Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Medial Collateral Ligament (MCL)

SYMPTOMS

The symptoms are immediate haemarthrosis and pain in the medial part of the knee. If only the external portion is ruptured there will be superficial bruising rather than haemarthrosis. This is an injury common in contact sports such as football, rugby and other high-intensity sports. The MCL ruptures during an excessive valgus sprain and
usually causes the inability to continue sport.

AETIOLOGY

In many cases this is a non-contact injury, where the player loses their balance and twists the knee. The ligament can rupture partially (Grade I-II) or completely (Grade III-IV), externally from its origin on the femur to its insertion on the tibia or internally at the insertion into the medial meniscus. This injury is, consequently, frequently
associated with other injuries to cartilage, menisci, capsule or other ligaments.

CLINICAL FINDINGS

There is haemarthrosis and/or medial bruising and swelling. If there is an isolated rupture of the insertion to the meniscus, there is a capsule rupture as well and blood can penetrate from the joint and cause bruising around
the medial part of the knee. This causes a meniscocapsular lesion. The valgus stress test is positive if the rupture is complete. This is the most sensitive test and can verify a medial ligament rupture in more than 90 per cent of occurrences. The test should be done with a straight knee and is positive if there is a complete tear. With the knee flexed 20–25 degrees, the test is positive if the inner portion is ruptured. The latter positive test should raise the suspicion of injury to the medial meniscus, where the inner portion of the MCL is attached. Note! Since there are often associated injuries, examination must also include tests for cruciate ligaments, capsular structures and menisci.

INVESTIGATIONS

Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is valuable to rule out fractures, in particular in growing or elderly athletes. MRI can verify the MCL tear in most cases but is more important for evaluating associated injuries.

TREATMENT

An athlete with haemarthrosis and suspected MCL tear should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and also deal with associated injuries that are often missed. Grade I-II injuries can most often be treated non-operatively, by a brace, but Grade III-IV may need surgery.

REFERRALS

Refer to Dr Kevin Yip, orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon.

EXERCISE PRESCRIPTION

Cycling and swimming (not breast stroke) are good alternatives to keep up general fitness. Valgus stress to the knee
should be avoided. Rehabilitation back to full sport usually takes three to six months depending on severity.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Valgus stress test should be negative. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES

This is a straightforward diagnosis but associated injuries to the menisci, cartilage or cruciate ligaments should always be borne in mind.

PROGNOSIS

Appropriate treatment will allow a return to professional sports within three months (non-operative) to six months (after surgery for Grade III-IV injury). The risk of re-rupture is low.

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