Rehabilitation of a medial collateRal ligament teaR

the anatomy of a sportex article for new authors
case study mcl tear
[article strap]
[TITLE]
Rehabilitation of a medial
collateral ligament tear:
[SUB TITLE]
By Dan Amin BSc
INTRODUCTION AND THE NATURE OF THE
INJURY
[H1] OR
[Heading 1]
This is a retrospective case study, based on a grade-III tear
of the medial collateral ligament (MCL) of the knee in a semiprofessional footballer. The issues faced by the patient and
the subsequent management plan are highlighted along with
a critical appraisal.
Anatomy
[H2] OR
[Heading 2]
[H3] OR
Heading 3
The MCL is comprised of superficial and deep portions.
The superficial MCL (sMCL) has two tibial attachments:
the proximal, which is attached to the anterior arm of the
semimembranosus tendon (fig.1); and the distal, which is
attached anteriorly to the posteromedial crest of the tibia.
The deep MCL (dMCL) has meniscofemoral and meniscotibial
components (1). The MCL, in particular, the superficial aspect,
is suggested to be the primary knee stabiliser for valgus
laxity in both intact and injured conditions (2). At 25° of knee
flexion, the MCL provides 78% of valgus-restraining force and
at full knee extension it provides 57% of valgus-restraining
force (3).
Result
The MCL is the most commonly injured structure of the
knee in the general population and, in sport an equally high
incidence of MCL injury occurs. MCL injuries are the second
most common knee ligament injuries (29%) and account for
11.3% of all knee injuries sustained in professional soccer (4).
This article presents a case study of the diagnosis,
treatment and rehabilitation of a medial knee injury
sustained by a semi-professional footballer. MCL injuries
are the second most common knee ligament injuries
in the general population and form a very common
class of injuries in professional football. A successful
treatment regime is described, and further suggestions
are made for expanding this protocol to include more
objective measurements of progress, which could lead
to more effective healing.
[ABSTRACT]
©2011 Primal Pictures Ltd
[BYLINE]
MCL ligament
Figure 1: MCL
ligament
(reproduced with
permission from
Primal Pictures)
Aetiology
[H2] OR
[Heading 2]
After 65 minutes of match play in a losing game, four games
into the competitive season, a player stretched for a loose
ball with a near fully extended knee of his non-kicking leg.
Simultaneously, an opponent made an effort to reach the ball
and, in doing so, imparted a valgus and, potentially externalrotation, force to the player’s knee. The cause of the injury
is very similar to many other such cases reported in the
literature, with the most likely, statistically significant (P<0.05),
occurrence of an MCL tear in soccer being a non-contact
injury to the kicking leg of a midfielder, occurring during the
last 15 minutes of a losing match (4).
Biomechanics and potential contributing factors
The majority of MCL tears are isolated, with the mechanism
of injury involving valgus knee loading, external rotation, or a
combined force vector occurring in sports which require knee
www.sportEX.net
[Figure]
+ [IMAGE
FILENAME]
flexion such as soccer (5).
Cadaveric studies have found the MCL to have a yield
point of 534.1N and maximal load of 664.4N at a strain of
50cm/min (Kennedy et al., 1976). These studies have also
found that the distal sMCL was significantly (P<0.05) stronger
than the other medial knee structures with respect to load
and stiffness at failure (534.0-557.1 and 63.1 N, respectively)
(1). The distal sMCL had a significantly (P<0.05) greater load
response to valgus force than the proximal sMCL, particularly
at 60° flexion (103.5 versus 71.9 N, respectively) (6). This is
probably due to the proximal attachment dispersing the load
among the soft tissue it attaches to, in contrast to the distal
[Figure
number:
caption
+ credit]
25
[table
NUMBER:
TABLE
CAPTION]
Table 1: Typical data for professional
midfield players. These figures are
an indication of what to aim for in a
rehabilitation programme (9–12)
[table]
Test
Typical values
VO2max 55-68ml/kg/min
Half-squat 1-RM
2.2kg/kg body weight
CMJ Height
41.6–56.4cm
10m sprint
1.80–1.82s
30m sprint
4.0–4.2s
THE REHABILITATION PROGRAMME
The rehabilitation programme that was designed for the
patient took place over 12 weeks (table 2) and resulted in
the successful outcome with the player returning to the first
team and not suffering further knee injury for the rest of the
season.
Indicates it’s
an online
feature
Video 1: Animation showing the footprint of the ACL (reproduced with permission
from Primal Pictures)
attachment where the tensile force is transferred directly to
the distal tibial bony attachment. The response to an external
rotation force increased in both distal and proximal sMCL as
knee flexion increased from 0° to 60° (2).
Perhaps the patient had a weak semimembranosus
muscle, which seems to play a positive protective role in
the dynamic stability of the medial side of the knee. This
muscle tightens the normally lax posterior oblique ligament
(POL), which acts as secondary stabiliser to both valgus and
external rotation forces.
The athlete on presentation
Forty eight hours post-injury the patient first presented with
valgus laxity of the knee. Pain limited an accurate objective
assessment of how much joint-line gapping was present,
but valgus instability occurred at both 0° and 30° knee
flexion. This suggested a grade III sprain based on Fetto
and Marshall’s classification (7). Lachman’s posterior and
McMurray’s anterior drawer tests were all negative, which
suggested that this was an isolated MCL tear.
The entire knee was swollen and warm, but no noticeable
heamarthrosis was present. Pain on palpation was located
over the joint line and towards the tibial attachment,
suggesting this as the primary point of failure. The femoral
attachment has been found to be the most common site of
failure in the majority of studies, particularly when the knee
is in full extension. However, the tibial insertion has also been
found to be a common failure location.
PROBLEM LIST
Actual
The actual problems encountered and observed with the
patient were the following: general pain; activity-dependent
pain; oedema; valgus laxity through a range of knee flexion;
low confidence; early non-weight bearing status; limited
range, particularly towards full-extension; and diminished
cardiovascular and functional capability.
[video NUMBER:
video CAPTION
+ credit]
Expected
Immediately after the injury the knee is likely to hurt across
its entirety with limitations to flexion. After several hours
heamarthrosis is likely with pain beginning to localise on the
medial knee and a side-to-side feeling of instability. In the
absence of early intervention, catabolic behaviour means
poor quality scar tissue may form, which could cause a
grade III MCL injury to never fully “heal” (5). A history of
ligament injury is a strong risk factor for subsequent injury,
predominantly due to the reparative scar being mechanically
deficient at the completion of healing.
In general, an isolated MCL tear means valgus laxity
in the flexed knee, while injury to secondary stabilisers [ie.
POL or anterior cruciate ligament (ACL)] tends to lead to
increased laxity in the extended knee.Injuries to the individual
components of the MCL also alter the intricate load-sharing
relationships that exist between the medial knee structures,
including the POL (1). ACL load is statistically (P<0.05) higher
in response to valgus or internal rotation torque in a knee
with grade III MCL injury at 0° and 30° knee flexion (8).
Video
embedded
within the
article
sportEX medicine 2011;50(Oct):25-29
26
case study mcl tear
Aggressive early rehabilitation
had good-to-excellent
subjective outcomes
Needs analysis of end-stage rehabilitation
[quote]
Based on the extensive literature available, the following
physiological characteristics are said to be the most pertinent
for a soccer player.
n Aerobic capacity - there is a significant relationship with
team performance, though no difference is seen between
first and reserve team players.
n Anaerobic capacity - high-intensity activities occur every
30s; whereas a maximal, 15m sprint occurs every 90s.
Professional v. amateur soccer players’ 10m sprint times
are significantly different; however, there is no significant
difference in 30m times.
n Lower limb maximal strength - most regular first team
members have higher lower-limb muscle strength, both
concentric and eccentric isokinetic, knee extension and
free-weight squatting and a higher ration of eccentric
hamstring strength relative to concentric quadriceps
strength (Hecc:Qcon).
nP
ower - counter movement jump (CMJ) height and ball
velocity is greater in the elite than in the sub-elite soccer
player.
referencing
Insert the number of the reference in curved
brackets at the appropriate point in your text.
They should appear in sequential order with
the first ref starting at number (1). They should
then appear listed in the same order in the
reference list at the end of the article.
[key point]
[Box number: caption]
+
KEY POINT:
Familiarise yourself
with the muscles of
ambulation and their attachments
- to fully understand their
actions - both concentrically and
eccentrically. A good history and
examination will often help locate
the source of the ankle ‘problem’.
Box 1: Definitions
n Fore-foot - consists of the metatarsals and phalanges
n Mid-foot - consists of the tarsal bones i.e. navicular, cuboid, and three
cuneiforms (see figure 1)
n Rear-foot - consists of the talus and calcaneum
n Supination - is a 3-D (triplanar) combination movement at the subtalar
joint of eversion, abduction and dorsi-flexion – the foot moves down and
towards the centre of the body
n Pronation - is a 3-D (triplanar) combination movement of inversion,
adduction and plantar flexion (i.e. opposite of supination) – the foot moves
up and away from the centre of the body
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JUSTIFICATION, CRITICAL APPRAISAL AND
REFLECTION OF THE MANAGEMENT PLAN
Justification and critical appraisal
Grade III MCL tears are often treated non-operatively with
good clinical results that are similar to operatively repaired
injuries in terms of range of motion, laxity, muscle power,
functional activity and Lysholme score (13).
Surgery may be indicated in chronic MCL injury or if a
major MCL injury is part of a multi-ligamentous knee injury.
However, knee flexion and concentric isokinetic (60°/s)
quadriceps strength was significantly (P<0.05) poorer in
patients who had operative treatment of both ACL and
MCL after a combined injury compared with those who just
had ACL repair, at 52 weeks’ follow-up (13). Considering
the patient had a first-time, isolated MCL grade III tear, it
was deemed sufficient to treat him non-operatively. One
issue, however, is the different grading systems of MCL
injury. Hughston’s definition of a grade III injury is based on
laxity at 30° of knee flexion (14) whereas with Fetto and
Marshall’s definition, grade III injuries are also unstable at
0° (7). The majority of clinically successful non-operative
rehabilitative protocols were not based on Fetto and
Marshall’s more unstable grade III injuries. As such, operative
treatment is often recommended due to the slightly better
results identified regarding reductions in persistent medial
instability, secondary ACL dysfunction, muscle weakness,
and osteoarthritis (1). As laxity was present at 0° flexion
in this case study, the decision to treat the patient purely
conservatively may be questioned.
Attempts to improve ligament healing have included
motion, immobilisation, hyperbaric oxygen, energy application,
the use of a knee brace, and treatment with growth
factors via gene transfer delivery. NSAIDs and low-intensity
ultrasound have also been advocated as they have beneficial
effects on ligament healing in animal models, although results
have proven inconclusive in human studies (15).
Early treatment with protected range-of-motion,
progressive strengthening and weight-bearing regimes has
been shown to produce excellent results, including high
rate of return to sport irrespective of severity (16). Early
mobilisation is an important component of non-operative
treatment, as it improves the longitudinal alignment and
concentration of cells and collagen and thus increases
the ultimate load-bearing of the healing ligament (17), and
reduces laxity and increases the tensile strength of the
healing sMCL in animals. With this in mind, the management
strategy applied in this case study should perhaps have
involved commencing the progressive strengthening protocol
earlier than 2 weeks post-injury. Athletes with isolated grade
III MCL injuries who were treated with aggressive early
rehabilitation had good-to-excellent subjective outcomes at a
5-year follow-up; however, objective tests revealed that 70%
had residual knee laxity (16). This chronic pain and instability
is often an indicator for surgeons to favour treatment (18).
The literature suggests that early progressive resistance
exercises should focus on the adductors as this muscle
group crosses the tibiofemoral joint and provides the
greatest active muscular stability against valgus motion
meaning that there is an increased risk of further injury.
27
Needs analysis of end-stage rehabilitation
Based on the extensive literature available, the following
physiological characteristics are said to be the most
pertinent for a soccer player.
n Aerobic capacity - there is a significant relationship with
team performance, though no difference is seen between
first and reserve team players.
n Anaerobic capacity - high-intensity activities occur every
30s; whereas a maximal, 15m sprint occurs every 90s.
Professional v. amateur soccer players’ 10m sprint times
are significantly different; however, there is no significant
difference in 30m times.
n Lower limb maximal strength - most regular first team
members have higher lower-limb muscle strength, both
concentric and eccentric isokinetic, knee extension and
free-weight squatting and a higher ration of eccentric
hamstring strength relative to concentric quadriceps
strength (Hecc:Qcon).
n Power - counter movement jump (CMJ) height and ball
velocity is greater in the elite than in the sub-elite soccer
player.
JUSTIFICATION, CRITICAL APPRAISAL AND
REFLECTION OF THE MANAGEMENT PLAN
Justification and critical appraisal
Grade III MCL tears are often treated non-operatively with
good clinical results that are similar to operatively repaired
injuries in terms of range of motion, laxity, muscle power,
functional activity and Lysholme score (13).
Surgery may be indicated in chronic MCL injury or if a
major MCL injury is part of a multi-ligamentous knee injury.
However, knee flexion and concentric isokinetic (60°/s)
quadriceps strength was significantly (P<0.05) poorer in
patients who had operative treatment of both ACL and
MCL after a combined injury compared with those who just
had ACL repair, at 52 weeks’ follow-up (13). Considering
the patient had a first-time, isolated MCL grade III tear, it
was deemed sufficient to treat him non-operatively. One
issue, however, is the different grading systems of MCL
injury. Hughston’s definition of a grade III injury is based on
laxity at 30° of knee flexion (14) whereas with Fetto and
Marshall’s definition, grade III injuries are also unstable at
0° (7). The majority of clinically successful non-operative
rehabilitative protocols were not based on Fetto and
Marshall’s more unstable grade III injuries. As such, operative
treatment is often recommended due to the slightly better
results identified regarding reductions in persistent medial
instability, secondary ACL dysfunction, muscle weakness, and
osteoarthritis. As laxity was present at 0° flexion in this case
study, the decision to treat the patient purely conservatively
may be questioned.
Attempts to improve ligament healing have included
motion, immobilisation, hyperbaric oxygen, energy application,
the use of a knee brace, and treatment with growth
factors via gene transfer delivery. NSAIDs and low-intensity
ultrasound have also been advocated as they have beneficial
effects on ligament healing in animal models, although results
have proven inconclusive in human studies (15).
Early treatment with protected range-of-motion,
progressive strengthening and weight-bearing regimes has
28
been shown to produce excellent results, including high
rate of return to sport irrespective of severity (16). Early
mobilisation is an important component of non-operative
treatment, as it improves the longitudinal alignment and
concentration of cells and collagen and thus increases
the ultimate load-bearing of the healing ligament (17), and
reduces laxity and increases the tensile strength of the
healing sMCL in animals. With this in mind, the management
strategy applied in this case study should perhaps have
involved commencing the progressive strengthening protocol
earlier than 2 weeks post-injury. Athletes with isolated grade
III MCL injuries who were treated with aggressive early
rehabilitation had good-to-excellent subjective outcomes at a
5-year follow-up; however, objective tests revealed that 70%
had residual knee laxity (16). This chronic pain and instability
is often an indicator for surgeons to favour operative
treatment (18).
The literature suggests that early progressive resistance
exercises should focus on the adductors as this muscle
group crosses the tibiofemoral joint and provides the
greatest active muscular stability against valgus motion
when in a contractile state (19). Konin (19) also advised
that resistance to adductor contractions should be placed
above the tibiofemoral joint line as this would avoid motion
that applies valgus force; however, with this patient, it was
believed preferable to place the resistance band gradually
more distal as the strengthening protocol progressed in
order to actually increase this valgus strain on the knee.
The isometric nature of the MCL means that it should be
subjected to valgus strains of various forces in order to
enhance its load to failure (1). There is very little literature
pertaining to the loads exerted by resistance bands (eg.
Thera-Band®), so it was felt best to have subjective postactivity pain response as a marker for progression through
activity.
Cross-fibre friction massage has been recommended
as an effective treatment for speeding the healing of the
ligament and for promoting a healthy scar tissue formation,
when performed in an instrument-assisted manner (using
a stainless steel device). Beginning this treatment 1 week
post-injury, three times a week for 3 weeks was found to
significantly (P<0.05) increase tensile strength by 43.1%,
increase stiffness by 39.7% and increase energy before
failure by 57.1% (20).
Reflections on the management plan
The two main limitations of the management plan were the
limited resources available (one piece of low resistance band,
multiple cones and multiple balls) and low contact time with
the case study (5 hours / week).
They would have also provided a more objective method
of measuring progress, in terms of increased volume load
capacity.
sportEX medicine 2011;50(Oct):25-29
case study mcl tear
FURTHER REsources
Engstrom B, Johansson C, Tornquist H. Soccer injuries
among female elite players. American Journal of Sports
Medicine 1991;19:372–375
Feller J. Anterior cruciate ligament rupture: is osteoarthritis
inevitable? British Journal of Sports Medicine
2004;38:383–384
Gray J, Taunton JE, McKenzie DC, et al. A survey of
injuries to the anterior cruciate ligament of the knee in
female basketball players. International Journal of Sports
Medicine 1985;6:314–316
Giza E, Mithofer K, Farrell L, Zarins B, Gill T. Injuries in
women’s professional soccer. British Journal of Sports
Medicine 2005;4:212–216
Griffin LY, Agel J, Albohm MJ, Arendt EA, et al. Noncontact
anterior cruciate ligament injuries: risk factors and prevention
strategies. Journal of the American Academy of
Orthopaedic Surgery 2000;8:141–150
References
1. Wijdicks C, Ewart D, Nuckley D, et al. (2010a). Structural properties
of the primary medial knee ligaments. American Journal of Sports
Medicine 2010;38:1638-1646
2. Griffith C, LaPrade R, Johansen S, et al. Medial knee injury, part 1:
static function of the individual components of the main medial knee
structures. American Journal of Sports Medicine 2009;37:17621770
3. Grood E, Noyes F, Butler D, et al. Ligamentous and capsular
restraints preventing straight medial and lateral laxity in intact human
cadaver knees. Journal of Bone and Joint Surgery (American
edition) 1981;63:1257-1269
4. Rahnama N, Bambaeichi E, Daneshjoo A. The epidemiology of
knee injuries in Iranian male professional soccer players. Sport
Sciences for Health. 2009;5:9-14
5. Wijdicks C, Griffith C, Johansen S, et al. Injuries to the medial
collateral ligament and associated medial structures of the
knee. Journal of Bone and Joint Surgery (American edition)
2010;92:1266-1280
6. Griffith C, Wijdicks C, LaPrade R, et al. Force measurements
on the posterior oblique ligament and superficial medial collateral
ligament proximal and distal divisions to applied loads. American
Journal of Sports Medicine 2009;37:140-148
7. Fetto J, Marshall J. Medial collateral ligament injuries of the knee:
a rationale for treatment. Clinical Orthopaedics and Related
Research 1978;132:206-218
8. Battaglia M, Lenhoff M, Ehteshami J, et al. Medial collateral
ligament injuries and subsequent load on the anterior cruciate
ligament: a biomechanical evaluation in a cadaveric model. American
Journal of Sports Medicine 2009;37:305-311
9. Aagard P, Simonsen E, Trolle M, et al. Specificity of training velocity
and training load on gains in isokinetic knee joint strength. Acta
Physiologica Scandanavica. 1996;156:123-129
10. Wisloff U, Helgerud J, Hoff J. Strength and endurance of elite
soccer players. Medicine & Science in Sports & Exercise
1998;30:462-467
11. Reilly T, Bangsbo J, Franks A. Anthropometric and physiological
predispositions for elite soccer. Journal of Sports Sciences
2000;18:669-683.
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THE AUTHOR
Dan Amin is a lecturer on the BSc (Hons) programme in
Sport, Exercise and Health Sciences at The University Centre,
Doncaster. He graduated in Sports Rehabilitation and Injury
Prevention from Middlesex University in 2007 and is currently
undertaking a part-time MSc in Sport Injury Rehabilitation at The
University of Salford. Dan has just returned from Romania where, as a
guest lecturer, he delivered a week of seminars in “Functional Screening
as a Method of Injury prevention” at the National University for Physical
Education and Sport in Bucharest. In addition to his lecturing role, Dan
worked as the rehabilitator for Ilkeston Town Football Club from 20072009.
reference list Numbered corresponding to the numbers in the text and
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author
biography
maximum
100 words
with photo
PAtient
advice
If your article
could be
accompanied
by a rehab
programme or
an information
leaflet - we’d
love it even
more!
Rehab leaflets
require no
more than
8 exercises
(usually a mix
of stretch/
strength) with
an exercise
title, short
description
& reps/sets
suggestions (we
find the pictures
but stick men
are a useful aid).
Info leaflets
can be just
text based and
sometimes
suit the topic
matter better.
The should
be about 700
words in length
and pitched
at the patient
rather than the
practitioner.
Exercises for
MCL
rehabilitation
stretching and Strengthening exercises
Adductor strengthening
with ball in supine
Sit on a chair, place a towel or ball
between your thighs, tighten your
buttocks and squeeze your thigh
muscles together. Hold this position for
10 seconds before relaxing.
Mini squats
Begin with small squats on both legs.
Squat to 45o if there is no pain
(otherwise try reducing the depth of the
squat until you can perform it without
pain).. If this is easy then progress to
holding weights or wearing a rucksuck
containing weight.
SetsReps
3
10
static quadriceps flexion
with heel lift
Contract the muscles on the front of
your thigh so that your heel raises off
the floor (you could put a rolled up towel
under your knee to help). Hold for 5
seconds, relax and then repeat.
SetsReps
SetsReps
3
10
controlled knee flexion
Sit on the floor with your knee straight,
slowly bend the affected knee (by sliding
the foot up to your buttocks) as much
as you can. When you feel a stretch in
the thigh muscle hold the
position for 10 seconds and then
straighten.
1
ADDUCTOR STRENGTHENING
IN SIDE LYING
Lie on your side with your head
supported by your hand. Place your top
leg forwards so your hip and knee are at
90o. Then keeping the bottom leg
straight, raise it upwards towards the
ceiling and hold for 5 seconds.
SetsReps
3
SetsReps
5-8
prone knee flexion
Lie on your front and bend your knee,
bringing your heel towards your buttocks
as far as it’s comfortable for you. Then
lower your leg and foot back to the floor.
Both movements should be slow and
controlled.
10
10
Quadriceps strengthening
– sit to stand
Sit on a chair or higher block if a chair is
too low, and slowly stand up without
using your arms to push off. When you
are standing up, return slowly to the
sitting position again without using your
arms. Repeat this movement 5-10 times
as long as it doesn’t
SetsReps
cause pain.
3
10-15
SetsReps
3
3
10
Adductor strengthening
with ball in supine
Lie on your back with your feet flat on
the floor and your knees bent. Hold a
ball or towel between your knees.
Tighten your buttock muscles and
keeping the ball in position lift your
buttocks off the floor. Hold for 5 seconds
before returning slowly
to the starting position. SetsReps
3
10
The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as
a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors accept no liability for any loss, injury or
damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article.
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