Management of Medial Collateral Ligament …

1 48 THE PHYSICIAN AND SPORTSMEDICINE ISSN 0091-3847, June 2010, No. 2, Volume 38 CLINICAL FOCUS: ORTHOPEDIC AND Ligament INJURIESI ntroducti onTh e Medial Collateral Ligament (MCL) is the most frequently injured Ligament in the knee, with low-grade sprains oft en going Th ese injuries frequently occur in active and athletic populations as a result of both contact and noncontact sporting activities. Clinically, they are graded based on the amount of joint space opening with valgus stress at 30 of knee fl exion. Th e American Medical Association describes a classifi cation system for the grading of the joint space opening (Table 1).

2 2 It is also crucial that the clinician evaluate damage to associated structures, including the anterior cruciate Ligament (ACL), posterior cruciate Ligament (PCL), posterior oblique Ligament (POL), Medial meniscus, and chondral injury, particularly with higher-energy injuries. Most MCL injuries are treated nonoperatively with stabilization and rehabilitation. In cases where instability exists aft er nonoperative treatment, or instances of persistent instability aft er ACL and/or PCL reconstruction, the MCL tear may be addressed through surgical repair or reconstruction.

3 Some surgeons prefer to address bony avulsions with opera-tive Management when e Medial side of the knee has classically been described in 3 Layer 1 is the most superfi cial, and includes the fascia investing the sartorius muscle. Layer 2 is the middle layer, including the superfi cial MCL, the POL, structures of the posteromedial corner (including the musculotendinous attachments of the semimembranosus), and the Medial patellofemoral Ligament (MPFL). Layer 3 is the deep layer, including the true joint capsule and the deep component of the MCL. Th e MCL has both superfi cial and deep components, found in the second and third layers of the Medial compartment of the knee, respectively, and are separated by a bursa.

4 Th e superfi cial MCL originates from the Medial femoral condyle and inserts on the Medial tibial crest, about 4 cm below the tibial plateau, and posterior to the pes anserinus (Figure 1).4,5 Recent anatomic studies of the Medial knee anatomy have shown the superfi cial MCL to have 2 distinct attachments on the Th e deep MCL can also be divided into 2 distinct portions meniscofemoral and meniscotibial. Th e meniscofemoral portion originates from the femur distal to the origin of superfi cial component and inserts on the Medial meniscus, and the meniscotibial portion inserts on the tibial plateau from the meniscus.

5 Th e superfi cial and deep compo-nents of the MCL are separated by a bursa, allowing for translation of the structures with fl exion and Management of Medial Collateral Ligament Injuries in the Knee: An Update and ReviewPatrick S. Duffy, MD; Ryan G. Miyamoto, MDAbstract: The Medial Collateral Ligament (MCL) is the most frequently injured Ligament in the knee, with mild-to-moderate tears oft en going unreported to physicians. Medial Collateral Ligament injuries can result from both contact and noncontact sporti ng acti viti es. The mainstay of treatment is nonoperati ve; however, operati ve Management of symptomati c grade II and grade III injuries is considered when laxity and instability persist.

6 The ti ming of surgical repair in the setti ng of a multi Ligament knee injury remains an area of con-troversy among surgeons, with proponents of early reconstructi on of the anterior and posterior cruciate ligaments and nonoperati ve Management of the MCL versus proponents of delayed reconstructi on following nonoperati ve treatment of the MCL. Prophylacti c bracing may conti nue to increase and evolve as bracing technology improves and athleti c cultures : Medial Collateral Ligament ; anterior cruciate Ligament ; knee bracing; ti bial Collateral ligamentPatrick S. Duffy, MD1 Ryan G. Miyamoto, MD21 University Hospitals Case Medical Center, Cleveland, OH; 2 Fair Oaks Orthopaedics, Fairfax, VACorrespondence: Patrick S.

7 Duffy, MD,University Hospitals,Case Medical Center,11100 Euclid Ave.,Cleveland, OH : 719-660-4435E-mail: reprints distributed only by The Physician and Sportsmedicine USA. No part of The Physician and Sportsmedicine may be reproduced or transmitted in any form without written permission from the publisher. All permission requests to reproduce or adapt published material must be directed to the journal office in Berwyn, PA. Requests should include a statement describing how material will be used, the complete article citation, a copy of the figure or table of interest as it appeared in the journal, and a copy of the new (adapted) material if appropriate 041509eManagement of MCL Injuries in the KneeCLINICAL FOCUS: ORTHOPEDIC AND Ligament INJURIES THE PHYSICIAN AND SPORTSMEDICINE ISSN 0091-3847, June 2010, No.

8 2, Volume 38 49extension of the knee. Th e posterior fi bers of the deep MCL blend with the fi bers of the posteromedial capsule of the knee and the e supporting structures of the Medial side of the knee are important in understanding the evaluation, treatment, and rehabilitation of the patient with a knee injury. Muscular attachments on the Medial aspect of the knee include the sar-torius, gracilis, and semitendinosus, with a collective insertion point termed the pes anserinus that is located at the anterior Medial border of the tibia below the tibial plateau. Th e semi-membranosus and the Medial head of the gastrocnemius also provide support and have attaching fi bers on the Medial and posteromedial corner of the knee.

9 Ligamentous attachments on the Medial side of the knee include the MPFL, POL, the oblique popliteal Ligament , and the superfi cial and deep MCL, also known as the tibial Collateral Ligament (Figure 2).Th e biomechanical function of the Medial knee structures is to provide stability against valgus stress, along with internal Table 1. American Medical Association Nomenclature for MCL Injury2 Grade of injuryAmount of Medial joint line openingGrade I< 5 mmGrade II5 10 mmGrade III>10 mmReproduced with permission from LaPrade et : MCL, Medial Collateral Ligament ; POL, posterior oblique Ligament ; SM, semimembranosus; sMCL, superfi cial 1.

10 This illustration shows the superfi cial MCL with its proximal femoral attachment and 2 distal tibial attachments. The tip of the hemostat sits between the 2 S. Duffy and Ryan G. MiyamotoCLINICAL FOCUS: ORTHOPEDIC AND Ligament INJURIES50 THE PHYSICIAN AND SPORTSMEDICINE ISSN 0091-3847, June 2010, No. 2, Volume 38and external rotation. A recent sectioning study investigated the role of each Ligament in providing resistance to these Th e primary stabilizer to valgus stress at all angles of knee fl exion is the superfi cial MCL, with the deep MCL acting as the secondary stabilizer.