MCL Tears and Repairs By Dr. Charlie Peterson, MD

MCL Tears and Repairs

The medial collateral ligament (MCL), located on the inside portion of the knee, is one of the more common sporting injuries to the lower extremity. It is usually an “acute” injury, meaning that it happens suddenly due to trauma. In sports, the athlete may take a sudden blow to the outside of the knee, creating excessive tensile force to the MCL, such as being tackled in football. This injury also occurs commonly in sports where the ankle is immobilized such as hockey and downhill skiing, where the ankle is stabilized in a skate or boot. This immobilization leaves the knee to absorb the full impact of a collision or fall and increases the risk of knee injury.

Functional Anatomy

The skeletal anatomy of the knee consists of three bones. The thigh bone, medically termed the femur connects with the shin bone, called the tibia. In the front of the knee is the knee cap, or the patella. Holding these bones together are the four major knee ligaments. Two are located deep within the joint and are called cruciate ligaments. They prevent excessive forward and backward motion, as well as rotation. The remaining two are the collateral ligaments, and are located on the sides of the knee. Their job is to prevent lateral, or sideways, motion of the knee. The MCL is located on the inside of the knee joint and prevents the knee from collapsing inward. In addition to the bones and ligaments, the knee has two cartilage pads called the medial meniscus and lateral meniscus. These pads act as shock absorbers within the knee.

Types of MCL Injury

Tears to the MCL are usually a result of direct trauma, either from a blow to the outside of the knee, such as with a football tackle, or a fall that pushes the lower leg sideways. Partial tears will cause varying degrees of instability within the knee, and are often treated successfully with conservative interventions including bracing and physical therapy to strengthen the surrounding musculature. Complete tears may cause significant instability in the knee, especially if in combination with other ligament injuries such as the ACL.

If isolated, even high-grade MCL tears can still often be treated with bracing alone. However, such tears often occur in conjunction with other structures such as the medial meniscus or the anterior cruciate ligament (ACL). The medial meniscus has a direct connection to the MCL, making it particularly susceptible to injury during an acute MCL sprain. Should this be the case, surgical intervention may be required to restore full function due to the degree of instability caused by multiple injuries.

Non-operative Treatment

MCL tears are most often treated successfully without surgery. With significant tears there may be an initial degree if instability following injury. A hinged knee brace may be prescribed to limit control of this aberrant movement. As the ligament heals, your orthopedic surgeon may refer you to physical therapy to strengthen the leg musculature surrounding the knee, and also to restore normal movement patterns that may have been disrupted following injury and immobilization. Patients are able to perform most of their normal daily activities during this process, with the possible exception of high intensity athletics, and generally have very good outcomes following four to eight weeks of rehabilitation.

Surgical Treatment

In cases where non-operative treatment has failed or in some multiple ligament injuries, the surgeon will recommend repair or reconstruction surgery. This means that the damaged MCL will be repaired with sutures if possible. If that is not possible, then a new ligament can be fashioned from a soft-tissue “graft,” a piece of tendon taken from either the patient or a cadaver. A small incision is made to gain access to the area, and the repair made, or the tendon graft is anchored in place with surgical screws.

Following surgery, there will be a period of immobilization, followed by physical therapy. The duration and intensity of the rehabilitation process is dependent on the type of MCL repair or reconstruction, and the other injuries present. In most cases, patients can return to full function including athletics at the conclusion of treatment.

Seahawks DE Michael Bennett taken off field on stretcher

On Sunday, September 29, seattlepi.com reported that Seahawks defensive end Michael Bennett, who has been a big story this season as Seattle’s sack leader, was taken off the field Sunday on a stretcher after he was injured on a play against the Texans in Houston. The article reported, “Late in the second quarter, Bennett was rushing Texans quarterback Matt Schaub when he was pushed from behind by a Houston defender into Schaub’s leg. Bennett’s head appeared to snap back, and his helmet flew off as he hit the ground. Bennett laid face-down on the turf for several minutes as trainers tended to him.”

According to the news article, “Bennett suffered a strained muscle in his back that was close to his vertebrae. The location of the injury was why medical personnel were extra-careful and carted Bennett off the field on a stretcher.” Head coach, Pete Carroll said that he was “fine” and a tweet was sent out the next day stating that Bennet was practicing and that he may be able to play in their upcoming game against Indianapolis.

Treatment of a lumbar muscle strain is important to understand. Once you know the cause of your symptoms, you can proceed with treatment. It is important that if you are not sure of the cause of low back pain, that you are evaluated by a physician. According to Dr. Charlie Peterson, “Back injuries can be painful, frustrating and even scary, but are also common. As such, the vast majority can be managed with a few simple techniques. However, if you have unusual symptoms or your pain persists, it’s time to seek advice from a specialist.”

If you are experiencing pain in your lower back or it has been injured as a result of physical activity, below is a list to help you treat your injury:

Step 1: Rest

The first step in the treatment of a lumbar muscle strain is to rest the back. This will allow the inflammation to subside and control the symptoms of muscle spasm. Bed rest should begin soon after injury, but should not continue beyond about 48 hours. While it is important to rest the injured muscles, it is just as important to not allow the muscle to become weak and stiff. Once the acute inflammation has subsided, some simple stretches and exercises should begin.

Step 2: Medications

Two groups of medications are especially helpful in treating the acute symptoms of a lumbar back strain. The first of these are anti-inflammatory medications. These medications help control the inflammation caused by the injury, and also help to reduce pain. There are many anti-inflammatory options, talk to your doctor about what medication is appropriate for you.

The second group of medications commonly prescribed for the treatment of lumbar strains is muscle relaxing medications. Again, there are several options that you may discuss with your doctor. These medications are often sedating, so they need to be used with care. For patients who have back spasm symptoms, these muscle relaxing mediations can be a very useful aspect of treatment.

Step 3: Physical Therapy/Exercises

Proper conditioning is important to both avoid this type of problem and recover from this injury. By stretching and strengthening the back muscles, you will help control the inflammation and better condition the lumbar back muscles. The exercises should not be painful. Without some simple exercises, the low back muscles can become “deconditioned,” or weak. When the low back muscles are “deconditioned”, it is very difficult to fully recover from low back injuries.

It is also important to understand that even if you are “in good shape,” you may have weak low back muscles. When you have a low back muscle injury, you should perform specific exercises that stretch and strengthen the muscles of the low back, hips and abdomen. These exercises are relatively simple, do not require special equipment, and can be performed at home.

Step 4: Further Evaluation

If your symptoms continue to persist despite treatment, it is appropriate to return to your doctor for further evaluation. Other causes of back pain should be considered, and perhaps x-rays or other studies (MRI, CT scan, bone scan, laboratory studies) may be needed to make an accurate diagnosis.

If you believe you are suffering from a back injury and need specialized orthopedic care, Orthopedic Specialists of Seattle has excellent treatment options available for you.