MCL Tears: They all heal..or Do They? ERIK D. PETERSON, MD ORTHOPEDIC SPORTS MEDICINE SURGEON CORE ORTHOPEDICS

MCL Tears: They all heal..or Do They? ERIK D. PETERSON, MD ORTHOPEDIC SPORTS MEDICINE SURGEON CORE ORTHOPEDICS

Incidence Most Commonly Injured Ligament in the knee

Mechanism Valgus applied stress to fixed/planted foot With increasing amounts of axial rotation, combined ligament injuries occur, i.e. ACL

Function Primary restraint to valgus stress at knee joint Primarily in 30+degrees flexion (80%) Extension (50%); ACL, PMC additional Controls External Rotation AMRI

Anatomy Warren Layers Concept

Biomechanics Extrarticular 11 cm length Equal Strength of ACL Majority of Tears at Femoral Insertion: Stress Concentration w/ valgus

Minimal Contribution to Valgus Stability. Rotational control mainly Sectioning study = no increased valgus

Anatomy Deep MCL

Anatomy 5-7 cm distal insertion on tibia Majority of tears at Proximal insertion

Classification AMA Grade 1: 0-5mm Grade 2: 6-9mm Grade 3: 10+mm Hughston Grade 1: no tearing/sprain/no instability Grade 2: partial tearing/no instability Grade 3: high grade/complete tear/varying degrees on instability

Incidence of MCL Tears Roach AJSM 2014 West Point Study InterCollegiate and Intramural sports (all cadets participate) Multi Sport participation not just incidence in a single sport gives truest estimation of athletes risk. N=20 Incidence Rate (IR) 7.3 /1000 person-years (22-25/yr) 0.11 /1000 Athletic exposures 1 of 100 kids every 100 practices or games will tear MCL Grade 1 (73%) Grade 2 (23%) Grade 3 (4%)

Epidemiology Roach AJSM 2014 Men 2.6 times more likely to tear MCL Hockey/Football highest prevalence = Male only at West Point Confounding IR no different when comparing sex participating in same sport i.e. Rugby

Epidemiology Roach AJSM 2014 Highest Risk IR/1000 AE = Wrestling>Judo>Hockey>Rugby Wrestling IR = 0.57 / 1000 AE 1 of 100 kids will tear their MCL every 20 practice/match Intercollegiate 57% higher IR compared w/ Intramural

Demographics Male > Female (Intercollegiate level) Roach AJSM 2014 & Stanley AJSM 2016 Female > Male (High School level) Stanley AJSM 2016 Contact > Non-Contact (opposite of ACL risk) Football, Soccer, Hockey, Basketball Higher Level of Participation increases risk of injury (opposite ACL) Professional/Intercollegiate>High School>Adolescent Roach AJSM 2014

Hershman AJSM 2012 NFL Injury database 2000-2009 FieldTurf vs. Grass Demographics Playing Surface MCL injuries Not statistically increased on Turf vs Grass (p=.68) ACL injuries 67% higher risk on Turf vs Grass (P<.001)

Exam *Valgus Laxity at 30 degrees and Zero degrees = 78% prevalence of combined ACL/MCL injury

Diagnostic Tests Radiographs Beware!! Pelligrini Steida Lesion: Chronic

Diagnostic Tests MRI I have a Low threshold Higher Grade Lesions > MRI use Grade 2/3 associated with increased concomitant knee injury Medial Meniscus ACL 78% of Grade 3 have additional injury (ACL/men) Contra Coup edema

MRI Grade 1 sprain

MRI Grade 2 sprain

MRI Grade 3 sprain

Treatment: Nonoperative RICE Controlled Motion > Immobilization Hinged Brace Weight bearing: initially w/ locked brace NSAIDS: Avoid?? (Warden AJSM 06) Rat study w/ Celebrex 33% reduced load to failure at 2 week Ultrasound: Improved strength, stiffness, energy absorption, cross sectional area at 6 wks (Sparrow AJSM 05) High Success for Complete Healing >98% when tear is femoral insertion of midsubstance

Treatment: Nonoperative ARP wave

Recovery Directly proportional to severity of Injury Average Time Lost 23 days Grade 1 : 13 days Grade 2/3: 29 days Grade 3: D1 college mean 9 wks (Indelicato AJSM 90) Roach AJSM 2014

Prevention Systematic Review We cannot advocate nor discourage the use of prophylactic bracing for prevention of knee injuries based on current levels of evidence JAT Pietrisimone 2008

Prevention Prophylactic Bracing Albright AJSM 2004 Looking specifically at MCL injury risk 1000 Big Ten Football players followed prospectively for one season 50% braced Stratified injury risk based on position Conclusion Consistent, but non statistically significant trend toward < MCL injuries Linemen (offensive and defense) Linebackers Tightends

Surgical Management Indications: Chronic MCL tear-unhealed, unstable Acute Grade 3 MCL w/ concomitant ACL/PCL injury Controversial Early Surgery: repair/reconstruct Delay Surgery, rehab, See if MCL heals Early Surgery: Reconstruct ACL, rehab MCL Grade 4 lesions Millett JKS 04: No difference at Followup Halinen AJSM 06: Prospective ACL +- MCL repair; early surgery: No difference Tibia: Stener equivalent Femur: Intraarticular entrapment Avulsion Fracture of MCL origin

Case Presentation 17 yo HS football player Collision/Valgus stress Immediate medial swelling Excruciating Pain Exam: Superficial Ecchymosis Negative Lachman Stable Varus Valgus 0 degrees: stable Valgus 30 degrees: +3 opening 15mm

MRI

Stener-Like MCL tear Grade 4

Stener Lesion: Skier s thumb UCL

Case Presentation 60 yo woman Painting on step stool Fell to ground with leg twisting underneath her Felt a pop Excruciating Pain Exam: Positive Lachman Stable Varus Valgus 3+ in 0 & 30 degrees

MRI

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