Courtesy of Randale Sechrest, MD, CEO, Medical Multimedia Group.

References

1. Fu FH, Harner CD, Johnson DL, et al. Biomechanics of knee ligaments: basic concepts and clinical application. Instr Course Lect. 1994;43:137-48. [Medline].

2. Swenson TM, Harner CD. Knee ligament and meniscal injuries. Current concepts. Orthop Clin North Am. Jul 1995;26(3):529-46. [Medline].

3. Young JL, Olsen NK, Press JM. Musculoskeletal disorders of the lower limbs. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:783-812.

4. Amiri S, Cooke D, Kim IY, et al. Mechanics of the passive knee joint. Part 2: interaction between the ligaments and the articular surfaces in guiding the joint motion. Proc Inst Mech Eng [H]. Nov 2007;221(8):821-32. [Medline].

5. National Collegiate Athletic Association. NCAA Injury Surveillance System. 1999-2000;[Full Text].

6. Yawn BP, Amadio P, Harmsen WS, et al. Isolated acute knee injuries in the general population. J Trauma. Apr 2000;48(4):716-23. [Medline].

7. Quarles JD, Hosey RG. Medial and lateral collateral injuries: prognosis and treatment. Prim Care. Dec 2004;31(4):957-75, ix. [Medline].

8. Dugan SA. Sports-related knee injuries in female athletes: what gives?. Am J Phys Med Rehabil. Feb 2005;84(2):122-30. [Medline].

9. El-Dieb A, Yu JS, Huang GS, et al. Pathologic conditions of the ligaments and tendons of the knee. Radiol Clin North Am. Sep 2002;40(5):1061-79. [Medline].

10. Pimentel L. Orthopedic trauma: office management of major joint injury. Med Clin North Am. Mar 2006;90(2):355-82. [Medline].

11. Strayer RJ, Lang ES. Evidence-based emergency medicine/systematic review abstract. Does this patient have a torn meniscus or ligament of the knee?. Ann Emerg Med. May 2006;47(5):499-501. [Medline].

12. Crotty JM, Monu JU, Pope TL Jr. Magnetic resonance imaging of the musculoskeletal system. Part 4. The knee. Clin Orthop Relat Res. Sep 1996;288-303. [Medline].

13. Beall DP, Googe JD, Moss JT, et al. Magnetic resonance imaging of the collateral ligaments and the anatomic quadrants of the knee. Radiol Clin North Am. Nov 2007;45(6):983-1002, vi. [Medline].

14. Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop. Mar-Apr 1980;(147):22-8. [Medline].

15. Bin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy. Oct 2007;23(10):1066-72. [Medline].

16. Wahl CJ, Nicandri G. Single-Achilles allograft posterior cruciate ligament and medial collateral ligament reconstruction: a technique to avoid osseous tunnel intersection, improve construct stiffness, and save on allograft utilization. Arthroscopy. Apr 2008;24(4):486-9. [Medline].

17. Medvecky MJ, Zazulak BT, Hewett TE. A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-ligament injured athlete. Sports Med. 2007;37(2):169-87. [Medline].

18. Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. Sep 2005;33(9):1380-5. [Medline].

Keywords

medial collateral ligament injury, lateral collateral ligament injury, MCL injury, LCL injury, tibial collateral ligament, fibular collateral ligament

Contributor Information and Disclosures

Author

Adam B Agranoff, MD, Physiatrist and Partner, Chelsea Back Care, Chelsea Community Hospital
Adam B Agranoff, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

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