Medial Collateral Knee Ligament Injury Clinical Presentation

  • Author: Thomas M DeBerardino, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Mar 30, 2012
 

History

A thorough history should be obtained prior to performing the physical examination. The following questions should be answered:

  • How and when did the injury occur?
  • What was the mechanism of injury?
  • What was the position of the knee at the time of injury?
  • Was the patient able to ambulate immediately after the injury? If so, is the patient still able to ambulate?
  • Did the knee swell immediately or was swelling delayed?
  • Did the patient experience a sensation of a tearing or hear an audible pop?
  • Did any deformity occur? (Deformity may signify a patella subluxation or dislocation.)
  • Have any prior injuries or fractures occurred?
  • Where is the site of injury within the MCL?
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Physical

A complete physical examination of the knee should be performed after a thorough history is obtained. Attention should be directed toward localizing the MCL injury and identifying any associated injuries.

  • Inspection and palpation of the knee should identify the presence and location of point tenderness, localized soft tissue swelling, deformity, or ecchymosis. The region of injury within the ligament should be noted. A large joint effusion indicates an associated intra-articular injury. Outcome can be influenced by the location of the injury within the ligament.
  • The integrity of the MCL is tested with a valgus stress. If any abnormal laxity is noted, the quality of the endpoint should be determined. Testing should be performed in full extension and at 30° of flexion. Grading of the injury is based on the amount of laxity. Any laxity is compared to the opposite knee.
  • Rotation should be compared to the opposite knee when evaluating for associated posteromedial injuries.
  • Anterior and posterior draw signs and a Lachman are performed to rule out associated injuries.
  • Associated injuries include the following:
    • Other structures within the knee may be injured in association with the MCL. The anterior cruciate ligament (ACL) is injured in approximately 20% of grade 1 injuries and as many as 78% of grade 3 injuries.
    • The medial meniscus is injured 5-25% of the time; the incidence increases with severity of the MCL injury.
    • The extensor mechanism, including the vastus medialis obliquus and retinacular fibers, is also injured in 9-21% of the cases.
    • The posterior cruciate ligament (PCL) may be injured, but no incidence has been reported.
  • Classification systems include the following:
    • American Medical Association Committee on the Medical Aspects of Sports (1966)
      • Grade 1 - 0-5 mm of opening
      • Grade 2 - 5-10 mm of opening
      • Grade 3 - Greater than 10 mm of opening
    • O'Donoghue classification
      • Grade 1 - Few torn fibers, structurally intact
      • Grade 2 - Incomplete tear, no pathologic laxity
      • Grade 3 - Complete tear, pathologic laxity
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Causes

Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.

  • Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
  • Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
  • Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.
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Contributor Information and Disclosures
Author

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds None; Musculoskeletal Transplant Foundation Grant/research funds None; Histogenics Grant/research funds None; Advanced Biomedical Technologies Stock Options Medical Director, North America

Coauthor(s)

Jeffrey C Gundel, MD  Consulting Surgeon, Department of Orthopedic Surgery, Glen Falls Hospital; Consulting Surgeon, Department of Orthopedic Surgery, Saratoga Hospital

Jeffrey C Gundel, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew L Sherman, MD, MS  Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, 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: Pfizer Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

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  2. Griffith CJ, LaPrade RF, Johansen S, et al. Medial knee injury: part 1, static function of the individual components of the main medial knee structures. Am J Sports Med. Sep 2009;37(9):1762-70. [Medline].

  3. Wijdicks CA, Griffith CJ, LaPrade RF, et al. Medial knee injury: part 2, load sharing between the posterior oblique ligament and superficial medial collateral ligament. Am J Sports Med. Sep 2009;37(9):1771-6. [Medline].

  4. Laprade RF, Bernhardson AS, Griffith CJ, et al. Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. Dec 4 2009;[Medline].

  5. Laprade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. Feb 2010;38(2):330-8. [Medline].

  6. Lind M, Jakobsen BW, Lund B, et al. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med. Jun 2009;37(6):1116-22. [Medline].

  7. Albright JP, Powell JW, Smith W, et al. Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces. Am J Sports Med. Jan-Feb 1994;22(1):12-8. [Medline].

  8. Fanelli GC, Edson CJ, Orcutt DR, et al. Treatment of combined anterior cruciate-posterior cruciate ligament-medial-lateral side knee injuries. J Knee Surg. Jul 2005;18(3):240-8. [Medline].

  9. Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture With Early Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study. Am J Sports Med. Feb 1 2006.

  10. Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med. Mar-Apr 1996;24(2):160-3. [Medline].

  11. Lundberg M, Messner K. Ten-year prognosis of isolated and combined medial collateral ligament ruptures. A matched comparison in 40 patients using clinical and radiographic evaluations. Am J Sports Med. Jan-Feb 1997;25(1):2-6. [Medline].

  12. Reider B. Medial collateral ligament injuries in athletes. Sports Med. Feb 1996;21(2):147-56. [Medline].

  13. Reider B, Sathy MR, Talkington J, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med. Jul-Aug 1994;22(4):470-7. [Medline].

  14. Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am. Jan 1979;61(1):56-62. [Medline].

 
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