Injuries to the Medial Collateral Ligament and ...

1 downloads 0 Views 5MB Size Report
The medial collateral ligament (MCL) is commonly injured during spor,ng ac,vi,es. ▫ This can be either in isola,on or combined with injuries such as anterior ...
INTRODUCTION  

§  The  medial  collateral  ligament  (MCL)  is   commonly  injured  during  spor:ng  ac:vi:es.   §  This  can  be  either  in  isola:on  or  combined  with   injuries  such  as  anterior  cruciate  ligament  (ACL)   ruptures[1,2].   §  The  MCL  is  comprised  of  the  superficial  (sMCL)   and  deep  (dMCL)  ligaments[3].   §  The  stronger  sMCL  provides  an  important   restraint  to  valgus  movement  while  the  dMCL  is   closely  related  to  the  joint  capsule  and  resists   external  rota:on[3,4].   §  Injuries  to  the  MCL  are  graded  as[5]:     §  I  =  pain  without  gapping   §  II  =  pain  +  increased  movement   §  III  =  pain  +  no  firm  end  point     •  Grade  I  and  II  injuries  usually  heal  well  through   conserva:ve  measures[6,7].   §  Anecdotal  evidence  suggests  athletes,   par:cularly  those  taking  part  in  mul:-­‐direc:onal   sports,  experience  medial  knee  pain  when  kicking   a  ball  following  an  injury  to  the  MCL   §  Case  series  have  iden:fied  a  subset  of  pa:ents   post  ACL-­‐repair  with  persistent  medial  knee  pain;   this  has  been  aLributed  to  the  dMCL[8].   §  Macroscopic  injuries  to  the  dMCL  have  also  been   iden:fied  intra-­‐opera:vely[1].   §  Anteromedial  laxity  with  external  rota:on  of  the   :bia  is  a  recognised  phenomenon  following  MCL   and  medial  capsular  injury[3].   §  It  is  postulated  that  this  rota:on  originates  from   the  dMCL  and  contributes  to  persistent  medial   pain  following  injury  to  the  MCL.  

RESULTS   Structure  

Injury  Grading   1   2   3  

No  Injury  

dMCL*  

16  

34  

1  

28  

sMCL  

12  

35  

0  

32  

*dMCL  comprises  Meniscotibial  (MT)and  Meniscofemoral  (MF)   elements  

Frequency  of  dMCL  and  sMCL  injuries  

100%   80%   60%   40%  

64%  

59%  

dMCL  

sMCL  

20%  

79%  

0%   Total  

Grading  of  dMCL  and  sMCL  injuries   60   50   40  

1   34  

35  

30  

Grade  1   Grade  2  

20   10  

16  

12  

Grade  3  

0   dMCL  

sMCL  

DISCUSSION  AND  CONCLUSION  

AIM  AND  HYPOTHESIS  

§  This  study  aimed  to  assess  the  frequency  of  sMCL   and  dMCL  injuries  in  pa:ents  who  presented   with  an  ACL  rupture.   §  Due  to  the  mechanism  of  injury  in  ACL  ruptures,   it  was  hypothesised  that  injury  to  the  medial   knee  structures  would  be  readily  witnessed.  

METHODS  

§  A  retrospec:ve  popula:on  study  was  conducted   to  determine  the  incidence  of  MCL  injury  in   pa:ents  with  ACL  rupture.   §  Seventy-­‐nine  pa:ents  were  included  in  the  study.   §  A  consultant  radiologist,  specializing  in   musculoskeletal  imaging,  reviewed  Magne:c   Resonance  Images  (MRIs)  to  determine  the   presence  of  sMCL  and  dMCL  injury.   REFERENCES  

1.  Narvani,  A.,  et  al.,  Injury  to  the  proximal  deep  medial  collateral  ligament.  Journal  of  Bone  and  Joint  Surgery,  2010.  92-­‐B(7):  p.  949-­‐953.   2.  Frobell,  R.B.,  L.S.  Lohmander,  and  H.P.  Roos,  Acute  rota.onal  trauma  to  the  knee:  poor  agreement  between  clinical  assessment  and  magne.c  resonance  imaging   findings.  Scand  J  Med  Sci  Sports,  2007.  17(2):  p.  109-­‐14.   3.  Robinson,  J.R.,  et  al.,  The  role  of  the  medial  collateral  ligament  and  posteromedial  capsule  in  controlling  knee  laxity.  Am  J  Sports  Med,  2006.  34(11):  p.  1815-­‐23.   4.  Robinson,  J.R.,  et  al.,  The  posteromedial  corner  revisited.  An  anatomical  descrip.on  of  the  passive  restraining  structures  of  the  medial  aspect  of  the  human  knee.  J  Bone   Joint  Surg  Br,  2004.  86(5):  p.  674-­‐81.   5.  Wijdicks,  C.A.,  et  al.,  Injuries  to  the  Medial  Collateral  Ligament  and  Associated  Medial  Structures  of  the  Knee.  The  Journal  of  Bone  and  Joint  Surgery  (American),  2010.   92(5):  p.  1266-­‐1280.  5-­‐13;  discussion  3-­‐4.  

§  This  inves:ga:on  highlights  the  frequency  of  injury  to   medial  knee  structures  in  pa:ents  with  ACL  rupture.   §  59%  injured  the  sMCL  and  64%  the  dMCL  (63%  MT  and   1%  MF)  in  our  cohort  of  pa:ents  with  ACL  rupture.   §  It  is  therefore  unsurprising  when  athletes  complain  of   medial  knee  pain  aVer  successful  ACL  re-­‐construc:on.   §  Most  MCL  symptoms  respond  to  a  conserva:ve   approach  but  the  dMCL  plays  an  important  role  in   persistent  medial  knee  pain[6,7,8].   §  Examina:on  of  the  dMCL  is  not  common  place  but   anterior  draw  test  in  external  rota.on  can  be  used  in   assessing  external  rota:on  and  the  dMCL  in  clinical   prac:ce[9,10,11].   §  As  Sports  Medicine  doctors  working  with  professional   athletes,  par:cularly  those  in  kicking  sports  where  :bial   external  rota:on  is  an  important  movement,  we  must   have  greater  awareness  of  the  dMCL  and  the  func:onal   role  it  plays.   §  Further  work  is  required  to  validate  the  examina:on   method  in  assessing  medial  laxity,  but  with  appropriate   clinical  assessment  we  should  be  alerted  to  the   possibility  of  this  co-­‐existent  injury  and  aim  to  minimise   func:onal  impairment  for  our  athletes.   6.  Holden,  D.L.,  A.W.  Eggert,  and  J.E.  Butler,  The  non-­‐opera.ve  treatment  of  Grade  I  and  II  medial  collateral  ligament  injuries  to  the  knee.  American  Journal  of  Sports   Medicine,  1983.  11(5):  p.  340-­‐344.   7.  Hillard-­‐Sembell,  D.,  et  al.,  Combined  Injuries  of  the  Anterior  Cruciate  and  Medial  Collateral  Ligaments  of  the  Knee.  Journal  of  Bone  and  Joint  Surgery,  1996.  78-­‐A(2):  p.   169-­‐176.   8.  Jones,  L.,  et  al.,  Persistent  symptoms  following  non  opera.ve  management  in  low  grade  MCL  injury  of  the  knee  -­‐  The  role  of  the  deep  MCL.  Knee,  2009.  16(1):  p.  64-­‐8.   9.  Slocum,  D.B.,  et  al.,  Clinical  test  for  anterolateral  rotary  instability  of  the  knee.  Clin  Orthop  Relat  Res,  1976(118):  p.  63-­‐9.   10.  Slocum,  D.B.  and  R.L.  Larson,  Rotatory  instability  of  the  knee:  its  pathogenesis  and  a  clinical  test  to  demonstrate  its  presence.  1968.  Clin  Orthop  Relat  Res,  2007.  454:  p.     11.  Hughston,  J.  and  L.  Norwood,  The  Posterolateral  Drawer  Test  and  External  Rota.onal  Recurvatum  Test  for  Posterolateral  Rotatory  Instability  of  the  Knee.  Clin  Orthop   Relat  Res,  1980.  147:  p.  82-­‐87.