MCL Injury - clinical pattern sheet PDF

Preview

Summary

clinical pattern sheet...

Description

Condition MCL Injury Definition / Description A sprain (stretch, partial tear or complete tear) of the ligament on the inner side of the knee. It is one of the most common knee injuries (along with ACL injury) and results mostly from a valgus force on the knee. An MCL avulsion can also occur - when the ligament tears away from the bone.

Populations / Risk Factors MCL injuries are relatively common amongst sporting people (particularly in rugby, hockey and American football) and can occur through both contact and non-contact. However, mostly they result from an impact to the outside the knee (on the lateral side) when the foot is in contact with the floor and unable to move. Non-contact injuries can be caused by the combined movements of knee flexion and lateral rotation. Generally male athletes are at greater risk than females and while MCL injuries can be isolated, the likelihood of injury to associated structures of the knee increases with increasing severity. For example, an ACL sprain commonly occurs with a grade III MCL sprain. Can also occur in older population due to a fall. Symptoms As with all the ligament injuries, the MCL injury is graded 1, 2 or 3 (this grade is given depending on the degree of damage).  Grade I spraino Stretching of the ligament or tearing less than 10% of the fibers o Some tenderness o No instability o Mild medial pain o Possible (but if so, little) swelling o Most patients will feel pain when force is applied to the outside of a slightly bent knee  Grade II sprain-



o A larger but still incomplete tear of the fibers in the ligament o Vary in symptoms so can be broken down further into ‘2-’ which is closer to a grade 1 or ‘2+’ which is closer to a grade 3 o Increased tenderness o Instability (can be significant) o Moderate medial pain o Swelling o Reduced function Grade III spraino Total rupture of the ligament o Significant pain, swelling and tenderness o Significant instability- can give way (moves into valgus movement) o Can have difficulty flexing knee o Further reduced function

Additional infoClassification systems include the following:  American Medical Association Committee on the Medical Aspects of Sports (1966) o Grade 1 - 0-5 mm of opening o Grade 2 - 5-10 mm of opening o Grade 3 - Greater than 10 mm of opening  O'Donoghue classification o Grade 1 - Few torn fibers, structurally intact o Grade 2 - Incomplete tear, no pathologic laxity o Grade 3 - Complete tear, pathologic laxity Clinical Signs Physical examination helps to rule out other injuries that have the same symptoms      

  

Occurs after a valgus force has been applied to the knee (especially if the foot was in contact with the ground) Alternatively, knee flexion and lateral rotation may have occurred There may have been an audible popping at the time of injury Pain and tenderness on palpation or valgus stress test Swelling of the area Increased laxity of the joint when the knee is stressed o Increased joint space (grade I- 0-5mm, Grade II- 6-10mm, Grade III- 10+mm) Grade I and II sprains have a firm end feel but grade III has an unclear or soft end feel (however taking an injury to end feel may cause further damage) Inability to actively flex or giving way when weight bearing Excessive movement in anteromedial drawer test

History

     

Past medical history may include a previous MCL injury Mechanism of injury (e.g. impact to the lateral side of the knee or knee flexion + lateral rotation) Position of knee when inured Audible pop or feeling of tearing at time of injury Able to walk immediately after injury or now? Depends on grade of tear Knee pain and swelling at time/ now?

Investigations Comparing to the other knee:  Observation and palpation  Observe gate- instability present?  X-ray to rule out fracture  Valgus stress test- in full extension and 30 o flexion  End feel (related to above)  Anteromedial drawer test- assesses whether superficial or deep fibers are damaged  Swain test- indicates MCL injury  Lachman test to rule out ACL injury  Posterior and anterior draw to rule out PCL and ACL injury  MRI to grade MCL tear and locate exact area of ligament that has been damaged (towards femur or tibia) Atypical Presentations Conditions that have the same symptoms and so need to be ruled out: o Medial meniscal tear/injury o Anterior cruciate ligament (ACL) tear o Tibial plateau fracture o Femur injury or fracture o Patellar subluxation/dislocation o Medial knee contusion (bruise) o Pediatric distal femoral fracture o Damage to the posteromedial corner structures Management Options and Levels of Evidence Most isolated MCL injuries (regardless of severity) can be treated with conservative, non-surgical measures. However, injuries involving other ligaments (and some other scenarios) do require surgery. Physiotherapy (conservative treatment): o Rest (from excessive load) for the ligament to repair so not to cause further damage o Bracing of the knee for support. More common than immobilizing as this can cause stiffness and weakness, but can still be used.

o Focusing immediately on improving range of motion, reducing swelling (cryotherapy) and protected weight bearing. o Progression toward strengthening and stability exercises. o Eventually full weight bearing (ROUGHLY after 1 week for grade 1 and 4 weeks for grade 2/3). Physio for grade I: o During the first 48 hours: ice, compression and elevation should be used as much as possible. o Possible temporary immobilization (however could cause other issues) or bracing and use of crutches for pain control. o Isometric, isotonic and eventually isokinetic progressive resistive exercises are begun within a few days of the subsidence of pain and swelling. Weight-baring is encouraged, the rate being dictated by the level of pain.

o o o

o

Physio for grade II/III: Important that the ends of the ligament are protected and left to heal without continually being disrupted. Should avoid applying significant stresses to the healing structures until 3-4 weeks after the injury to ensure that the injury can heal properly. However, grade III injuries are unclear and sometimes benefit from surgical involvement. In these cases, a trial of conservative treatment should be performed but patients with symptomatic residual instability after conservative treatment should be treated surgically. Grade III injury based at the femoral site generally do not require surgery.

Physio for grade III combined with other ligament damage (grade IIII): o Injuries with multiple ligamentous involvement (sometimes referred to as grade 4) should undergo surgical intervention. o Commonly, rehabilitation of the MCL injury occurs first (following isolated grade III guidelines). When there is good clinical and/or objective evidence of healing of the medial knee injury, mostly 5 to 7 weeks after the injury, the reconstructive surgery of the ACL can begin. (For anyone who wants more detail on the phases of rehab for each grade of injury would highly recommend reading this pagehttp://www.sportsinjuryclinic.net/sport-injuries/knee-pain/mclsprain/rehabilitation-mcl-injury. But without rewriting the whole thing I couldn’t get it on here and wasn’t sure if we needed that level of detail anyway). Surgical intervention: MCL reconstruction (or ACL reconstruction if also damaged) Needed if: o Avulsion occurred o Patients with chronic medial side knee injuries and problems with instability o Grade III injuries that are unstable in full extension

o Grade 4 injury (injury with multiple ligamentous involvement) Useful Resources For everythinghttp://www.physiopedia.com/Medial_Collateral_Ligament_Injury_of_the_Knee For populations/risk factors- https://www.ncbi.nlm.nih.gov/pubmed/24603529 http://www.ryanmiyamotomd.com/pdf/clinical-focus-orthopaedic-ligamentinjuries.pdf For history and investigationhttp://emedicine.medscape.com/article/89890-clinical Investigationhttp://www.orthosports.com.au/SiteMedia/w3svc994/Uploads/Documents/MCL %20Injuries.pdf Managementhttp://www.sportsinjuryclinic.net/sport-injuries/knee-pain/mclsprain/rehabilitation-mcl-injury...