MCL Tears: They all

heal…..Or Do

They? ERIK D. PETERSON, MD

ORTHOPEDIC SPORTS MEDICINE SURGEON

CORE ORTHOPEDICS

Incidence

Most Commonly Injured Ligament in the knee

Mechanism

Valgus applied stress to fixed/planted foot

With increasing amounts of axial rotation, combined ligament

injuries occur, i.e. ACL

Function

Primary restraint to valgus stress at

knee joint

Primarily in 30+degrees flexion (80%)

Extension (50%); ACL, PMC additional

Controls External Rotation

AMRI

Anatomy

Warren Layers Concept

Biomechanics

Extrarticular

11 cm length

Equal Strength of ACL

Majority of Tears at Femoral Insertion: Stress Concentration w/ valgus

Minimal Contribution to

Valgus Stability.

Rotational control

mainly

Sectioning study = no

increased valgus

Anatomy

Deep MCL

Anatomy

5-7 cm distal insertion on tibia

Majority of tears at Proximal insertion

Classification

AMA

Grade 1: 0-5mm

Grade 2: 6-9mm

Grade 3: 10+mm

Hughston

Grade 1: no tearing/sprain/no

instability

Grade 2: partial tearing/no

instability

Grade 3: high grade/complete

tear/varying degrees on

instability

Incidence of MCL Tears Roach AJSM 2014

West Point Study

InterCollegiate and Intramural sports (all cadets participate)

Multi Sport participation not just incidence in a single sport gives

truest estimation of athletes risk. N=20

Incidence Rate (IR)

7.3 /1000 person-years (22-25/yr)

0.11 /1000 Athletic exposures

1 of 100 kids every 100 practices or games will tear MCL

Grade 1 (73%) Grade 2 (23%) Grade 3 (4%)

Epidemiology Roach AJSM 2014

Men 2.6 times more likely to tear MCL

Hockey/Football highest prevalence = Male only at

West Point

Confounding

IR no different when comparing sex participating in same sport

i.e. Rugby

Epidemiology

Roach AJSM 2014 Highest Risk IR/1000 AE = Wrestling>Judo>Hockey>Rugby

Wrestling IR = 0.57 / 1000 AE

1 of 100 kids will tear their MCL every 20 practice/match

Intercollegiate 57% higher IR compared w/ Intramural

Demographics

Male > Female (Intercollegiate level) Roach AJSM 2014 & Stanley AJSM 2016

Female > Male (High School level) Stanley AJSM 2016

Contact > Non-Contact (opposite of ACL risk)

Football, Soccer, Hockey, Basketball

Higher Level of Participation increases risk of injury (opposite ACL)

Professional/Intercollegiate>High School>Adolescent

Roach AJSM 2014

Demographics Playing Surface

Hershman AJSM 2012

NFL Injury database 2000-2009

FieldTurf vs. Grass

MCL injuries Not statistically increased on Turf vs Grass (p=.68)

ACL injuries 67% higher risk on Turf vs Grass (P<.001)

Exam

*Valgus Laxity at 30 degrees and Zero degrees = 78%

prevalence of combined ACL/MCL injury

Diagnostic Tests

Radiographs

Pelligrini Steida Lesion:

Chronic

Beware!!

Diagnostic Tests

MRI I have a Low threshold

Higher Grade Lesions > MRI use

Grade 2/3 associated with increased concomitant knee injury

Medial Meniscus

ACL

78% of Grade 3 have additional injury (ACL/men)

Contra Coup edema

MRI

Grade 1 sprain

MRI

Grade 2 sprain

MRI

Grade 3 sprain

Treatment: Nonoperative

RICE

Controlled Motion > Immobilization

Hinged Brace

Weight bearing: initially w/ locked brace

NSAIDS: Avoid?? (Warden AJSM 06) Rat study w/ Celebrex

33% reduced load to failure at 2 week

Ultrasound: Improved strength, stiffness, energy absorption, cross sectional area at 6 wks (Sparrow AJSM 05)

High Success for Complete Healing

>98% when tear is femoral insertion of midsubstance

Treatment: Nonoperative

ARP wave

Recovery

Directly proportional to severity of Injury

Average Time Lost 23 days

Grade 1 : 13 days

Grade 2/3: 29 days

Grade 3: D1 college mean 9 wks (Indelicato AJSM 90)

Roach AJSM 2014

Prevention

Systematic Review

JAT Pietrisimone 2008

We cannot advocate nor

discourage the use of

prophylactic bracing for

prevention of knee injuries

based on current levels of

evidence

Prevention

Prophylactic Bracing

Albright AJSM 2004

Looking specifically at MCL injury risk

1000 Big Ten Football players followed prospectively for one season

50% braced

Stratified injury risk based on position

Conclusion

Consistent, but non statistically significant trend toward < MCL injuries

Linemen (offensive and defense)

Linebackers

Tightends

Surgical Management

Indications:

Chronic MCL tear-unhealed, unstable

Acute Grade 3 MCL w/ concomitant ACL/PCL injury

Controversial

Early Surgery: repair/reconstruct

Delay Surgery, rehab, See if MCL heals

Early Surgery: Reconstruct ACL, rehab MCL

Millett JKS 04: No difference at Followup

Halinen AJSM 06: Prospective ACL +- MCL repair; early surgery: No difference

Grade 4 lesions

Tibia: Stener equivalent

Femur: Intraarticular entrapment

Avulsion Fracture of MCL origin

Case Presentation

17 yo HS football player

Collision/Valgus stress

Immediate medial swelling

Excruciating Pain

Exam:

Superficial Ecchymosis

Negative Lachman

Stable Varus

Valgus 0 degrees: stable

Valgus 30 degrees: +3 opening 15mm

MRI

Stener-Like

MCL tear

Grade 4

Stener Lesion: Skier’s thumb

UCL

Case Presentation

60 yo woman

Painting on step stool

Fell to ground with leg twisting underneath her

Felt a pop

Excruciating Pain

Exam:

Positive Lachman

Stable Varus

Valgus 3+ in 0 & 30 degrees

MRI

Thank You