Transcript MCL Injuries - Athletic Training at Iowa

MCL Injuries
Dr. David Vasconcellos
Sports Fellow
University of Iowa
Sports Medicine Center
The Latest and Greatest
Evidence Based
Case
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17 y/o male tackled at his left knee from the
outside while playing intramural football.
Knee buckled inward.
Felt a pop in his knee, limped off the playing
field.
Case
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PE
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Stiff Knee Gait
Mild Effusion
No Joint Line TTP
+TTP over femoral insertion of the MCL
Negative Lachman, Negative Anterior and Posterior
Drawer.
Negative McMurrays
Varus and Valgus stable in extension.
Moderate laxity in 30 degrees of flexion with valgus stress
with firm endpoint.
Case
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XR: Negative
Case
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Diagnosis?
Case
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Grade II MCL Tear
Case
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Treatment
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Conservative Treatment.
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Crutches
Anti-inflammatories
ROM Brace
Rehab
Outcome
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RTP in 4 weeks, weaned as tolerated from brace.
Anatomy
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Layer I
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Layer II
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Deep fascia, Sartorius
Superficial MCL
Layer III
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Deep MCL
Posteromedial Capsule
Medial Knee Anatomy
MCL Function
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Primary stabilizer to valgus force.
Secondary stabilizer to Anterior translation.
Resist external rotation.
MCL and ACL have a codependent
relationship.
Diagnosis
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History
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Classic Mechanism: Isolated Valgus moment to
knee.
PE
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Complete Knee Exam
Examine MCL with the knee both in full extension
and at 30 degrees of flexion.
Valgus Stress with knee at 30 degrees of
flexion causes pain or instability of medial
knee.
MCL Injury Model
MCL Grading System
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I - Stretching of fibers. Localized TTP. No
instability.
II - Disruption of Fibers. Mild to moderate
instability.
III - Complete disruption of ligament. Gross
instability.
Imaging
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XR
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May demonstrate avulsions.
MRI
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Confirms Diagnosis
Evals other ligaments, cartilage.
Treatment
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The injured MCL heals predictably without
repair regardless of its grade.
Non-op management of all MCL tears is
considered standard practice.
Treatment of Isolated MCL Injury
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Grade I and II Injuries
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Non-Surgical Treatment
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Crutches until symptoms improve, WBAT, ROM.
Edema Control - Ice, Compression, Massage.
NSAIDS
Hinged knee brace
Speeding Recovery
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Good control of swelling can decrease the amount of
time for full recovery of motion and strength.
Treatment of Isolated MCL Injury
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Grade III MCL
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Non-Surgical Rehab
Brief period of immobilization
Start ROM when initial swelling subsides.
May need a longer period of protected weight bearing.
Persistant valgus instability
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May consider for early surgical reconstruction.
Tibial Sided vs. Femoral Sided MCL injury
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Proximal MCL tears at
the femoral insertion
more common than at
the distal tibial
insertion.
In general, femoral side
injuries tend to heal
better than tibial side or
midsubstance injuries.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
ACL + MCL
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Usually do not require MCL reconstruction
Rehab the medial side and achieve full ROM
then do ACL reconstruction.
However, if valgus instability persists after
rehab then reconstruction of ACL and MCL
should be considered.
PCL + MCL
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If significant posterior subluxation is present
following injury, both ligaments should be
reconstructed acutely.
If the Joint is well reduced, can treat MCL
nonsurgically with bracing. PCL can be
reconstructed when full ROM is achieved and
valgus stability is restored.
If valgus instability persists, reconstruct PCL
and MCL.
Chronic MCL Injury
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Chronic injury results when the MCL complex
loses its potential for spontaneous healing.
Usually occurs 3 to 4 months following the
initial injury.
Can develop secondary ligamentous
instabilities or secondary limb malalignment.
Chronic MCL Injury
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Valgus deformity of limb secondary to chronic MCL
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Osteotomy may be required at time of MCL reconstruction.
Surgical Options
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POL Advancement
Proximal Capsular Advancement
Distal Capsular Advancement
Semimembranosis advancement
Allograft
Child with Medial Knee Injury
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Don’t forget to rule out physeal injury!
Prevention
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Prophylactic and Functional Bracing for MCL
Protection
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Controversial
Latest Research
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Animal Studies suggest that AntiInflammatory medications do not impede
ligament healing in early and intermediate
healing phases
Sports Med. 1999; 27; 738. Claude T. Moorman, III, Udita Kukreti, David C. Fenton and Stephen M. Belkoff. The Early Effect of
Ibuprofen on the Mechanical Properties of Healing Medial Collateral Ligament
ACL + MCL
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Operative and Nonoperative Treatments of Medial Collateral Ligament
Rupture Were Not Different in Combined Medial Collateral and Anterior
Cruciate Ligament Rupture.
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Review
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ACL + Grade 3 MCL
Surgery at 4 - 23 days after injury.
No difference in results at 2 years.
Surgery took place before MCL healing.
Low Demand Patients
Treated with continuous hinged knee brace
Conclusion: Patients with combined ACL + MCL injuries who undergo early
surgery after injury may do well without surgical treatment of the MCL, but they
should be treated in a hinged knee brace. Caution should be used in a different
patient population such as high demand athletes.
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 Jul;34:1134-40.
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Questions?