The medial collateral ligament (MCL) is commonly injured during spor,ng ac,vi,es. â« 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.
