• Medial aspect of the knee

Patient Profile

• Young athlete
• Usually an isolated injury
• Combined injury in 95% of cases with ACL injury, of which 78% are ACL injuries with Grade III injury of the MCL

Pathophysiology

Mechanism of injury

• Direct Valgus-stress with foot planted +/- tibia in external rotation
• “popping” sound often mentioned

Source
Acute:

• Atrophy or weakness; plyometric deficits
• Capsule/ligament damage or degeneration
• Valgus stress; Foot planted

Grades

• Grade I: 0-5mm gap, painful to touch, no instability
• Grade II: 6-10mm gap, painful to touch, no instability
• Grade III: >10mm gap in 0° and 30° flexion, commonly valgus- and rotatory instability

Course

MCL Grade I & II injuries can successfully be treated with conservative management using a brace and physiotherapy. Grade I & II injuries have had good short term prognosis with early return-to-play. There is good long term prognosis with >90% regaining normal knee function during sports in isolated grade I & II MCL injuries

History

History of knee trauma. Knee exposed to high loads in work, sport, ADL usually trauma. Older patients also inadequate trauma (degenerative tear)

• “Giving way” to the side (medially and in internal rotation)
• Feeling of instability in medial direction and internal rotation
• Acute: Swelling at medial side of the knee, limited ROM, local/stinging/superficial to deep pain
• Chronic: Feeling of instability, “giving way” despite complete wound healing

Physical Examination

Inspection
Acute: Signs of inflammation medial side, possible hemarthrosis, protective posture
Chronic: Quadriceps/gastrocnemius atrophy, barely any swelling

Functional Assessment
Acute: not possible due to symptoms
Chronic: Deep squat, climbing stairs, cutting motion, “giving way” rather described than demonstrated

Active Examination
Acute: limited ROM in Flex/Ext/Rot and pain upon small load
Chronic: end of range limitation in Flex/Ext; high loads in combination with these movements is painful

Passive Examination
Acute: PROM limited, swelling
Chronic: End or range ROM can be limited, structural instability apparent

Special Testing

 Differential Diagnosis

1. Subchondral injury
2. Damaged cartilage
3. Gonarthrosis
4. Avulsion fracture biceps femoris
5. Tibial plateau fracture
6. Unhappy triad
7. Pes anserinus irritation
8. Patella luxation
9. PFPS
10. Quadriceps tendon rupture
11. Patella tendon rupture
12. Osgood Schlatter

Strategy

Conservative: coper, isolated injury, >45 years old, linear sportsSurgical: non-coper, multidirectional injury, <45 years old, high risk sports

Interventions

Post-OP: Reach milestones of each rehabilitation phase before progressing. Adapt to tissue healing phases

Conservative: Identify deficits in strength, neuromuscular control, passive structures

Principles: concentric before eccentric, slow to fast, low load + high rep to high load + low rep, two-legged to one-legged, pay attention to sport specific demands

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