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Medial Collateral Knee Ligament Injury Treatment & Management

  • Author: Thomas M DeBerardino, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: May 13, 2014
 

Acute Phase

Rehabilitation Program

Physical Therapy

The initial treatment of all sprains is similar and follows the RICE protocol with rest, ice, compression, and elevation. Protective weightbearing is instituted with crutches. This is continued until a normal gait is obtained. The severity of the injury dictates further treatment.

Grade 1 and 2 sprains are routinely treated nonoperatively. They may be braced with a knee sleeve or a double-upright hinged knee orthosis, individualized to the patient's discomfort. Crutches are only necessary for a few days. These injuries represent incomplete tears and allow for a rapid return to activities.

Historically, grade 3 tears were treated operatively but currently are routinely treated nonoperatively. In the past, nonoperative treatment meant a long leg cast. Currently, bracing with a hinged knee orthosis is common. Some authors recommend immediate braced increase in range of motion (ROM), while others prefer waiting up to 6 weeks with the knee at 30° of flexion. Crutches are usually necessary for 1-2 weeks.

The goals of therapy are to decrease pain, restore ROM, and regain strength. Crutches are used until weightbearing is comfortable. ROM exercises are performed in a cold whirlpool. Quadriceps strengthening is started with quad sets and progressed to closed-chain exercises as tolerated. Running is allowed when weightbearing is comfortable and is progressed to more narrow S-shaped patterns, until pivoting is comfortable. At this point, sport-specific exercises and drills are added and advanced until the athlete is ready to return to the sport. Return to play is allowed when sport-specific agility testing is performed comfortably. People with grade 1 and 2 injuries usually return to play within 2-3 weeks. People with grade 3 injuries frequently require 6 or more weeks before a return to play.

After sufficient healing of the ligament has occurred, the initial focus of rehabilitation is to restore full ROM. After acceptable knee ROM is restored, the therapist is to concentrate on controlled strengthening. Often in the knee, the functional strength of the quadriceps muscle, especially the medial VMO muscle, is weak and atrophied. After restoration of sufficient strength, the athlete needs to go through sport-specific or function-based training. Upon achieving full strength and pain-free ROM in the lower extremity, the athlete can be cleared to return to their sport, most often without any brace or external support.

Medical Issues/Complications

Persistent instability and laxity may require surgical treatment.

Surgical Intervention

The consensus is that isolated MCL tears rarely require operative repair, while treatment of severe combined ruptures of the MCL and ACL or PCL would require reconstruction. A study found that nonoperative and operative treatments of medial collateral ligament injuries lead to equally good results. Another indication for surgical intervention would be persistent instability, with surgery consisting of tissue repair and imbrication. Often, reinforcement with an allograft is necessary.

Lind et al investigated the effectiveness of treating chronic valgus instability of the knee with a surgical reconstruction technique involving the MCL and the posteromedial corner of the knee.[7] Patients in the study underwent either isolated MCL reconstruction, combined MCL and ACL reconstruction, or multiple ligament reconstruction, with surgery in each case including the use of ipsilateral semitendinosus autografts for MCL and posteromedial reconstruction. In the 50 patients who received a follow-up examination more than 2 years postsurgery, substantial improvements were seen in the International Knee Documentation Committee (IKDC) scores.

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Recovery Phase

Rehabilitation Program

Physical Therapy

Long-term outcome studies have shown that almost all patients with grade 1 and 2 injuries have returned to full preinjury activities by 3 months. Isolated grade 3 injuries still allow excellent return to preactivity levels by 6-9 months.

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Contributor Information and Disclosures
Author

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Research Director, BRIO of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician; Adjunct Associate Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, 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, American Medical Society for Sports Medicine

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, 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

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, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

References
  1. Roach CJ, Haley CA, Cameron KL, Pallis M, Svoboda SJ, Owens BD. The epidemiology of medial collateral ligament sprains in young athletes. Am J Sports Med. 2014 May. 42(5):1103-9. [Medline].

  2. Chahal J, Al-Taki M, Pearce D, et al. Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study. Knee Surg Sports Traumatol Arthrosc. 2009 Dec 15. [Medline].

  3. 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. 2009 Sep. 37(9):1762-70. [Medline].

  4. 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. 2009 Sep. 37(9):1771-6. [Medline].

  5. 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. 2009 Dec 4. [Medline].

  6. 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. 2010 Feb. 38(2):330-8. [Medline].

  7. 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. 2009 Jun. 37(6):1116-22. [Medline].

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

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

  10. 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. 2006 Feb 1.

  11. 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].

  12. 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. 1997 Jan-Feb. 25(1):2-6. [Medline].

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

  14. 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. 1994 Jul-Aug. 22(4):470-7. [Medline].

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

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