MCL collateral ligament injury

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MCL ligament function

The MCL collateral ligament attaches to the medial epicondyle of the femur, runs in a wide band down anteriorly, and attaches to the medial surface of the proximal tibia. The MCL collateral ligament consists of two layers:

superficial - inhibiting the movements of knee valgus,
deep - strengthening the articular capsule and stabilizing the straightened knee more than the medial-posterior side.

MCL collateral ligament injury

Most injuries involve the femoral insertion or medial ligament over the rift of the tibial joint. Isolated MCL ligament injuries are most often the result of a direct impact to the side of the knee with excessive valgus of the joint. MCL collateral ligament rupture can also occur indirectly, when the knee rotates uncontrollably, such as when falling with an unfastened ski. Accompanying injuries to other knee structures may then occur, e.g. rupture of the anterior cruciate ligament (ACL).

During the clinical examination, the orthopedic surgeon collects a detailed history of the moment of the injury, examines the knee for extra-articular edema above the MCL ligament, and palpates along its course. Then it performs the so-called an attempt to valgize the knee joint. The patient is lying on his back and should relax the muscles of the examined limb. The test consists in knee valgus with full extension and then with the knee flexed at an angle of 20-30 degrees. Knee flexion allows the posterior part of the articular capsule to relax and allows for more targeted examination of the MCL ligament. The doctor assesses the degree of medial dilatation of the tibial joint, final sensation and pain symptoms reported by the patient. The condition of the knee after injury should always be compared with that of the healthy knee on the opposite side to exclude the effect of generalized ligamentous laxity on the test result.

Symptoms accompanying the tibial collateral ligament injury depend on the extent of the injury. There are three degrees of MCL ligament damage:

Stretching the ligament without lengthening it - the validation test shows no instability, but there is a clear palpation along the course of the ligament,
Partial rupture of the ligament with its lengthening - ligament laxity is found, which is manifested by opening the space of the tibial joint over 5 mm during an attempt of knee valgus. Pain worsens during the test.
Complete rupture of the tibial collateral ligament with disruption of its continuity or its significant stretching - the gap of the knee joint opens more than 1 cm, a soft end feeling is noted.
The differential diagnosis includes: contusion of the medial surface of the knee, rupture of the medial meniscus, rupture of the medial patella and epiphyseal fracture (through the growth plate) occurring in children and adolescents.

Imaging tests allow for confirmation of the diagnosis and confirmation of the accompanying knee injuries. X-rays taken in the A-P and lateral "rising sun" views allow to exclude fractures, for example, avulsive detachment of a bone fragment or fracture of the epiphysis. Occasionally, X-rays around the medial femoral condyle show calcification (the so-called Pellegrini-Stied symptom), which indicates an aged strain of the MCL ligament. Ultrasound examination allows for a full assessment of superficial tissues, e.g. patellar retinaculum, bursae or damage to the peroneal collateral ligament. Magnetic resonance imaging is performed when there is suspicion of simultaneous damage to the medial meniscus and / or the ACL ligament (O'Donoghue unhappy triad), cartilage damage of the knee joint and other intra-articular injuries.

Conservative treatment

Treatment of isolated injuries of the tibial collateral ligament while maintaining its continuity consists in rehabilitation. The patient wears a light hinge orthosis that protects the knee joint against valgus forces and at the same time allows a full range of flexion and extension movements. The area of ​​the medial side of the knee can be cryotherapy in the form of cooling - i.e. cold compresses applied for 20 minutes every 2-3 hours. This will reduce possible swelling and eliminate pain. Supportively, you can use collateral ligament taping, i.e. colored tapes glued on the skin. They can reduce local swelling or help stabilize the knee - depending on the technique used.

The healing process of the MCL ligament with the formation of a valuable scar should be supported by special techniques of manual therapy, including deep transverse massage of the ligament. The mobilization of soft tissues also allows to avoid undesirable adhesions and maintain the sliding of the fascia within the knee joint. Rehabilitation also involves exercises in the range of motion of the knee joint in the sagittal plane, strengthening the quadriceps muscle and training the muscles responsible for the active stabilization of the knee joint. The patient may put pressure on the limb within the pain limits. Gait training with the correct emphasis on each phase is introduced as soon as possible.

The time of rehabilitation depends on the degree of damage - slight strains or minor tears of the ligament heal quickly and the patient often returns to activity after just 2 weeks. The tearing of most of the ligament fibers is associated with a longer recovery period. People practicing sports require additional specialized knee stabilization exercises, which will reduce the risk of repeated ligament injuries.

A rupture of the tibial collateral ligament with simultaneous rupture of the anterior cruciate ligament ACL is most often treated conservatively - i.e. without invasive MCL repair procedures. Arthroscopic reconstruction of the anterior cruciate ligament is performed, and the partially damaged MCL is allowed to heal.

Surgery

Third degree MCL injury heals spontaneously, but the auto-repair effect does not restore the correct biomechanics of the knee joint. In the case of a complete rupture of the tibial collateral ligament or its significant stretching causing knee instability that hinders everyday functioning, a surgical procedure is performed. Failure to undertake appropriate treatment may result in a significant acceleration of degenerative changes and an increased risk of acute damage to the remaining knee structures, e.g. menisci. Moreover, in conditions of high medial instability of the knee combined with external rotation of the tibia, the anterior cruciate ligament ACL or its graft is adversely affected. It may be important in the case of rupture of both ligaments - then the surgical treatment consists in the simultaneous reconstruction of the ACL ligament and repair or reconstruction of the MCL ligament. In the case of simultaneous rupture of the MCL ligament and posterior cruciate ligament (PCL), the simultaneous reconstruction of both ligaments is also performed.

Repair, suturing of the MCL collateral ligament

The surgeon makes an incision on the medial side of the knee, reaching the damaged tibial collateral ligament. Then, he works out parts of the ligament in such a way as to recreate its anatomical layers as closely as possible. The most common repair procedure for the MCL ligament is suturing it in place of the femoral attachment with the use of special anchors.

MCL collateral ligament reconstruction

In reconstructive surgery, the patient's own tissues (e.g. the tendon of the slender or semitendinous muscle) or the tissues obtained from the deceased donor (e.g. the Achilles tendon) are used for the transplant. In the case of MCL reconstruction with the use of the slender muscle tendon, only the proximal end of the graft is dissected, and the distal attachment on the tibia is left [1]. The tendon is cleaned of muscle tissue and sewn with a special suture. Then a place is prepared on the femur, where the tendon graft will be attached - for this purpose, the surgeon drills a hole in the area of ​​the femoral adductor tubercle. The tendon is placed in the bone tunnel and then swung back towards the tibia to form a "double" ligament graft. The double tendon is sutured and the end of the tendon is clamped over the tibia. During the procedure, it is checked several times whether the graft has the correct tension in different settings of the knee bend. The procedure ends with the closure of the operating wound.

The above description concerns an exemplary technique of MCL collateral ligament reconstruction. The choice of the graft and the method of its fixing depends on the individual anatomy of the patient's knee and the skill of the operator in various surgical techniques.

Rehabilitation after MCL ligament surgery

Most MCL surgical techniques enable early joint activation, i.e. knee flexion and extension movements in the range of 10-60 degrees in the first days after the procedure. This avoids secondary restrictions on the mobility of the knee joint. For the first few weeks, the patient after the surgery should wear a special orthosis stabilizing the knee from the medial side and protecting the stitched ligament or graft against excessive stretching.

The rehabilitation program assumes that the patient achieves specific functional and functional goals. The duration of the individual phases of physiotherapy may therefore be variable. Rehabilitation after surgery of a damaged MCL ligament should include:

Restoration of the full painless range of motion of the knee while maintaining the integrity of the sutured ligament or graft,
Obtaining a painless scar,
Improving the activation of the muscles responsible for the active stabilization of the knee joint,
restoration of the muscle strength of the operated limb,
obtaining the results of functional tests at the level of at least 80-90% of the healthy limb,
Discipline-specific training elements and a gradual return to sporting activity.

Source

1. Śmigielski R. Mioduszewski A. Rekonstrukcja więzadła pobocznego piszczelowego uszypułowanym dystalnie ścięgnem mięśnia smukłego. Acta Clinica 2002 2: 146-150.

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