Collateral Ligament Tear of Knee

Aka: Collateral Ligament Tear of Knee, Knee Collateral Ligament Injury, Knee Collateral Ligament Sprain, Knee Lateral Collateral Ligament Tear, Knee Medial Collateral Ligament Tear, Knee Medial Collateral Ligament Injury, Knee Lateral Collateral Ligament Injury, Knee LCL Tear, Knee MCL Tear, Knee Lateral Collateral Ligament Rupture, Knee Medial Collateral Ligament Rupture, Knee Medial Collateral Ligament Sprain, Knee Lateral Collateral Ligament Sprain

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II. Mechanism

  1. Medial Collateral Ligament Rupture (common)
    1. Pure valgus load without rotation
    2. Force against lateral knee (in slight flexion)
    3. Common injury in Contact Sports (Football)
  2. Lateral Collateral Ligament Rupture (uncommon)
    1. Pure varus load without rotation
    2. Force against medial knee
    3. Rarely occurs without concurrent PCL or ACL injury

III. Signs

  1. See Knee Exam to evaluate associated injuries
  2. Localized collateral ligament signs
    1. Pain on palpation
    2. Localized Bruising or swelling
  3. Knee Valgus Stress Test evaluates MCL
  4. Knee Varus Stress Test evaluates LCL

IV. Grading: Ligamentous Sprain

  1. Grade 1 Injury: Minimal tear with no Joint Laxity
    1. Angle opening on stress: 0 to 5 mm
  2. Grade 2 Injury: Moderate tear with Joint Laxity
    1. Angle opening on stress: 6 to 10 mm
  3. Grade 3 Injury: Complete tear with no firm endpoint
    1. Angle opening on stress: 11 to 15 mm

V. Imaging: Knee XRay indicated in all suspected tears

  1. Views
    1. Anteroposterior
    2. Posteroanterior weight bearing
    3. Lateral
    4. Merchant view
  2. Findings: Chronic MCL insufficiency
    1. Calcific Medial Femoral Epicondyle (Pellegrini-Stieda Lesion)
    2. Findings: Chronic LCL insufficiency
      1. Chip Fracture of fibular head
      2. Differentiate from Segond sign (ACL Tear)

VI. Imaging: Knee MRI Indications

  1. Persistent joint line pain 4-6 weeks after injury

VII. Differential Diagnosis

  1. Medial Collateral Ligament Injury
    1. Medial Collateral Ligament Tear
    2. Medial Meniscus Tear
    3. Pes Anserine Bursitis
    4. Plica Syndrome
    5. Calcific Medial Femoral Epicondyle (Pellegrini-Stieda Lesion)
    6. Stieda Fracture (bony avulsion Fracture of medial femoral condyle)
    7. Myositis Ossificans
    8. Knee Osteoarthritis
    9. Tendonitis (Semimembranosus, Semitendinosus)
    10. Slipped Capital Femoral Epiphysis (referred pain from hip in adolescents)
  2. Lateral Collateral Ligament Injury
    1. Knee Lateral Collateral Ligament Tear
    2. Lateral Meniscus Tear
    3. Iliotibial Band Syndrome

VIII. Course: MCL Healing

  1. Stage 1: Inflammation
    1. Onset within 3 days of injury
    2. Fibroblasts produce Type III Collagen
  2. Stage 2: Repair and Regeneration
    1. Onset 6 weeks after injury
    2. Type I Collagen replaces Type III Collagen
  3. Stage 3: Remodeling
    1. Persists for more than 1 year after injury
    2. MCL regains 50-70% of elasticity, strength by 1 year
  4. Injury characteristics that slow healing
    1. Grade 3 sprains heal more slowly than Grades 1 and 2
    2. LCL tears heal more slowly than MCL tears

IX. Management

  1. RICE-M
  2. NSAIDs
  3. Local Cold Therapy
  4. Local Ultrasound or Phonophoresis
  5. Hinged Knee Brace
    1. Allows full flexion
    2. Limits terminal knee extension to 20 degrees
  6. Relative rest
    1. Grade 1 to 2
      1. Weight bearing as tolerated
    2. Grade 3
      1. Non-weight bearing initially
      2. Partial weight bearing by second week
      3. Full weight bearing by 4 weeks
  7. Rehabilitation
    1. Quadriceps strengthening Exercises
    2. Knee range of motion Exercises
  8. Surgical Indications
    1. Grade 3 Lateral Collateral Ligament tear
    2. Other concurrent knee Ligamentous Injury

X. Management: Return to play indications

  1. Functional Tests suggesting return to play
    1. One legged hopping
    2. Skipping rope
    3. Trampoline jumping
    4. Balance board (wobble board)
    5. Stair climbing
  2. Grade 1 to 2 MCL Sprain
    1. Anticipate return to play at 4-6 weeks after injury
    2. Return to forward Running at 60% of knee strength
    3. Return to sprinting at 80% of knee strength
    4. Return to contact at 90% of knee isokinetic strength
  3. Grade 3 MCL Sprain
    1. Anticipate return to play at 8-12 weeks after injury
    2. Criteria for return to play
      1. Isokinetic strength at 80%
      2. Adequate performance while sprinting
      3. Valgus stress tolerated without medial Knee Pain

XI. References

  1. Indelicato (1990) Clin Orthop Relat Res, (256):174-7 [PubMed]
  2. Kakarlapudi (2001) West J Med 174:266-72 [PubMed]
  3. Meislin (1996) Phys Sportsmed, 24(3):67-80 [PubMed]
  4. Reider (1994) Am J Sports Med 22(4):470-7 [PubMed]

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