Medial collateral ligament injury of the knee
- William W Dexter, MD
William W Dexter, MD
- University of Vermont College of Medicine
- Director, Sports Medicine Program
- Maine Medical Center
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Injuries of the medial collateral ligament (MCL), also referred to as the tibial collateral ligament, occur frequently in athletes, particularly those involved in sports that require sudden changes in direction and speed, and in patients struck on the outside of the knee. Most heal well with conservative treatment, but some are associated with other significant injuries and careful evaluation is needed.
The evaluation and management of MCL injuries is reviewed here. A general approach to the patient with knee pain and the management of other types of knee injuries are discussed separately. (See "Approach to the adult with knee pain likely of musculoskeletal origin" and "Anterior cruciate ligament injury" and "Meniscal injury of the knee" and "Lateral collateral ligament injury and related posterolateral corner injuries of the knee" and "Posterior cruciate ligament injury".)
According to one systematic review, studies of the epidemiology of knee injuries are deeply flawed and should be interpreted cautiously . Nevertheless, ligament injuries account for up to 40 percent of all knee injuries, and of these, medial collateral ligament (MCL) injuries appear to be the most common [2,3]. MCL tears accounted for 7.9 percent of all injuries in an observational study of 19,530 knee injuries in 17,397 athletes over a 10 year period . The precise incidence of MCL injuries is unlikely to ever be known because many low grade injuries go unreported. While still common, MCL injuries declined in number during the course of an 11-year study of injuries in the Union of European Football Associations (UEFA) .
Given the limitations of the medical literature, it is not possible to determine the exact risk of MCL injury by sport. Football (ie, soccer) and basketball players appear to have a relatively high prevalence, as do participants in contact sports such as wrestling, hockey, and rugby [1,6]. Whether the risk of MCL injury varies significantly by gender remains unclear, some studies suggest that females are at higher risk [1,6]. A large survey study of United States high schools reported that females had a higher risk for knee injury than boys playing the same sport . Data from a prospective study of cadet athletes at the United States Military Academy suggest a significantly higher risk for isolated MCL injury among female intercollegiate athletes .
Other potential risk factors of note include prior injury, higher level of play (eg, intercollegiate athletes are at higher risk than secondary school athletes), game participation (versus practice), and type of sport. Various other risk factors have been proposed ranging from equipment (eg, ski bindings) to different shoe-surface interfaces, but no definitive data exist to confirm these claims. (See 'Mechanism of injury and healing' below.)
- Louw QA, Manilall J, Grimmer KA. Epidemiology of knee injuries among adolescents: a systematic review. Br J Sports Med 2008; 42:2.
- Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med 2000; 34:227.
- Wilk, KE, Andrews, JR, Clancy, WG. Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee. Op Tech Sports Med 1996; 4:192.
- Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee 2006; 13:184.
- Lundblad M, Waldén M, Magnusson H, et al. The UEFA injury study: 11-year data concerning 346 MCL injuries and time to return to play. Br J Sports Med 2013; 47:759.
- Roach CJ, Haley CA, Cameron KL, et al. The epidemiology of medial collateral ligament sprains in young athletes. Am J Sports Med 2014; 42:1103.
- Swenson DM, Collins CL, Best TM, et al. Epidemiology of knee injuries among U.S. high school athletes, 2005/2006-2010/2011. Med Sci Sports Exerc 2013; 45:462.
- Singhal M, Patel J, Johnson D. Medial ligament injuries. In: DeLee and Drez Orthopaedic Sports Medicine, DeLee J, Drez D, Miller M (Eds), Saunders, Philadelphia 2010. p.1629.
- Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 1979; 61:56.
- Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc 2006; 14:78.
- LaPrade RF, Moulton SG, Nitri M, et al. Clinically relevant anatomy and what anatomic reconstruction means. Knee Surg Sports Traumatol Arthrosc 2015; 23:2950.
- Satterwhite, Y. The anatomy and biomechanics of the medial structures of the knee. Op Tech Sports Med 1996; 4:134.
- Griffith CJ, Wijdicks CA, LaPrade RF, et al. Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. Am J Sports Med 2009; 37:140.
- Craft JA, Kurzweil PR. Physical examination and imaging of medial collateral ligament and posteromedial corner of the knee. Sports Med Arthrosc 2015; 23:e1.
- Takagi T, Nakao Y, Takayama S, Toyama Y. Traction injury of common peroneal nerve associated with multiple ligamentous rupture of the knee: a case report. Microsurgery 2002; 22:339.
- Creighton, RA, Spang, JT, Dahners, LE. Basic Science of Ligament Healing: Medial Collateral Ligament Healing With and Without Treatment. Sports Med Arthrosc 2005; 13:145.
- Shepherd L, Abdollahi K, Lee J, Vangsness CT Jr. The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging. J Orthop Trauma 2002; 16:628.
- Kurzweil PR, Kelley ST. Physical examination and imaging of the medial collateral ligament and posteromedial corner of the knee. Sports Med Arthrosc 2006; 14:67.
- Laprade RF, Bernhardson AS, Griffith CJ, et al. Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med 2010; 38:330.
- Wang JC, Shapiro MS. Pellegrini-Stieda syndrome. Am J Orthop (Belle Mead NJ) 1995; 24:493.
- 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; 19:489.
- Nakamura N, Horibe S, Toritsuka Y, et al. Acute grade III medial collateral ligament injury of the knee associated with anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a treatment regimen. Am J Sports Med 2003; 31:261.
- Jones L, Bismil Q, Alyas F, et al. Persistent symptoms following non operative management in low grade MCL injury of the knee - The role of the deep MCL. Knee 2009; 16:64.
- De Maeseneer M, Shahabpour M, Pouders C. MRI spectrum of medial collateral ligament injuries and pitfalls in diagnosis. JBR-BTR 2010; 93:97.
- De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures. Skeletal Radiol 2014; 43:1025.
- Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med 2004; 32:337.
- Smyth MP, Koh JL. A review of surgical and nonsurgical outcomes of medial knee injuries. Sports Med Arthrosc 2015; 23:e15.
- Narvani A, Mahmud T, Lavelle J, Williams A. Injury to the proximal deep medial collateral ligament: a problematical subgroup of injuries. J Bone Joint Surg Br 2010; 92:949.
- Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc 2006; 14:84.
- Shelbourne KD, Patel DV. Management of combined injuries of the anterior cruciate and medial collateral ligaments. Instr Course Lect 1996; 45:275.
- Marx RG. Operative and nonoperative treatments of medial collateral ligament rupture were not different in combined medial collateral and anterior cruciate ligament rupture. J Bone Joint Surg Am 2007; 89:457.
- Millett PJ, Pennock AT, Sterett WI, Steadman JR. Early ACL reconstruction in combined ACL-MCL injuries. J Knee Surg 2004; 17:94.
- Zaffagnini S, Bonanzinga T, Marcheggiani Muccioli GM, et al. Does chronic medial collateral ligament laxity influence the outcome of anterior cruciate ligament reconstruction?: a prospective evaluation with a minimum three-year follow-up. J Bone Joint Surg Br 2011; 93:1060.
- Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med 2006; 34:1134.
- Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am 2009; 91:1305.
- Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am 1987; 69:1120.
- Zaffagnini S, Bignozzi S, Martelli S, et al. Does ACL reconstruction restore knee stability in combined lesions?: An in vivo study. Clin Orthop Relat Res 2007; 454:95.
- Papalia R, Osti L, Del Buono A, et al. Management of combined ACL-MCL tears: a systematic review. Br Med Bull 2010; 93:201.
- Osti L, Papalia R, Del Buono A, et al. Simultaneous surgical management of chronic grade-2 valgus instability of the knee and anterior cruciate ligament deficiency in athletes. Knee Surg Sports Traumatol Arthrosc 2010; 18:312.
- Miyamoto RG, Bosco JA, Sherman OH. Treatment of medial collateral ligament injuries. J Am Acad Orthop Surg 2009; 17:152.
- Hanson CA, Weinhold PS, Afshari HM, Dahners LE. The effect of analgesic agents on the healing rat medial collateral ligament. Am J Sports Med 2005; 33:674.
- Reider B, Sathy MR, Talkington J, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med 1994; 22:470.
- Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med 1996; 24:160.
- Lundberg M, Messner K. Ten-year prognosis of isolated and combined medial collateral ligament ruptures. A matched comparison in 40 patients using clinical and radiographic evaluations. Am J Sports Med 1997; 25:2.
- Sparrow KJ, Finucane SD, Owen JR, Wayne JS. The effects of low-intensity ultrasound on medial collateral ligament healing in the rabbit model. Am J Sports Med 2005; 33:1048.
- Warden SJ, Avin KG, Beck EM, et al. Low-intensity pulsed ultrasound accelerates and a nonsteroidal anti-inflammatory drug delays knee ligament healing. Am J Sports Med 2006; 34:1094.
- Walsh WR, Wiggins ME, Fadale PD, Ehrlich MG. Effects of a delayed steroid injection on ligament healing using a rabbit medial collateral ligament model. Biomaterials 1995; 16:905.
- Carmeli, E, Beer, Y, Halperin, N, et al. Medial collateral ligament repair following complete ligament transaction: an experimental study in rabbits. Biology of Sport 2004; 21:379.
- Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament. Sports Med Arthrosc 2006; 14:105.
- Albright JP, Powell JW, Smith W, et al. Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces. Am J Sports Med 1994; 22:12.
- Albright JP, Powell JW, Smith W, et al. Medial collateral ligament knee sprains in college football. Brace wear preferences and injury risk. Am J Sports Med 1994; 22:2.
- MECHANISM OF INJURY AND HEALING
- PHYSICAL EXAMINATION
- Overall approach
- Range of motion
- Special tests and grade of injury
- Magnetic resonance imaging
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR CONSULTATION OR REFERRAL
- INITIAL TREATMENT
- FOLLOW-UP AND REHABILITATION
- RETURN TO SPORT
- Prophylactic bracing
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS