MCL Knee Injuries - Knee & Sports (2024)

• 40% of knee ligament injuries

• low grade injuries can be missed

• account of 8% of all athletic knee injuries

• highest risk in skiing, rugby, football, soccer and ice hockey

• usually with the knee held in slight flexion and external rotation

• more common than noncontact

• direct blow to the lateral knee with valgus force

• more often result in high grade / complete ligament disruption than noncontact injury

  • rupture usually occurs at the femoral insertion of the MCL

    • proximal MCL tears have greater healing rates

    • distal MCL tears have inferior healing and residual valgus laxity

• less common than contact but more common in skiing

• pivoting or cutting activities with valgus and external rotation force

• more often result in low grade / incomplete ligament injury

• most common associated injury

  • make up ~95% of injuries associated with nonisolated MCL injury

  • combined ACL-MCL is the most common multiligamentous knee injury

• presence of hemarthrosis is highly suggestive

• often associated with high grade MCL injuries

  • grade III > grade II > grade I

• medial > lateral

• up to 5% of isolated MCL injuries are associated with meniscus tears

• calcification at the medial femoral insertion site

• results from chronic MCL deficiency

• located in layer II of the medial knee

  • with posteromedial corner ligaments and medial patellofemoral ligament

• femoral attachment

  • medial epicondyle

  • 1cm anterior and distal to the adductor tubercle

• tibial attachment

  • proximal tibia periosteum

  • 4.5cm distal to the joint line

  • deep and posterior to the pes anserinus

• located in layer III of the medial knee

  • with the joint capsule

• composed of meniscofemoral and meniscotibial ligaments

superior medial and inferior medial geniculate arteries

• primary stabilizer to valgus stress

  • at all angles of knee flexion

  • greatest stability contribution at 25 degrees knee flexion (78%)

• secondary stabilizer to tibial external rotation and anterior/posterior tibial translation

• secondary stabilizer to valgus stress

  • greatest stability contribution at full knee extension

• static stabilizers

  • posterior oblique ligament

    • resists tibial internal rotation at full knee extension

    • secondary restraint to valgus stress

  • oblique popliteal ligament

  • posterior capsule

• dynamic stabilizers

  • semimembranosus complex

    • consists of 5 attachments

      • vastus medialis

      • medial retinaculum

      • pes anserine muscle group

        • sartorius

        • semitendinosus

        • gracilis

• tenderness along medial aspect of knee

• ecchymosis

• knee effusion

• valgus stress testing at 30° knee flexion

  • isolates the superficial MCL

  • medial gapping as compared to opposite knee indicates grade of injury

    • 1- 4 mm = grade I

    • 5-9 mm = grade II

    • > or equal to 10 mm = grade III

• valgus stressing at 0° knee extension

  • medial laxity with valgus stress indicates posteromedial capsule or cruciate ligament injury

• saphenous nerve exam

• ACL

• PCL

• patellar dislocation

• medial meniscal tear

• AP and lateral

• stress radiographs in skeletally immature patient

  • may indicate gapping through physeal fracture

• usually normal

• calcification at the medial femoral insertion site (Pellegrini-Stieda Syndrome)

modality of choice for MCL injuries

• indications

  • grade I

• therapy

  • quad sets, SLRs, and hip adduction above the knee to begin immediately

  • cycling and progressive resistance exercises as tolerated

• return to play

  • grade I may return to play at 5-7 days

• indications

  • grades II

  • grade III

    • if stable to valgus stress in full extension

    • no associated cruciate injury

• technique

  • immobilizer for comfort

  • hinged knee brace for ambulation

• return to play

  • grade II return to play at 2-4 weeks

  • grade III return to play at 4-8 weeks

• outcomes

  • distal MCL injuries have less healing potential than proximal injuries

• relative indications

  • acute repair in grade III injuries

    • in the setting of multi-ligament knee injury

    • displaced distal avulsions with "stener-type" lesion

    • entrapment of the torn end in the medial compartment

  • sub-acute repair in grade III injuries

    • continued instability despite nonoperative treatment

      • >10 mm medial sided opening in full extension

  • reconstruction

    • chronic injury

    • loss of adequate tissue for repair

• technique

  • diagnostic arthroscopy recommended for all surgical candidates to rule out associated injuries

• functional bracing may reduce MCL injury in football players, particularly interior linemen

• medial approach to the knee

• acute injuries

• ligament avulsions

  • should be reattached with suture anchors in 30 degrees of flexion

• interstitial disruption

  • anterior advancement of the MCL to femoral and tibial origins

• internal brace

• medial approach to the knee

• chronic instability

• insufficient tissue for repair

• can use semitendinosus autograft or hamstring, tibialis anterior or Achilles tendon allograft