MCL tears

The sport of football has long recognized the danger of clipping; that's why the offending team gets hit with a 15-yard penalty. But when the key player who was on the receiving end of the illegal block to the back of the legs ends up on the sidelines for six weeks with a torn medial collateral ligament (MCL), 15 yards seems small consolation.

Though an MCL injury is not as infamous as a tear to the neighboring anterior cruciate ligament (ACL), it is just as much a concern for athletes, particularly football and soccer players. "Any sport where there's potential for direct contact on the outside of the knee is where you're going to see MCL injuries," says Dr. Harlan Selesnick, a member of the Association of Professional Team Physicians (PTP) and team physician of the Miami Heat of the NBA. "The good news is that unlike other knee injuries, MCL tears usually respond very well to non-surgical treatment."

We asked Dr. Selesnick to provide an overview of the injury, including common causes and treatment options.

What is the MCL's function?

Dr. Selesnick: The MCL, the ligament on the inner aspect of the knee, connects the femur, or thigh bone, with the lower leg (tibia). The MCL's main function is as a stabilizer of the inside of the knee.

How is the MCL commonly injured?

Dr. Selesnick: Unlike the anterior cruciate liagment (ACL), which can often be torn in non-contact situations, the MCL is usually injured by direct contact through a force directed to the outside of the knee, called a valgus stress.

A good example of this type of blow is the clip block in football. The impact to the outside of the knee results in a stretch, sprain or tear of the MCL on the inside of the knee. There is a good reason this type of hit is illegal and penalized. MCL sprains also occur in sports where there are a lot of quick stops and turns, such as soccer and basketball.

What are the categories of the injury?

Dr. Selesnick: As with other sprains, MCL injuries are classified into three grades:

Grade I

• Ligaments are stretched and some fibers torn
  
• Minor pain and stiffness

Grade II

• Considerable tearing of ligament fibers but not a complete tear
  
• Major pain and tenderness at the inside of the knee
  
• Swelling in some cases
  
• Some joint instability

Grade III

• Complete tear of ligament
  
• Considerable pain and tenderness at the inside of the knee
  
• Some swelling
  
• Marked joint instability

How do you diagnose the severity of an MCL injury?

Dr. Selesnick: The first thing is to take a complete history to determine the mechanism of the injury -- how the injury occurred, where the impact was, whether it swelled right away, did the individual feel a "pop." The second thing is to determine where the patient is actually tender -- is there soreness over the MCL region or along some other structure of the knee? Then you determine if and where a tear occurred -- from the bone on either the tibia or the femur or perhaps along the ligament itself.

The key ligaments and cartilage of the knee (right knee, frontal view).

There are tests you perform that basically stress the knee by reproducing the force that caused the injury. By diagnosing the degree of instability present, the physician can determine what grade of injury has occurred.

Another diagnostic tool we use is taking a series of stress X-rays, which unfortunately can be painful to the individual. Finally, if there are any questions remaining concerning the extent of the injury, we can use MRI tests, which are quite accurate. One other advantage of the MRI scan is that you can use it to make certain that there were not any other injuries that occurred to the knee that weren't detected in the initial examinations.

In most cases, however, isolated MCL injuries are pretty easy to diagnose. Occasionally, though, MCL sprains do occur with other associated injuries such as an ACL tear, bone contusions, medial meniscus tears and occasional fractures of the tibial area.

How are MCL injuries treated?

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Dr. Selesnick: The good news about MCL injuries is that unlike ACL tears, which are most often repaired through surgery, the MCL has a good blood supply and usually responds very well to non-surgical treatment. Depending upon the grade, a period of rest, bracing and physical therapy is usually sufficient for a complete healing process. The rest period is prescribed to include ice, compression and elevation (RICE), while the brace is designed to allow the knee to move back and forth but not laterally.

After a range of motion is regained and the swelling has diminished, the individual may work on strengthening the muscles of the quadriceps and hamstrings.

What is the prognosis for MCL injuries?

Dr. Selesnick: The more minor sprains, like Grade I injuries, may only keep an athlete out of action for a few days to a week or two. Grade II sprains may take from two to four weeks to heal fully. In Grade III injuries, the athlete should expect to be sidelined from four to eight weeks. Usually, once these injuries heal fully, they do very well with a minimum of long-term effects.

Dr. Harlan Selesnick, a member of the Association of Professional Team Physicians (PTP) and team physician for the Miami Heat since the franchise was founded in 1988, practices orthopedic surgery and sports medicine in Miami. He is an assistant professor in the Department of Orthopaedics and Rehabilitation at the University of Miami and writes the "Jock Doc" Q&A column for the Miami Herald.

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