eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Medial Collateral and Lateral Collateral Ligament Injury: Treatment & Medication
Updated: Jul 9, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
The type of physical therapy (PT) treatment indicated for a medial collateral ligament (MCL) injury depends on the severity of the injury.7,14 Recommendations for treatment include the following:- 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.
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
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
Documented hypersensitivity; history of GI bleeding
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.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not recommended
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
Documented hypersensitivity
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.
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
Significantly decreases carbamazepine effects; cimetidine increases toxicity, risk of serotonin syndrome with co-administration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 days; use of SSRIs, TCAs, or opioids; acute alcohol intoxication
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
More on Medial Collateral and Lateral Collateral Ligament Injury |
| Overview: Medial Collateral and Lateral Collateral Ligament Injury |
| Differential Diagnoses & Workup: Medial Collateral and Lateral Collateral Ligament Injury |
 Treatment & Medication: Medial Collateral and Lateral Collateral Ligament Injury |
| Follow-up: Medial Collateral and Lateral Collateral Ligament Injury |
| Multimedia: Medial Collateral and Lateral Collateral Ligament Injury |
| References |
| « Previous Page | Next Page » |
References
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].
Swenson TM, Harner CD. Knee ligament and meniscal injuries. Current concepts. Orthop Clin North Am. Jul 1995;26(3):529-46. [Medline].
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.
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].
National Collegiate Athletic Association. NCAA Injury Surveillance System. 1999-2000;[Full Text].
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].
Quarles JD, Hosey RG. Medial and lateral collateral injuries: prognosis and treatment. Prim Care. Dec 2004;31(4):957-75, ix. [Medline].
Dugan SA. Sports-related knee injuries in female athletes: what gives?. Am J Phys Med Rehabil. Feb 2005;84(2):122-30. [Medline].
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].
Pimentel L. Orthopedic trauma: office management of major joint injury. Med Clin North Am. Mar 2006;90(2):355-82. [Medline].
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].
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].
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].
Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop. Mar-Apr 1980;(147):22-8. [Medline].
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].
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].
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].
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].
Further Reading
Keywords
medial collateral ligament injury, lateral collateral ligament injury, MCL injury, LCL injury, tibial collateral ligament, fibular collateral ligament
