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Medial and Lateral Collateral Ligament
Injury
Normal Anatomy
Medial collateral ligament
 Split into superficial (s-MCL) and deep (d-MCL) by MCL bursa
 s-MCL - Femoral attachment – Proximal and posterior to the medial femoral epicondyle
Tibial attachments - 1) Proximal arm blends with the fascia of the distal semimembranosus
tendon (mainly aids with valgus stability)
2) Distal arm attaches broadly to the posteromedial tibia (mainly aids with external rotation
stability)
 d-MCL - Continuous with the joint capsule of the knee and is closely associated with the
medial meniscus
Upper half called meniscofemoral, lower half meniscotibial
 Posterior oblique ligament (POL) – Continuous with s-MCL and extends posteriorly to blend
with semimembranosus and gastrocnemius tendons (important internal rotation stabiliser)
Lateral collateral ligament
 Femoral attachment - Posterolateral aspect of the lateral condyle
 Extends obliquely inferior and posterior
 Fibular attachment – Superolateral aspect of fibular head, immediately superior to popliteal
fossa
 More rounded and narrow than MCL
 Is not connected to meniscus nor capsular ligament
 More flexible than MCL
Mechanism of Injury
Medial collateral ligament
 Valgus stress
 Most commonly s-MCL
 d-MCL injuries rare although possible with only low grade s-MCL injuries (Persistent pain
often masquerading as medial meniscus tear can be attributed to small d-MCL tears)
 65% at femoral insertion, 25% tibial insertion.
Lateral collateral ligament
 Severe, high-energy, direct varus stress
 Uncommon due to relative flexibility of LCL and decreased incidence of lateral stress (Only
2% knee injuries occur at LCL)
 75% at fibular head, 20% at femoral side, 5% mid-substance
 Associated peroneal nerve injuries common (24%)
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Classification
Grade 1
 Clinical - Local pain on no significant gapping on varus / valgus stress
 MRI - Microscopic tears of individual fibers with associated swelling
Grade 2
 Clinical – Broader area of pain, significant gapping on varus / valgus stress with firm end feel
 MRI - Macroscopic partial tears with high signal in the ligament or morphological changes on
MRI
Grade 3
 Clinical – No definitive end point on varus / valgus stress
 MRI - Complete ligamentous discontinuity
Associated pathologies
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ACL injuries
PCL injuries
Avulsion fractures
Medial meniscus tears (2-4%)
Meniscocapsular separations
Bone bruising common (24%)
Examination
Subjective
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History of varus / valgus stress injury
Occasionally insidious onset
Pain over lateral / medial aspect of knee
Instant swelling
Pain on weight bearing
Objective
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Pain on palpation of injured site
Varus / valgus stress painful and/or laxity
o Grade I – No movement
o Grade II – 3-5mm joint opening
o Grade III - >5mm joint opening
Special Tests
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Varus stress test (LCL)
Valgus stress test (MCL)
Dial test (POL)
Further Investigation
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Valgus stress radiographs
MRI – 87% accurate at detecting MCL injury.
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Ultrasound imaging
Management
Conservative
• Grade I-II injuries
• Isolated s-MCL grade III injuries
Surgical
• Isolated grade III injuries which do not respond to conservative management
• Grade III injuries with associated pathology
• ACL + isolated s-MCL Gd III – Rehabilitate MCL injury before ACL reconstruction
There is no difference in subjective or objective, short term or long term outcomes between surgical
and conservative management of isolated grade III injuries.
Conservative Management
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Decrease weight bearing to allow pain free ambulation
Hinged knee brace to prevent varus / valgus stress
Maintain full ROM
Maintain quads strengthen
Maintain adductor strength (adductor attachment in close relation to MCL)
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Progress to full weight bearing once limp has disappeared
Stationary bike as soon as tolerated (has been shown to improve healing times)
Return to play within 3 weeks (mild injuries) or 5-10 weeks (severe injuries)
Phase 1 (Mild: 0-1 week; Severe: 0-4 weeks)
 Progress to FWB (mild); PWB (severe)
 Control swelling
o POLICE
o Effleurage
 Limit knee extension to +20o, knee flexion to 100o+
o Gentle ROM exercises
o Exercise bike
o Soft tissue
 4/5 Quads strength
o VMO setting
 4+/5 Hamstrings strength
o Resisted hamstrings (theraband)
 Maintain hip strength
o Standing hip abduction / extension
o Isometric adduction
Phase 2 (Mild: 1-2 weeks; Severe 3-6 weeks)
 Progress to FWB (severe)
 Eliminate swelling
 Limit knee extension to +20o, full flexion
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4+/5 Quads strength
o Mini squats / lunges
o Leg press
o Step ups
5/5 Hamstrings strength
o Bridges
o Swimming (light kick)
Begin straight line running with hinged knee brace (mild injuries)
Begin balance / proprioception drills
o Single-leg balance
Phase 3 (Mild: 2-4 weeks; Severe 5-10 weeks)
 Full ROM
 Full strength
 Full squat
 Return to running / sport specific drills
o Running progression
o Road bike
o Swimming
o Jump and land drills
o Agility drills
Phase 4 (Mild: 3-5 weeks; Severe 6-12 weeks)
 Full strength / ROM / endurance of affected limb
 Return to sport
Surgical Management
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Reconstruction
o MCL - Two separate grafts with four tunnels
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References
(Bahk & Cosgarea, 2006; Chen et al., 2008; Jacobson & Chi, 2006; Laprade & Wijdicks, 2012; Lim et
al., 2012; Logerstedt et al., 2010; Patel & Parker, 2008; Schein et al., 2012)
Bahk MS, Cosgarea AJ. Physical examination and imaging of the lateral collateral ligament and
posterolateral corner of the knee. Sports Med Arthrosc 2006; 14(1): 12-9.
Chen L, Kim PD, Ahmad CS, Levine WN. Medial collateral ligament injuries of the knee: current
treatment concepts. Curr Rev Musculoskelet Med 2008; 1(2): 108-13.
Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries
of the knee. Sports Med Arthrosc 2006; 14(2): 58-66.
Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports
Phys Ther 2012; 42(3): 221-33.
Lim HC, Bae JH, Bae TS, Moon BC, Shyam AK, Wang JH. Relative role changing of lateral collateral
ligament on the posterolateral rotatory instability according to the knee flexion angles: a
biomechanical comparative study of role of lateral collateral ligament and popliteofibular
ligament. Arch Orthop Trauma Surg 2012; 132(11): 1631-6.
Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ. Knee pain and mobility impairments: meniscal
and articular cartilage lesions. J Orthop Sports Phys Ther 2010; 40(6): A1-A35.
Patel SC, Parker DA. Isolated rupture of the lateral collateral ligament during yoga practice: a case
report. J Orthop Surg 2008; 16(3): 378-80.
Schein A, Matcuk G, Patel D, et al. Structure and function, injury, pathology, and treatment of the
medial collateral ligament of the knee. Emerg Radiol 2012; 19(6): 489-98.
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