Current Best Practice for Management of Medial Collateral Ligament Injury

Medical collateral ligament injuries are among the most common knee injuries for the athletic population. Immobilization once was the accepted course of treatment for MCL injuries but research has demonstrated the ineffectiveness of this approach. The knee is second only to the ankle in frequency of injuries in competitive sports and often more severe. Ruptures to the anterior cruciate ligament (ACL) are the most devastating injury to the knee while the medial collateral ligament (MCL) is the most frequently injured (Pickett & Altize, 1971). Although ACL injuries present greater structural deficiency resulting in more time lost when compared to MCL injuries, damage to the MCL is more common. A ruptured MCL often results in considerable structural deficit and may be considered a seasonending injury with return to full activity rates ranging from 4 to 9 weeks (Indelicato, Hermansdorfer, & Huegel, 1989; Jones, Henley, & Francis, 1985). Accepted current practice for treatment and rehabilitation of MCL injuries includes no surgical intervention and a protective hinge brace which allows the knee to flex and extend while limiting medial or lateral stresses on the knee. The brace is removed daily for therapeutic modalities and rehabilitative exercise. However, we have experienced physicians who continue to use immobilization techniques such as long leg casts for management of MCL injuries. This practice precludes appropriate application of modalities and therapeutic exercise and results in delayed recovery time. The purpose of this critical inquiry is to provide best evidence currently available on management of MCL injuries. Background and Significance Anatomy of the Knee The knee is a modified hinge joint supported statically by four main ligaments ACL, posterior cruciate ligament, MCL, lateral collateral ligament. The knee allows motion in the anterior to posterior plane with minimal rotation during flexion and extension. Due to popularity among lay people, the most well known ligament is the ACL, which prevents the tibia from sliding anteriorly on the femur. The posterior cruciate ligament prevents just the opposite, a posterior glide of the tibia on the femur. The lateral collateral ligament protects the lateral aspect of the knee by preventing a varus (medial to lateral) force (Moore, 1996). The MCL is the major stabilizing structure for the medial aspect of the knee joint protecting the knee from valgus (lateral to medial) forces. The MCL is divided into deep and superficial portions separated by a bursa, which is a small jelly filled sac that reduces friction that allows movement between the two segments. The superficial portion of the ligament arises proximally from the medial epicondyle on the femur and attaches 4-5 cm distal to the joint line on the medial surface of the tibia. The deep portion lies just beneath the superficial portion and has a firm attachment to the medial meniscus and the fibrous capsule surrounding the knee joint (Moore, 1996). The MCL can be disrupted in three ways; the attachment is avulsed from the femoral epicondyle, a mid substance tear, or the attachment is avulsed from the tibial shaft. Evaluation of MCL Injuries The integrity of the MCL is tested clinically with the valgus stress test. This test involves applying a valgus force to the lateral aspect of the knee while the knee is flexed approximately