MCL and LCL: Medial Collateral Ligament and Lateral Collateral Ligament
Knee stability is derived primarily from the four major ligaments: the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL).
The Medial Collateral Ligament originates from the medial (inside) aspect of the femur and inserts onto the tibia (shinbone). The lateral collateral ligament (LCL), sometimes called the “fibular collateral ligament”, originates on the lateral aspect of the femur and inserts \on the fibular head (2,5). These ligaments are in charge of limiting valgus and varus motion in the knee.
Which is more common to injure, MCL or LCL?
The MCL is the most commonly injured ligament of the knee (6-8) and accounts for almost 8% of all athletic injuries. (9) The primary mechanism for MCL injury involves application of a sudden outside to inside (valgus) stress such as a direct hit to the lateral knee, while the foot is planted (10). The incidence of MCL injury is higher in football, skiing, ice hockey, wrestling, rugby, and judo (8,11-14).
The LCL is the least commonly injured ligament of the knee (15). The typical mechanism of LCL injury involves the opposite of what caused the MCL injury, which would be an inside to outside stress, which is usually combined with hyperextension of the knee (16).
How are knee ligament injuries graded?
Ligament injuries are traditionally classified as Grade I, Grade II, or Grade III
Grade I- stretch with no visible fiber disruption
Grade II- partial fiber disruption
Unfortunately, significant knee trauma is capable of producing a multi-ligament injury. In fact, a Grade III MCL sprain results in associated ACL disruption in more than 75% of cases (20,21). A combined injury of the MCL, ACL and meniscus is termed an “unhappy triad” or “blown knee”.
What are the symptoms of a collateral ligament sprain?
The typical symptoms of collateral ligament sprain includes pain on the inside or outside aspect of the knee following trauma, i.e. sporting event or vehicular accident (15). Patients will often report hearing a “pop” with pain following. Decreased range of motion is common and attributed to pain and swelling. Increases in activity usually make the pain worse. Trouble walking is possible and not unusual. Some patients feel "weak" or unstable. Clicking is possible, and is generally seem with damage to the meniscus as well.
Do I need X-rays for a MCL or LCL sprain?
The Ottowa knee rule suggests that X-rays be performed in any patient with acute knee injury plus any of the following criteria: age over 55, isolated tenderness of the knee cap or fibular head, inability to flex the knee beyond 90 degrees, inability to bear weight for four steps (31,32).
Advanced imaging of knee sprains is generally unnecessary- as skilled clinical evaluation may detect knee injury with similar sensitivity to MRI (50). Advanced imaging should be reserved for pre-operative planning or investigating suspicions of multiple injuries (mensical tear, etc.) (35,50).
What are the best treatment options for MCL or LCL sprains?
The management of collateral ligament sprains has shifted to a more conservative, non-surgical approach (27,39-46). The rehabilitation of collateral ligament sprain can be divided into three phases.
Phase I of Rehab
The Phase I of treatment seeks to promote optimal conditions for healing- keeping torn fibers close together as well as controlling and limiting motion (especially valgus, varus, or rotational movements that place extra stress on the structures) (45).
Grade II injuries require a hinged brace, and Grade III sprains recommend 1-6 weeks of immobilization to maintain a stable environment for healing. (39,40) . Depending upon the severity of tear, crutches may be necessary until the patient is able to walk normally (40). To encourage cartilage nourishment, it is suggested that those with injuries get rid of crutches as soon as they are able (39).
Like most other types of sprains, the early management of collateral ligament injury involves a RICES protocol: rest, ice, compression, elevation and support (23,40). Controlled early motion may help accelerate collagen synthesis (39). Range of motion exercises should begin in a gentle non-painful pendulum of flexion- extension (39).
How do I know that I have completed Phase I of rehab?
The patient has completed Phase I rehab when they are able to attain full weight bearing with normal gait (39).
Phase II of Rehab
The goal of Phase II includes restoring a full, pain-free range of motion while increasing strength. Research has shown that closed chain kinetic exercises are most appropriate (39,40,47). Early aerobic activity could include a stationary bicycle, elliptical stepper, or water aerobics.
Myofascial release and stretching may be appropriate for the surrounding musculature. The use of IASTM may be appropriate and accelerate healing for Grade I or II ligament sprains (48).
When can I progress to Phase III?
The Final phase of rehabilitation can begin when there is full range of motion with no significant swelling (39).
Phase III of Rehab
The goal of Phase III is to return to functional activity through endurance exercise, proprioceptive training, and functional/agility drills. Straight-line running is allowed when the patient is able to bear weight comfortably. A running program begins with jogging and progresses into sprinting, then narrow S-shaped patterns, and finally sports specific agility drills.
When can I return to activity after an LCL or MCL sprain?
Return to full activity is dependent upon the degree of injury, as well as the location of tear, any other injuries, age, and activity demands (39). Most Grade I and II injuries can return to play within 1-3 weeks, while Grade III injuries require 6 weeks or more to heal (40). A hinged knee brace may be necessary to protect the knee from repeat injury during activity.
What are other treatment options?
Surgery is reserved for knees that are functionally unstable or for patients with persistent pain and/or disability, despite conservative treatments (16,23).
At Creekside Chiropractic & Performance Center, we are highly trained to treat MCL and LCL sprains. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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