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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