Medial Collateral Ligament Injury of the Knee: Difference between revisions

No edit summary
No edit summary
Line 73: Line 73:
Some surgeons describe a grade four injury to the MCL. This is called a medial column injury. It involves a more complex injury with different ligaments than just the MCL. <br>Some doctors prefer that all MCL injuries are healed without surgery, and others prefer to repair these most significant injuries. No difference has been demonstrated between both treatments.<br>
Some surgeons describe a grade four injury to the MCL. This is called a medial column injury. It involves a more complex injury with different ligaments than just the MCL. <br>Some doctors prefer that all MCL injuries are healed without surgery, and others prefer to repair these most significant injuries. No difference has been demonstrated between both treatments.<br>


== Physical Therapy Management <br> ==
== Physical Therapy Management <br> ==


The treatment of a medial collateral ligament injury rarely requires a surgical intervention. Some simple treatment steps, together with rehabilitation, will allow patients to return to their previous level of activity. The main goals of the rehabilitation are : reducing pain and swelling, restoring full mobility, improving strength and stability of the joint and returning to full activity.&nbsp;
The treatment of a medial collateral ligament injury rarely requires a surgical intervention. Some simple treatment steps, together with rehabilitation, will allow patients to return to their previous level of activity. The main goals of the rehabilitation are&nbsp;: reducing pain and swelling, restoring full mobility, improving strength and stability of the joint and returning to full activity.&nbsp;  


A <u>grade 1 injury</u>-treatment can be divided into three phases. Phase one (first week after injuring) consists of reducing the swelling by applying cold therapy (1) and a compression. The first day after injuring the patient needs to apply ice for 15 minutes every two hours. This frequency can gradually be reduced to three times a day (remember that ice burns, so do not apply ice directly to the skin). As soon as pain allows, the patient can start with some stretching exercises for hamstring- and quadriceps-muscles and light static strengthening exercises (After each stretch/strengthening session, make sure the patient applies cold therapy).<br>After a week we can start with phase two of the rehabilitation. At this phase we will try to eliminate any swelling completely and regain full range of motion. The patient still needs to train itself with the strength- and stretch exercises from phase one (after each session, apply cold therapy). He can return to jog or cycle slowly, to maintain aerobic fitness (as long as it is not painful). We can introduce dynamic strengthening exercises to each strengthening-session ( knee extension/flexion, half squats, step ups, … ). Cross friction massage can be added ( on alternate days ).<br>The third phase (after two weeks) consists of maintaining full range of motion, equaling strength of both legs and returning to running. The patient continues the stretch- and strengthening-sessions (after each session, apply cold therapy). Building on the dynamic strengthening exercises is one of the major goals of this phase. The intensity and number of repetitions ( between 10 and 20 reps) need to be increased until the strength of both legs is equal. <br>For <u>a grade 2/3 injury</u>-treatment it is important that the ends of the ligament are protected and left to heal without continually being disrupted. The rehabilitation can be split into 3 phases. Phase one consists of controlling the swelling of the knee by applying ice for 15 minutes every two hours (first two days). The rest of the week the frequency can be reduced to three times a day. Another aim of this phase is trying to maintain the ability to straighten and bend the knee more than 90°. Pain free stretches for the hamstrings, quads, groin and calf muscles (in particular) are suggested. The patient may begin with static strengthening exercises (as soon as pain allows it), such as quads and double leg calf raises. It’s important that the patient rests from all painful activities (use crutches if necessary), and that the MCL is well protected (by wearing a stabilized knee brace). After four weeks we can start phase two. Major goal for this phase : full weight-bearing on the injured knee. Dynamic strengthening exercises as knee flexion/extension, half squats and hip raises may benefit progression. We continue with cold therapy and compression to eliminate swelling. To maintain aerobic fitness the patient can use the stepper or (if possible) may begin to swim. Six weeks after injuring the knee, phase three can begin. Cold therapy still needs to be applied. The intensity of the strengthening exercises need to be increased and instead of double leg exercises we change to single leg exercises. The patient may start running again at a comfortable pace (make sure the patient doesn’t make sudden changes of direction).  
A <u>grade 1 injury</u>-treatment can be divided into three phases. Phase one (first week after injuring) consists of reducing the swelling by applying cold therapy (1) and a compression. The first day after injuring the patient needs to apply ice for 15 minutes every two hours. This frequency can gradually be reduced to three times a day (remember that ice burns, so do not apply ice directly to the skin). As soon as pain allows, the patient can start with some stretching exercises for hamstring- and quadriceps-muscles and light static strengthening exercises (After each stretch/strengthening session, make sure the patient applies cold therapy).<br>After a week we can start with phase two of the rehabilitation. At this phase we will try to eliminate any swelling completely and regain full range of motion. The patient still needs to train itself with the strength- and stretch exercises from phase one (after each session, apply cold therapy). He can return to jog or cycle slowly, to maintain aerobic fitness (as long as it is not painful). We can introduce dynamic strengthening exercises to each strengthening-session ( knee extension/flexion, half squats, step ups, … ). [[Cross friction massage]] can be added ( on alternate days ).<br>The third phase (after two weeks) consists of maintaining full range of motion, equaling strength of both legs and returning to running. The patient continues the stretch- and strengthening-sessions (after each session, apply cold therapy). Building on the dynamic strengthening exercises is one of the major goals of this phase. The intensity and number of repetitions ( between 10 and 20 reps) need to be increased until the strength of both legs is equal. <br>For <u>a grade 2/3 injury</u>-treatment it is important that the ends of the ligament are protected and left to heal without continually being disrupted. The rehabilitation can be split into 3 phases. Phase one consists of controlling the swelling of the knee by applying ice for 15 minutes every two hours (first two days). The rest of the week the frequency can be reduced to three times a day. Another aim of this phase is trying to maintain the ability to straighten and bend the knee more than 90°. Pain free stretches for the hamstrings, quads, groin and calf muscles (in particular) are suggested. The patient may begin with static strengthening exercises (as soon as pain allows it), such as quads and double leg calf raises. It’s important that the patient rests from all painful activities (use crutches if necessary), and that the MCL is well protected (by wearing a stabilized knee brace). After four weeks we can start phase two. Major goal for this phase&nbsp;: full weight-bearing on the injured knee. Dynamic strengthening exercises as knee flexion/extension, half squats and hip raises may benefit progression. We continue with cold therapy and compression to eliminate swelling. To maintain aerobic fitness the patient can use the stepper or (if possible) may begin to swim. Six weeks after injuring the knee, phase three can begin. Cold therapy still needs to be applied. The intensity of the strengthening exercises need to be increased and instead of double leg exercises we change to single leg exercises. The patient may start running again at a comfortable pace (make sure the patient doesn’t make sudden changes of direction).  


<br>(1) Applying cold therapy reduces swelling immediately after injuring and doesn’t help the healing process of the ligament. <br>
<br>(1) Applying cold therapy reduces swelling immediately after injuring and doesn’t help the healing process of the ligament. <br>

Revision as of 11:09, 22 May 2011

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Sem Bras

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Search Strategy[edit | edit source]

  •  Database : PEDro
  1. Medial collateral ligament
  2. MCL
  3. Medial collateral ligament AND injury
  4. MCL AND injury
  5. Medial collateral ligament AND lesion
  6. MCL AND lesion
  • Database : Pubmed
  1. MCL
  2. MCL AND RCT
  3. Medial Collateral ligament AND injury
  4. MCL AND injury
  • Database : GoogleSCHOLAR
  1. Medial Collateral ligament AND lesion
  2. MCL AND lesion
  3. Medial Collateral ligament AND injury
  4. MCL AND injury

Definition/Description[edit | edit source]

A medial collateral ligament (MCL) injury is a stretch, partial tear, or complete tear of the ligament on the inside of the knee. 

Clinically Relevant Anatomy [edit | edit source]

A ligament, made of tough fibrous material, functions to control excessive motion by limiting the joint mobility. The medial collateral ligament (MCL) is one of the four ligaments that are critical to maintain the stability of the knee joint. The four major ligaments of the knee-area are the cruciate ligaments ( anterior and posterior ), and the collateral ligaments (medial and lateral) . Important to know is that this ligament has two parts to it, respectively a deep inner section that attaches to the medial meniscus and joint margins, and a superficial section that attaches from higher up on the thigh bone to the inner surface of the shin bone. Its function is to resist forces applied from the outer surface of the knee and so prevent the medial portion of the joint from widening under stress.



 

Epidemiology /Etiology[edit | edit source]

 MCL injuries mostly occur after an impact on the outside of the knee. The MCL on the inside of the knee becomes stretched. When the force of the impact is big enough, some or all the fibres will tear. Mostly the deep part of the ligament gets damaged first, and this may lead to medial meniscal damage (more information about meniscal damage and meniscal repair is given in the article of my colleague-student, Céline Vankeerberghen) or anterior cruciate ligament damage (further information is given in the article of my colleague-student, Kevin Campion).

Characteristics/Clinical Presentation[edit | edit source]

As with all the ligament injuries, the MCL injury is graded 1, 2 or 3 (this grade is given depending on the degree of sustained) . A grade 1 tear consists of less than 10% of the collagen fibres being torn. Grade 2 tears vary in symptoms and therefore they are broken down further to grades 2- (closer to grade 1) and 2+ closer to grade 3). Obviously, this means that a grade 3 tear is a complete rupture of the MCL.
The symptoms for a grade 1 tear of the MCL are minimal. Patients complain about a mild tenderness on the inside of the knee. Usually we can’t detect a swelling over the ligament or joint laxity. Most of the patients feel pain when we apply force on the outside of a slightly bent knee.
Grade 2 injuries are also considered as incomplete tears of the MCL. Patients with a grade 2 tear mostly complain about instability when attempting to cut or pivot. The pain and swelling are more significant than with grade 1 injuries. When the knee is stressed (as for grade 1), patients complain about pain, moderate laxity in the joint and a significant tenderness on the inside of the knee.
When we speak of a grade 3 tear of the MCL, it is considered as a complete rupture of the ligament. Patients have significant pain and swelling over the MCL. Most of the time they have difficulty bending the knee. Another common finding of a grade 3 tear is instability. When we stress the knee (as described above) there is joint laxity.

Differential Diagnosis[edit | edit source]

add text here

Diagnostic Procedures[edit | edit source]

add text here related to medical diagnostic procedures

Outcome Measures[edit | edit source]

add links to outcome measures here (also see Outcome Measures Database)

Examination[edit | edit source]

add text here related to physical examination and assessment

Medical Management
[edit | edit source]

Some surgeons describe a grade four injury to the MCL. This is called a medial column injury. It involves a more complex injury with different ligaments than just the MCL.
Some doctors prefer that all MCL injuries are healed without surgery, and others prefer to repair these most significant injuries. No difference has been demonstrated between both treatments.

Physical Therapy Management
[edit | edit source]

The treatment of a medial collateral ligament injury rarely requires a surgical intervention. Some simple treatment steps, together with rehabilitation, will allow patients to return to their previous level of activity. The main goals of the rehabilitation are : reducing pain and swelling, restoring full mobility, improving strength and stability of the joint and returning to full activity. 

A grade 1 injury-treatment can be divided into three phases. Phase one (first week after injuring) consists of reducing the swelling by applying cold therapy (1) and a compression. The first day after injuring the patient needs to apply ice for 15 minutes every two hours. This frequency can gradually be reduced to three times a day (remember that ice burns, so do not apply ice directly to the skin). As soon as pain allows, the patient can start with some stretching exercises for hamstring- and quadriceps-muscles and light static strengthening exercises (After each stretch/strengthening session, make sure the patient applies cold therapy).
After a week we can start with phase two of the rehabilitation. At this phase we will try to eliminate any swelling completely and regain full range of motion. The patient still needs to train itself with the strength- and stretch exercises from phase one (after each session, apply cold therapy). He can return to jog or cycle slowly, to maintain aerobic fitness (as long as it is not painful). We can introduce dynamic strengthening exercises to each strengthening-session ( knee extension/flexion, half squats, step ups, … ). Cross friction massage can be added ( on alternate days ).
The third phase (after two weeks) consists of maintaining full range of motion, equaling strength of both legs and returning to running. The patient continues the stretch- and strengthening-sessions (after each session, apply cold therapy). Building on the dynamic strengthening exercises is one of the major goals of this phase. The intensity and number of repetitions ( between 10 and 20 reps) need to be increased until the strength of both legs is equal.
For a grade 2/3 injury-treatment it is important that the ends of the ligament are protected and left to heal without continually being disrupted. The rehabilitation can be split into 3 phases. Phase one consists of controlling the swelling of the knee by applying ice for 15 minutes every two hours (first two days). The rest of the week the frequency can be reduced to three times a day. Another aim of this phase is trying to maintain the ability to straighten and bend the knee more than 90°. Pain free stretches for the hamstrings, quads, groin and calf muscles (in particular) are suggested. The patient may begin with static strengthening exercises (as soon as pain allows it), such as quads and double leg calf raises. It’s important that the patient rests from all painful activities (use crutches if necessary), and that the MCL is well protected (by wearing a stabilized knee brace). After four weeks we can start phase two. Major goal for this phase : full weight-bearing on the injured knee. Dynamic strengthening exercises as knee flexion/extension, half squats and hip raises may benefit progression. We continue with cold therapy and compression to eliminate swelling. To maintain aerobic fitness the patient can use the stepper or (if possible) may begin to swim. Six weeks after injuring the knee, phase three can begin. Cold therapy still needs to be applied. The intensity of the strengthening exercises need to be increased and instead of double leg exercises we change to single leg exercises. The patient may start running again at a comfortable pace (make sure the patient doesn’t make sudden changes of direction).


(1) Applying cold therapy reduces swelling immediately after injuring and doesn’t help the healing process of the ligament.

Key Research[edit | edit source]

1. Irrgang JJ – Fitzgerald GK ( 2000 ), Rehabilitation of the multiple-ligament-injured knee, used : 17 november 2010  (http://www.ncbi.nlm.nih.gov/pubmed/10918965)

2. Yastrebov O. – Lobenhoffer P. ( 2009 ), Treatment of isolated and multiple ligament injuries of the knee: anatomy, biomechanics, diagnosis, indications for repair, surgery, used: 17 november 2010  (http://www.ncbi.nlm.nih.gov/pubmed/19430762)


3. Swenson TM (2000), Physical diagnosis of the multiple-ligament-injured knee, used: 18 november 2010 (http://www.ncbi.nlm.nih.gov/pubmed/10918957)

4. Scheidt DK (2003), Treatment of the multiple ligament injured knee and dislocations : a trauma perspective, used : 18 November 2010 (http://www.ncbi.nlm.nih.gov/pubmed/12690867)

Resources
[edit | edit source]

1. Roald Bahr – Sverre Maehlum- Tommy Bolic (2002), Clinical guide to sports injuries : an illustrated guide to the management of injuries in physical activity, p. 321-324 + p.328-329 ( used 16 and 24 november 2010 )


2. Paul K. Canavan (1998), Rehabilitation in sports medecine : a comprehensive guide, p. 293-295 + p. 301-304 ( used 16 and 24 november 2010 )


3. Patrick J. – Macmahon MD (2007), Current diagnosis and treatment in sports medecine, p. 77-82 ( used 19 November 2010 )


4. Francis A. Burgener (2006), Differential diagnosis in magnetic resonance imaging, p.396 ( used 19 november 2010 )


5. David E. Brown – Randall D. Neumann (2004), Orthopedic secrets, p. 328-332 ( used op 19 November 2010 )

Clinical Bottom Line[edit | edit source]

add text here

Recent Related Research (from Pubmed)[edit | edit source]

see tutorial on Adding PubMed Feed

Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10

References[edit | edit source]

see adding references tutorial.