[ CLINICAL COMMENTARY ]

ROBERT F. LAPRADE, MD, PhD1 • COEN A. WIJDICKS, PhD2

The Management of to the Medial Side of the

he incidence of the superficial medial collateral of valgus loading and external rotation (MCL) and other medial knee stabilizers (the deep MCL and that occurs in such sports as skiing, ice the posterior oblique ligament) has been reported to be 0.24 per hockey, and soccer, which require knee flexion.17,20,25 The vast majority of grade 19 1000 people in the United States in any given year and to be III (complete tear) T 19 twice as high in males (0.36) compared to females (0.18). The majority do heal; however, some do not, which can of medial knee ligament tears are isolated injuries, a!ecting only the lead to chronic instability and functional limitations. medial stabilizers of the knee. These ties. The mechanism of injury typically Much of the information about the injuries occur predominantly in young involves valgus knee loading, tibial exter- , diagnosis, and treatment of individuals participating in sport activi- nal rotation, or a combined force vector medial knee injuries is historical. More recently, it has been recognized that there is more to the medial knee structures SYNOPSIS: Injuries to the medial side of the performed at 30° and 90° of flexion, is important ! than just the medial collateral ligament. knee are the most common knee ligament injuries. because it evaluates for rotational abnormalities. The majority of injuries occur in young athletes Valgus stress radiographs are useful to objectively There are several important individual during sporting events, with the usual mechanism determine the amount of medial compartment structures that provide medial knee sta- involving a valgus contact, tibial external rotation, gapping and to discern whether there is medial bility, which, when injured, can result in or a combined valgus and external rotation force or lateral compartment gapping when a medial functional limitations. Recent anatomic delivered to the knee. Although most complete or posterolateral corner knee injury cannot be studies defining the attachment sites of grade III medial knee injuries heal, some do di"erentiated, especially with a chronic injury. The these structures have led to further ad- not, which can lead to continued instability. For majority of acute grade III medial knee injuries will these patients, a thorough understanding of the heal after a nonoperative rehabilitation program. In vancements in the understanding of presenting history and a physical examination are most instances when there is a knee dislocation or clinically relevant and di- important because these injuries can often be con- multiligament injury, a primary repair with sutures agnostic techniques.4,7,8,14,27 Furthermore, fused with posterolateral corner injuries. The main may be indicated. In severe midsubstance injuries these studies have helped to develop new anatomic structures of the medial side of the knee or chronic medial knee injuries, an anatomic anatomic reconstruction techniques.4 are the superficial medial collateral ligament, deep medial knee reconstruction with grafts may be in- Overall, increased knowledge of these medial collateral ligament, and posterior oblique dicated. Rehabilitation principles for acute medial ligament. In addition, accurately locating 3 bony knee injuries involve controlling edema, regaining areas has led to a more functional reha- prominences over the medial aspect of the knee— range of motion, and avoiding any significant bilitation program, resulting in improved the adductor tubercle, gastrocnemius tubercle, stress on the healing . A well-guided patient outcomes. The following clinical and medial epicondyle—is important to conduct rehabilitation program can result in excellent a proper physical examination and for surgical commentary reviews recent updates re- functional outcomes in the majority of patients. repairs and reconstructions. Clinical diagnosis of garding medial knee anatomy, clinically J Orthop Sports Phys Ther 2012;42(3):221-233. medial knee injuries is primarily performed via the relevant biomechanics, improved diag- doi:10.2519/jospt.2012.3624 application of a valgus stress in full extension and nostic techniques, treatment of medial KEY WORDS: MCL, medial collateral ligament, at 30° of knee flexion. In addition, an examination ! knee injuries, and nonsurgical and sur- of the amount of anteromedial tibial rotation is posterior oblique ligament, rehabilitation, , performed at 90° of flexion, while the dial test, valgus injury gical rehabilitation principles for medial knee injuries.

1Chief Medical Research O!cer, Steadman Philippon Research Institute, Vail, CO; Complex Knee Surgeon, The Steadman Clinic, Vail, CO. 2Director and Senior Sta" Scientist, Biomechanics Research Department, Steadman Philippon Research Institute, Vail, CO. This work was supported by the Research Council of Norway (grant 175047/D15) and Health East Norway (grant 10703604). Address correspondence to Dr Robert F. LaPrade, Chief Medical Research O!cer, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657. E-mail: [email protected]

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superficial MCL is within the confines of the pes anserine bursa.

Deep MCL The deep MCL is not a distinct structure but rather a thickening of the cap- sule deep to the superficial MCL.14 Its at- tachment site on the is just over 1 cm distal to that of the superficial MCL. The deep MCL courses distally to attach to the and then contin- ues to its tibial attachment site, approxi- mately 3 to 4 mm distal to the joint line. Due to its stout meniscal attachment, it has 2 distinct functional units, the me- niscofemoral and meniscotibial divisions (FIGURE 3).

Posterior Oblique Ligament The posterior oblique ligament is one of the most misunderstood structures of the FIGURE 1. Photograph of a left knee, demonstrating the ME, AT, and GT. The attachments of the AMT and the MGT medial aspect of the knee. In the older have been peeled back, while the superficial medial collateral ligament has been removed to demonstrate the deep MCL. Abbreviations: AMT, adductor magnus tendon; AT, adductor tubercle; GT, gastrocnemius tubercle; MCL, literature, it was often called the oblique medial collateral ligament; ME, medial epicondyle; MGT, medial gastrocnemius tendon. portion of the superficial MCL. It has been noted to have several components, ANATOMY OF THE MEDIAL Superficial MCL the most important of which is the central ASPECT OF THE KNEE The superficial MCL is the largest and arm,8,14 which is the largest and thickest most important structure on the medial portion of the posterior oblique ligament. Bony Landmarks aspect of the knee. It has 1 attachment The central arm is a fibrous extension o! here are 3 separate bony promi- on the femur and 2 attachments on the the distal aspect of the semimembrano- nences over the medial aspect of .14 The 2 tibial attachments divide sus tendon that blends with and rein- Tthe knee. It is important to recog- the superficial MCL into 2 functionally forces the posteromedial joint capsule nize the locations of these structures to di!erent sections.7,8 It is important to (FIGURE 4). Thus, the posterior oblique define the region of anatomic injury and recognize these attachment sites because ligament is not a separate structure but surgically repair the knee (FIGURE 1). The injuries to di!erent sections of the super- rather a thickening of the posteromedial medial epicondyle is the most distal and ficial MCL can result in valgus, external joint capsule, which extends from the anterior of these 3 bony landmarks. The rotation, or anteromedial rotatory insta- semimembranosus tendon to its femoral superficial MCL attaches slightly proxi- bility (FIGURE 2). attachment, located slightly distal and mal and posterior to this bony promi- The femoral attachment site of the anterior to the gastrocnemius tubercle nence. The adductor tubercle is the most superficial MCL is slightly proximal and on the posteromedial aspect of the femur. proximal of the 3 bony landmarks. It is posterior to the medial epicondyle. It is located just distal to the attachment of important to recognize that it does not Adductor Magnus Tendon the adductor mangus tendon and par- attach directly to the medial epicondyle. The adductor magnus tendon attachment allel to the medial epicondyle along the The superficial MCL then courses distally site on the femur is an important surgical femoral diaphysis. The gastrocnemius to its proximal tibial attachment, located landmark because the tendon is not fre- tubercle is the furthest posterior of the just over 1 cm distal to the joint line, and quently injured, and its attachment site 3 bony landmarks and can be the most is primarily connected to soft tissues. can serve as a reference for identifying prominent. The medial gastrocnemius The more distal tibial attachment, which the femoral attachment sites of the pos- tendon is located slightly proximal to the is located approximately 6 cm distal to terior oblique ligament and superficial gastrocnemius tubercle, while the poste- the joint line, is attached directly to bone MCL. The adductor magnus tendon does rior oblique ligament is located slightly and is the stronger attachment site of the not attach directly to the adductor tuber- distal and posterior to the tubercle. two. Most of the distal attachment of the cle but rather to a small bony depression

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/D3UDGHLQGG 30 approximately 3 mm posterior and 2.7 mm proximal to the adductor tubercle.14

Medial Gastrocnemius Tendon The femoral attachment site of the me- dial gastrocnemius tendon is another important landmark to identify on the medial aspect of the knee. The tendon forms at the medial edge of the medial belly,14 and then attaches slightly proximal and posterior to a bony depression adjacent to the gas- trocnemius tubercle. Thus, the attach- ment site of the medial gastrocnemius tendon is useful to identify the gastrocne- mius tubercle as well as the attachment of the posterior oblique ligament, especially when there is a chronic injury or previous surgery, which can obliterate the normal anatomic landmarks in this area. CLINICALLY RELEVANT BIOMECHANICS OF MEDIAL KNEE INJURIES FIGURE 2. Photograph of a left knee demonstrating the course of the superficial medial collateral ligament. t is important to understand me- Abbreviations: ME, medial epicondyle; SM, semimembranosus tendon; sMCL, superficial medial collateral dial knee biomechanics to correctly ligament. Iinterpret the motion instabilities as- sociated with medial knee injuries. In the deep MCL).7,24 vide internal rotational stability to the addition, understanding abnormal mo- Static-cutting studies have also dem- knee. The posterior oblique ligament is tion during knee examination will help onstrated that the medial knee structures important at all knee flexion angles, but to identify injured structures. are important to provide external rota- especially in full knee extension.8 The me- Static cutting studies of the individ- tional stability to the knee.27 This is clini- niscofemoral division of the deep MCL ual components of the primary medial cally important because it is commonly and the distal division of the superficial knee structures have revealed an impor- believed that patients with increased ex- MCL are also important internal rotation tant and intricate relationship between ternal rotation have posterolateral cor- stabilizers.8 The proximal division of the the medial knee structures and applied ner injuries; however, these studies have superficial MCL and the meniscotibial di- loads.27 In addition, it has been demon- revealed that there can be just as much vision of the deep MCL also are second- strated that the superficial MCL has 2 external rotational instability in a medial ary internal rotation stabilizers. important functional components.8 The knee structure injury as there can be in a In addition to the important static more proximal division, coursing from posterolateral corner injury.27 The prima- stabilizing function of the medial knee the femur to the proximal tibial attach- ry medial knee stabilizer during external structures, a study that applied buckle ment site, is important for valgus stabil- rotation at 30° of knee flexion is the distal transducers to these structures revealed ity, while the more distal division, with division of the superficial MCL. Second- an important load-sharing distribution attachment sites over the tibia, is more ary external rotation stabilizers, which between the superficial MCL and pos- important for external rotational stabil- are activated when the distal division of terior oblique ligament (FIGURE 5).8 This ity.7,24,27 While the superficial MCL serves the superficial MCL is injured, comprise study demonstrated that the superfi- as the primary static stabilizer, there are the proximal portion of the superficial cial MCL has the largest load response other important structures that provide MCL, the meniscofemoral division of to applied valgus and external rotation secondary valgus stability when the su- the deep MCL, and the posterior oblique torques, while the posterior oblique liga- perficial MCL is injured (eg, the menis- ligament.7,24,27 ment experiences the greatest load when cofemoral and meniscotibial divisions of The medial knee structures also pro- an internal rotation torque is applied

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near full knee extension. The results of these quantitative, anatomic, and clinically relevant biome- chanical studies were used to develop an anatomic medial knee reconstruc- tion technique that reconstructs the 2 divisions of the superficial MCL and the posterior oblique ligament.4 Data from sectioning studies with buckle transduc- ers attached to the reconstruction grafts indicate that anatomic reconstruction re- stores native stability to the medial knee and does not result in overconstraint, which could lead to overloading of the grafts and their eventual failure. The data also demonstrate that the normal load- sharing relationships among the medial knee structures were restored with this reconstruction technique (FIGURE 6).4 DIAGNOSIS OF MEDIAL FIGURE 3. Photograph of the deep medial collateral ligament of a left knee. The superficial medial collateral KNEE INJURIES ligament and the joint capsule anterior and posterior to the deep medial collateral ligament have been removed. The hemostat (bottom) is deep to the meniscofemoral portion of the deep medial collateral ligament, while the History forceps (top) is holding the meniscotibial portion of the deep medial collateral ligament. Abbreviations: MM, lmost all patients with medial medial meniscus; SM, semimembranosus tendon (anterior arm). knee injuries present with a history Aof having sustained a contact or with localized pain along the medial knee Clinical Examination noncontact valgus stress to the knee. Lo- structures and no significant medial com- Physical examination of acute medial calized pain and swelling along the me- partment gapping. An isolated grade II knee injuries can be very accurate at niscofemoral or meniscotibial division of medial knee injury also presents with lo- identifying the location and grade of in- the medial knee structures are sometimes calized pain along the medial knee struc- stability. Conversely, the examination of reported. For athletes with grade III me- tures, but also demonstrates significant chronic medial knee injuries can often be dial knee injuries, subjective complaints gapping with a definite end point pres- clinically challenging and requires more of side-to-side instability can often be ent. A grade III, or complete, medial knee objective means of measuring instabil- ascertained from their medical histories. injury is present when there is no defined ity, such as stress radiographs. As part end point after application of a valgus of the initial examination, inspection of Classification stress at 20° of knee flexion. Historically, the knee for any signs of abrasions, lac- The classification of medial knee inju- the gap sizes corresponding with grade I, erations, contusions, or localized edema ries is primarily based on the amount of II, and III injuries have been reported to should be performed.14 In addition, pal- medial compartment gapping present be 0 to 5 mm, 6 to 10 mm, and greater pation of the meniscofemoral and me- with an applied valgus stress during the than 10 mm, respectively, compared to niscotibial divisions of the medial knee clinical examination or a valgus stress the uninjured contralateral knee.1,10,15,21,22 structures along their entire lengths can radiograph, performed or taken at 20° However, it is important to recognize also be very useful to identify the injury of knee flexion. The American Medical that studies published after the Ameri- location. This is important because dif- Association’s grading scale is most com- can Medical Association guidelines were ferences in healing potential between me- monly utilized to classify the severity of initially proposed have demonstrated niscofemoral and meniscotibial medial injuries.3 It is important to recognize that that the actual amounts of medial com- knee injuries have been reported.6 this is a subjective grading scale based on partment gaps corresponding to grade I, Valgus stress loads applied to the knee the perceived amount of gapping that oc- II, and III injuries, when measured ob- at full extension or at 20° of knee flexion curs when a clinician performs a valgus jectively against the contralateral knee, can help estimate the amount of medial stress maneuver on the patient. are much smaller than the historically compartment gapping (FIGURE 7). For an In general, a grade I tear presents accepted values quoted above (TABLE). isolated grade III medial knee injury, a

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/D3UDGHLQGG 30 both 30° and 90° of knee flexion to evalu- ate suspected medial knee injuries (FIG- URE 8).7,9 In the past, a positive dial test was reported to be pathognomonic of a posterolateral corner injury, but biome- chanical testing has demonstrated that a positive dial test can also be present at both 30° and 90° of knee flexion in an isolated medial knee injury.7 Thus it is important to examine these patients both in the supine and prone positions when performing the dial test to deter- mine whether the amount of external rotation is due to anteromedial or pos- terolateral tibial rotation. When the dial test is performed in the prone position, it can more accurately allow for objective visualization of the amount of increased side-to-side external rotation; however, and visualization of actual tib- ial subluxation must be performed in the supine position.

Radiographic Diagnosis Valgus stress radiographs are very useful to objectively identify a medial knee in- jury. These radiographs are usually per- formed at 20° of knee flexion with a foam bolster under the knee, and a comparison is made between the amounts of medial FIGURE 4. Photograph of a right knee demonstrating the central arm of the posterior oblique ligament. compartment gapping in the injured and Abbreviations: AMT, adductor magnus tendon; MGT, medial gastrocnemius tendon; POL, posterior oblique FIGURE 9 ligament; SM, semimembranosus tendon; sMCL, superficial medial collateral ligament. uninjured contralateral knee ( ). It has been reported that a grade III injury to valgus stress test performed with the knee medial rotation in a medial knee injury the superficial MCL results in 3.2 mm of at full extension should demonstrate only is also important to determine whether increased medial compartment gapping at 1 to 2 mm of increased medial compart- the injury primarily a!ects the superfi- 20° of knee flexion.13 Complete sectioning ment gapping compared to the contralat- cial MCL or the posterior oblique liga- of the superficial MCL, posterior oblique eral side; more gapping would indicate ment and deep MCL. The anteromedial ligament, and deep MCL resulted in 9.8 a combined cruciate ligament injury.7 drawer test is performed with the knee mm of increased medial compartment Increased valgus gapping in extension flexed approximately 80° to 90° and the gapping at 20° of knee flexion.13 Thus, is usually an indication of a more severe foot externally rotated 10° to 15°. A cou- valgus stress radiographs can be a valu- combined medial knee and cruciate liga- pled anterior and external rotatory force able adjunct to the clinical examination ment injury. Assessment of the amount is applied to the knee, and the amount of by quantifying the amount of medial com- of medial compartment gapping at 20° of anteromedial tibial rotation is assessed. partment gapping in a medial knee injury knee flexion predominantly isolates the It is important to visually assess the and, when the diagnosis is in doubt, deter- superficial MCL, with the roles of the cru- amount of anteromedial tibial rotation, mining whether the side-to-side gapping ciate ligaments, deep MCL, and posterior rather than posterolateral tibial rotation, present in a chronic knee injury is due to oblique ligament being less important. because the amount of external tibial ro- either a medial or posterolateral injury. Feeling for an end point during this test tation that occurs is very similar to that Magnetic resonance imaging (MRI) is important to di!erentiate between a demonstrated during a positive postero- is also useful to diagnose injuries to the partial and complete medial knee injury.7 lateral drawer test. medial knee structures and demonstrate Assessment of the amount of antero- The dial test should be performed at the location of damaged structures. Coro-

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120 ‡ compartment when the medial ligamen- ‡ ‡ * tous structures tear, were present in 45% ‡ of isolated medial knee injuries.18 100 † †

†

lgus Moment Diagnostic Challenges of Medial †

Va ‡ 80 Knee Injuries Although acute medial knee injuries do † not pose a significant diagnostic chal- Nm Applied 60 10 lenge due to the localized pain that oc- th

Wi curs, it is not uncommon for chronic

40 medial knee injuries to masquerade as posterolateral corner injuries. It can be

esponse (N) di!cult, on clinical examination, to dif-

ad R 20 ferentiate between an increase in me- Lo dial or lateral compartment gapping when one assesses the toggle, which can 0 0 20 30 60 90 be seen in a chronic medial knee injury when performing valgus and varus stress Knee Flexion Angle, deg tests at 20° of knee flexion. Comparing the side-to-side di"erences between the POL Proximal sMCL Distal sMCL injured knee and uninjured contralateral knee on valgus and varus stress tests can FIGURE 5. Forces measured for the posterior oblique ligament (POL) and the proximal and distal superficial medial collateral ligament (sMCL) divisions during application of a 10-Nm valgus load. Statistically significant di!erences help determine whether the di"erence in between structures are indicated. *P<.05, †P<.001, ‡P<.0001. Error bars indicate the standard error of the mean. gapping is in the medial or lateral com- Reprinted with permission from Gri"th et al.8 partment. When the results of the physi- cal examination are in doubt, which is not uncommon with chronic medial knee injuries, bilateral valgus and varus stress radiographs can be obtained to objective- ly determine whether a chronic medial or posterolateral corner injury exists. This is an important concept to understand. Because of the general belief that most medial knee injuries heal over time, cli- nicians may fail to consider the possibil- ity of a chronic medial knee injury and misinterpret abnormal motion to be due to a chronic posterolateral knee injury. Because medial knee injuries comprise the largest number of total knee ligament injuries, the number of injuries that do not heal can still result in a significant FIGURE 6. Illustration of a medial knee reconstruction procedure demonstrating the reconstructed superficial number of patients with chronic insta- medial collateral ligament (sMCL) and posterior oblique ligament (POL) using 2 separate grafts with 4 bility and ongoing functional limitations. reconstruction tunnels. Note that the proximal tibial attachment point of the sMCL, which is primarily attached to In addition to the di!culty in dis- soft tissues and located just distal to the joint line, was re-created by suturing the sMCL graft to the anterior arm of cerning whether a side-to-side toggle the (medial view, left knee). Reprinted with permission from Coobs et al.4 observed during valgus and varus stress tests is due to a medial or lateral knee nal MRI sequences are especially useful to have an accuracy of 87%.28 In addition, injury, chronic medial knee injuries also in assessing acute medial knee injuries it has been reported that lateral compart- present with increased external rotation, (FIGURE 10). The diagnosis of medial knee ment bone bruises, due to either the im- which is often interpreted as evidence of injuries via MRI scans has been reported pact or the stress placed on the lateral a posterolateral corner injury. It is not

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/D3UDGHLQGG 30 TABLE Grading Scales for Medial Knee Injuries

Classification Definition Grade I Tenderness, no instability Grade II Broad tenderness, partially torn medial knee structures Grade III Complete medial knee disruption, no end point to an applied valgus stress at 20° of knee flexion Radiographic stress classification Isolated complete sMCL tear >1.7 mm of gapping at 0° of knee flexion; >3.2 mm of gapping at 20° of knee flexion Complete tear of medial knee structures >6.5 mm of gapping at 0° of knee flexion; >9.8 mm of gapping at 20° (sMCL, POL, dMCL) of knee flexion Abbreviations: dMCL, deep medial collateral ligament; POL, posterior oblique ligament; sMCL, super- ficial medial collateral ligament

uncommon in the senior author’s (R.F.L.) Although several di!erent knee rehabili- practice to treat patients who have a tation protocols have been proposed to chronic medial knee injury and were re- treat isolated, acute medial knee injuries, ferred because of suspicion of a chronic all of them generally have the same satis- posterolateral corner injury. Thus, it is factory outcome.2,11,12,16,23 A rehabilitation important to assess di!erences between program focusing on the above goals via anteromedial and posterolateral rota- the use of a stationary bike and other ex- tion on anteromedial and posterolateral ercises that do not involve side-to-side drawer tests. In addition, the dial test at activities results in healing of grade III both 30° and 90° of knee flexion must be medial injuries in the majority of cir- correctly interpreted to distinguish be- cumstances. In general, most athletes tween a posterolateral corner injury and can return to full competition, following FIGURE 7. Photograph of a valgus stress being a chronic medial knee injury. a well-guided rehabilitation program, 5 applied to the right knee at 20° of knee flexion. The tester’s fingers are placed directly over the joint line to 7 weeks after injury on average.26 to measure the amount of medial compartment TREATMENT OF GRADE III When a grade III medial knee injury is gapping, while a coupled valgus force is applied to MEDIAL KNEE INJURIES combined with an ACL tear, the general the knee at the foot and ankle. protocol is to rehabilitate the medial knee Nonoperative Treatment injury first, allowing it to heal according he decision regarding how to to the guidelines for isolated medial knee treat acute grade III medial knee injuries, and then to reconstruct the ACL Tinjuries depends on whether the in- 5 to 7 weeks after injury, once there is jury is isolated or combined with other good clinical and/or objective evidence knee ligament injuries. When there is a of healing of the medial knee injury.26 combined medial knee injury and anteri- There is currently no consensus re- or cruciate ligament (ACL) injury, there is garding whether a hinged knee brace is a di!erent treatment algorithm than that necessary to treat grade III medial knee for medial knee injuries combined with injuries. In general, it is believed that FIGURE 8. Patient with an isolated, chronic grade III posterior cruciate ligament or other knee meniscofemoral medial knee injuries medial knee injury to the right knee. A positive dial test at 90° of knee flexion is seen for the right knee. ligament injuries. diagnosed clinically and/or from MRI For isolated, acute grade III medial scans have a high likelihood of healing,5,6 knee injuries, nonoperative treatments and not all sports medicine centers treat tients with a grade III meniscotibial me- are typically recommended. Rehabilita- these injuries with a hinged knee brace. dial knee injury with a hinged knee brace. tion programs focus on restoring quad- However, meniscotibial lesions do have Typically, the protocol involves using the riceps function, improving knee range of a higher reported incidence of healing,6 brace during the early phases of rehabili- motion, and controlling knee edema.26 and the majority of centers will treat pa- tation, then either continuing to use the

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FIGURE 9. Preoperative (A) and postoperative (B) valgus stress radiographs (left knee).

brace through the ongoing competitive important for patients with chronic me- season or discontinuing use 8 to 12 weeks dial knee injuries to assess their weight- FIGURE 10. Proton-density-weighted magnetic after injury. bearing frontal plane knee alignment. For resonance imaging coronal view demonstrating an patients who have a valgus alignment, a avulsion fracture of the femoral attachment of the superficial medial collateral ligament (sMCL) and Operative Treatment first-stage osteotomy with a concurrent meniscofemoral portion of the deep medial collateral The indications for operative treatment distal femoral osteotomy is indicated to ligament (dMCL, right knee). are di!erent for acute and chronic grade shift the weight-bearing axis to the cen- III medial knee injuries. In an acute in- ter of the knee (FIGURE 11), because it is biomechanically validated and found to jury, surgery is often indicated with mul- believed that any graft would restore the native distribution of forces to tiligament injuries or knee dislocations have a greater risk of stretching out if the applied loads on the reconstructed liga- involving the MCL. In such circumstanc- alignment was not corrected first. For ments.4 In this technique, the superficial es, direct repair of the injured structures those who undergo a distal femoral os- MCL reconstruction graft is fixed into with sutures, augmentation of the repair teotomy first (usually cases with chronic a femoral-based tunnel at the anatomic with a graft, or acute recon- multiligament injuries), it is important to attachment site of the superficial MCL, struction with an autograft or allograft rehabilitate patients for several months and is then fixed distally in a closed- replacement of the superficial MCL and after the osteotomy heals to verify socket tibial tunnel approximately 6 cm posterior oblique ligament may be indi- whether they are still having functional distal to the tibial joint line. This is the cated. In these surgical circumstances, limitations. In patients whose osteotomy location of the native attachment site of there is a greater risk of patients devel- has healed and who still have functional the superficial MCL on the distal tibia. oping arthrofibrosis or heterotopic bone limitations after rehabilitation, or in pa- In addition, a suture anchor is placed at formation, known as Pellegrini-Stieda tients who have a genu varus or neutral the proximal tibial attachment site of the disease. Consequently, postoperative alignment, surgical reconstruction is in- superficial MCL to replicate the anatomy rehabilitation principles should be fol- dicated. Direct suture repairs of chronic and strength of the normal soft tissue lowed within the guidelines of the “safe medial knee injuries are generally not proximal tibial attachment of the super- zone,” the range of motion that is intra- recommended because of a higher risk ficial MCL. The posterior oblique liga- operatively measured by the surgeon of having these repairs stretch out over ment is reconstructed using a graft that and during which knee motion can be time. The goals of a postoperative reha- is fixed into femoral and tibial tunnels achieved with no significant tension on bilitation program in chronic cases are made at the anatomic attachment sites the repaired structures. This safe zone similar to those for acute cases, in that an of the original structure. Because the of postoperative knee motion will vary early range-of-motion protocol to prevent posterior oblique ligament is tightest in between patients, and it is important for postsurgical arthrofibrosis is indicated. extension, the graft is tightened with the this information to be communicated to Our preferred technique for the treat- knee extended and in neutral rotation. all members of the healthcare team. ment of severe acute or chronic medial The superficial MCL graft is tightened at In patients who present with chronic knee injuries is a reconstruction of both 20° of knee flexion and with the knee in grade III medial knee injuries, surgery divisions of the superficial MCL and the neutral rotation. An early range-of-mo- is indicated for patients who have com- posterior oblique ligament. Two separate tion and quadriceps reactivation program plaints of rotatory instability and/or con- grafts with 4 separate graft tunnels are is recommended with this reconstruction current side-to-side instability. It is also utilized in this technique, which has been technique.

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/D3UDGHLQGG 30 to ride a stationary bike to improve range are encouraged. The initial postoperative of motion. It is believed that the range- protocol encourages edema control via of-motion exercise a patient achieves on compression and cryotherapy, as well as a stationary bike is similar to the heal- reactivation of the quadriceps. Patients ing stimulus that has been found in ani- are non–weight bearing to touch-down mals with the use of a constant passive weight bearing for the first 6 weeks af- motion device, resulting in accelerated ter surgery. For the first 2 weeks after the healing of grade III MCL injuries. Ath- reconstruction, gentle, passive range-of- letes are required to work on a range-of- motion exercises are performed within motion program on a stationary bike as the limits of what the patient can toler- soon as they can tolerate it. The amount ate. Ideally, the goal is to achieve 90° of time and e!ort on the stationary bike of knee flexion 2 weeks after surgery to is increased as tolerated. In general, one minimize the development of adhesions. should avoid applying any significant Quadriceps setting exercises, straight leg stresses to the healing structures during raises in a knee brace, and hip extension the clinical examination and side-to-side and abduction exercises are encouraged activities until 3 to 4 weeks after injury immediately after surgery (APPENDIX B). to ensure that the grade III medial knee Two weeks after surgery, range of mo- injury can heal properly.26 Once the clini- tion is increased as tolerated. The goal is cal examination demonstrates healing, to have the patient achieve at least 130° of balance and proprioceptive activities can knee flexion 6 weeks after surgery. After 6 commence. The general goal is to have weeks of protected weight bearing, closed- an athlete return to full activities or have kinetic-chain exercises are permitted for healed the medial knee injury su"ciently functional rehabilitation. The use of a to proceed with an ACL reconstruction stationary bike with light resistance is en- 26 FIGURE 11. Anteroposterior radiograph of the left within 5 to 7 weeks after injury. Obvi- couraged, and resistance is increased over knee 4 months after concurrent distal femoral ously, every patient is di!erent, and the time as tolerated. Double-leg presses to a osteotomy, medial knee reconstruction, double- application of these principles should maximum of 70° of knee flexion are also bundle posterior cruciate ligament reconstruction, be guided by the goals of restoring full performed, with flexion past 70° discour- and endoscopic anterior cruciate ligament range of motion, ensuring quadriceps aged to minimize excessive joint motion. reconstruction. reactivation, and demonstrating clinical Once the patient is bearing full weight, and/or objective evidence of healing of restoration of normal gait mechanics is REHABILITATION the grade III MCL injury when apply- emphasized. It is important for the pa- OF ACUTE GRADE III ing a valgus stress at 20° of knee flexion tient to ambulate without a limp and en- MEDIAL KNEE INJURIES (APPENDIX A). sure that e!usions do not develop with increasing activities. A persistent e!usion Nonoperative Rehabilitation Principles Postoperative Rehabilitation can contribute to decreased knee flexion, s mentioned previously, the ma- It is important to stress that a safe zone quadriceps muscle shutdown, and in- jority of nonoperatively treated for range of motion, determined intra- creased joint pain. Agrade III medial knee injuries are operatively by the surgeon, is communi- Provided that lower extremity either isolated injuries combined solely cated to the rehabilitation specialist to strength, motion, and balance have been with an ACL tear. The overall rehabilita- ensure that the appropriate knee range appropriately regained, basic plyometric tion principles are to control edema and of motion can be safely achieved im- and agility exercises may be initiated 16 initiate quadriceps reactivation in the mediately after a medial knee repair or weeks after surgery. In addition, the pa- initial hours to days after injury, and then reconstruction. Ideally, we strive for a tient should be able to tolerate 2 to 3 km to work to restore knee range of motion. passive or passive-assisted range of mo- of brisk ambulation without limping prior Early weight bearing is encouraged, with tion from 0° to 90° of knee flexion im- to initiating an interval jogging program. patients increasing their weight bearing as mediately after surgery to minimize the Once the patient has progressed without tolerated and progressively reducing their risk of arthrofibrosis. In addition, an significant functional limitations, an as- dependence on crutches until they can aggressive patellofemoral mobilization sessment can be made regarding a return ambulate without a limp. As soon as pa- program, quadriceps reactivation, and to full activities via sport-specific func- tients can tolerate it, they are encouraged the frequent performance of ankle pumps tional tests and evaluations of objective

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knee stability on clinical examination and 1988;107:273-276. posteromedial corner of the knee in patients from stress radiographs. 3. Committee on the Medical Aspects of Sports. with chronic medial collateral ligament instabil- Standard Nomenclature of Athletic Injuries. Chi- ity. Am J Sports Med. 2009;37:1116-1122. http:// It is important to recognize that the cago, IL: American Medical Association; 1966. dx.doi.org/10.1177/0363546509332498 presence of concurrent cruciate ligament 4. Coobs BR, Wijdicks CA, Armitage BM, et 17. Lorentzon R, Wedren H, Pietila T. Incidence, primary or revision reconstructions or os- al. An in vitro analysis of an anatomical nature, and causes of ice hockey injuries. medial knee reconstruction. Am J Sports A three-year prospective study of a Swed- teotomies may require altering the pro- Med. 2010;38:339-347. http://dx.doi. ish elite ice hockey team. Am J Sports Med. gression of this rehabilitation program to org/10.1177/0363546509347996 1988;16:392-396. allow for further healing of biologic tis- 5. DeLee JC, Drez D, Jr., Miller MD. DeLee & Drez’s 18. Miller MD, Osborne JR, Gordon WT, Hinkin DT, sues related to an osteotomy or concur- Orthopaedic Sports Medicine: Principles and Brinker MR. The natural history of bone bruises. Practice. Philadelphia, PA: Saunders; 2003. A prospective study of magnetic resonance rent cruciate ligament reconstruction. 6. Frank CB, Loitz BJ, Shrive NG. Injury loca- imaging-detected trabecular microfractures in Thus, it is recommended that the reha- tion a!ects ligament healing. A morphologic patients with isolated medial collateral ligament bilitation specialists work closely with the and mechanical study of the healing rabbit injuries. Am J Sports Med. 1998;26:15-19. treating surgeon to verify that the patient medial collateral ligament. Acta Orthop Scand. 19. Pedowitz RA, O’Connor JJ, Akeson WH. Daniel’s 1995;66:455-462. Knee Injuries: Ligament and Cartilage Structure, progresses appropriately in the postoper- 7. Gri"th CJ, LaPrade RF, Johansen S, Armitage B, Function, Injury, and Repair. 2nd ed. Philadel- ative rehabilitation program. Wijdicks C, Engebretsen L. Medial knee injury: phia, PA: Lippincott Williams & Wilkins; 2003. part 1, static function of the individual compo- 20. Peterson L, Junge A, Chomiak J, Graf-Baumann CONCLUSIONS nents of the main medial knee structures. Am J T, Dvorak J. Incidence of football injuries and Sports Med. 2009;37:1762-1770. http://dx.doi. complaints in di!erent age groups and skill-level org/10.1177/0363546509333852 groups. Am J Sports Med. 2000;28:S51-57. he superficial MCL, deep MCL, 8. Gri"th CJ, Wijdicks CA, LaPrade RF, Armitage 21. Phisitkul P, James SL, Wolf BR, Amendola A. and posterior oblique ligament must BM, Johansen S, Engebretsen L. Force measure- MCL injuries of the knee: current concepts re- be clinically and objectively evalu- ments on the posterior oblique ligament and view. Iowa Orthop J. 2006;26:77-90. T superficial medial collateral ligament proximal 22. Quarles JD, Hosey RG. Medial and lateral ated for instability in any patient with a and distal divisions to applied loads. Am J collateral injuries: prognosis and treatment. medial knee injury. Although most acute Sports Med. 2009;37:140-148. http://dx.doi. Prim Care. 2004;31:957-975. http://dx.doi. medial knee injuries that occur in isola- org/10.1177/0363546508322890 org/10.1016/j.pop.2004.07.005 tion or with an ACL tear heal without 9. Grood ES, Stowers SF, Noyes FR. Limits of 23. Reider B, Sathy MR, Talkington J, Blyznak N, movement in the human knee. E!ect of sec- Kollias S. Treatment of isolated medial collateral surgery, those that occur with a concur- tioning the posterior cruciate ligament and ligament injuries in athletes with early func- rent grade III posterior cruciate ligament posterolateral structures. J Bone Joint Surg Am. tional rehabilitation. A five-year follow-up study. tear or other multiligament knee injury 1988;70:88-97. Am J Sports Med. 1994;22:470-477. 24. Robinson JR, Bull AM, Thomas RR, Amis AA. often do not heal, and early surgical treat- 10. Hughston JC. Acute knee injuries in athletes. Clin Orthop. 1962;23:114-133. The role of the medial collateral ligament and ment may be indicated for those cases. In 11. Hughston JC. The importance of the posterior posteromedial capsule in controlling knee laxity. addition, it is important to recognize that oblique ligament in repairs of acute tears of Am J Sports Med. 2006;34:1815-1823. http:// not all isolated grade III medial knee in- the medial ligaments in with and without dx.doi.org/10.1177/0363546506289433 an associated rupture of the anterior cruciate 25. Warme WJ, Feagin JA, Jr., King P, Lambert KL, juries heal properly, and therefore some ligament. Results of long-term follow-up. J Bone Cunningham RR. Ski injury statistics, 1982 to patients will still have functional limi- Joint Surg Am. 1994;76:1328-1344. 1993, Jackson Hole Ski Resort. Am J Sports tations after these injuries. For chronic 12. Hughston JC, Eilers AF. The role of the posterior Med. 1995;23:597-600. injuries, it is important to assess frontal oblique ligament in repairs of acute medial (col- 26. Wijdicks CA, Gri"th CJ, Johansen S, Enge- lateral) ligament tears of the knee. J Bone Joint bretsen L, LaPrade RF. Injuries to the medial knee alignment and verify that patients Surg Am. 1973;55:923-940. collateral ligament and associated medial do not have a grade III posterolateral 13. LaPrade RF, Bernhardson AS, Gri"th CJ, Ma- structures of the knee. J Bone Joint Surg Am. knee injury. If operative treatment is in- calena JA, Wijdicks CA. Correlation of valgus 2010;92:1266-1280. http://dx.doi.org/10.2106/ dicated for these chronic injuries, an ana- stress radiographs with medial knee ligament JBJS.I.01229 injuries: an in vitro biomechanical study. Am J 27. Wijdicks CA, Gri"th CJ, LaPrade RF, et al. tomic reconstruction is recommended. ! Sports Med. 2010;38:330-338. http://dx.doi. Medial knee injury: part 2, load sharing org/10.1177/0363546509349347 between the posterior oblique ligament and 14. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, superficial medial collateral ligament. Am J REFERENCES Wentorf FA, Engebretsen L. The anatomy of the Sports Med. 2009;37:1771-1776. http://dx.doi. medial part of the knee. J Bone Joint Surg Am. org/10.1177/0363546509335191 1. Bahk MS, Cosgarea AJ. Physical examination 2007;89:2000-2010. http://dx.doi.org/10.2106/ 28. Yao L, Dungan D, Seeger LL. MR imaging of JBJS.F.01176 tibial collateral ligament injury: comparison and imaging of the lateral collateral ligament 15. LaPrade RF, Terry GC. Injuries to the posterolat- with clinical examination. Skeletal Radiol. and posterolateral corner of the knee. Sports eral aspect of the knee. Association of anatomic 1994;23:521-524. Med Arthrosc. 2006;14:12-19. injury patterns with clinical instability. Am J 2. Ballmer PM, Jakob RP. The non-operative Sports Med. 1997;25:433-438. treatment of isolated complete tears of the 16. Lind M, Jakobsen BW, Lund B, Hansen MS, MORE INFORMATION medial collateral ligament of the knee. A Abdallah O, Christiansen SE. Anatomical recon- WWW.JOSPT.ORG prospective study. Arch Orthop Trauma Surg. struction of the medial collateral ligament and @

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NONOPERATIVE TREATMENT OF ACUTE GRADE III MEDIAL KNEE INJURIES

Goals for All Phases • Step-ups • Early, pain-free full range of motion of the knee Precaution: • Minimal loss of quadriceps strength • Examination by physician is necessary at approximately 3 weeks to • Healing of injured ligament complex with little to no residual instability verify ligament healing

Phase 1: 1 to 2 Weeks Phase 3: 5 Weeks Ice: Weight bearing: • Ice knee as tolerated and as needed based on symptoms • Gait in hinged knee brace through 6 weeks, as comfortable Weight bearing: • Use crutches and apply touchdown to partial weight bearing and Brace: progress as tolerated. Progress to 1 crutch (on opposite side), then • Gradually open fully per quadriceps control discontinue crutches only when normal gait is possible • Discontinue use when ambulating with full weight bearing and no gait Brace: deviation • Hinged knee brace set from 0° to 90° of knee flexion Range of motion: Range of motion: • Full, symmetrical • Emphasize full extension Therapeutic exercises: • Progress flexion as tolerated • Continue at least 20 minutes of daily exercise bike program. Resistance Therapeutic exercises: should be progressively increased at each session • Quadriceps sets: 30 repetitions, 10 times a day • Progress to weight-room exercises. Limit motion to 30° to 90° of knee • Straight leg raises. No weights. The knee must be held in full exten- flexion while performing leg presses, squats, etc sion (no sag). If not, exercise is performed with brace locked in full extension • Hamstring curls • Range-of-motion exercises as tolerated • Leg presses: double-leg press and single-leg press • Sitting hip flexion, 10 sets of 10 repetitions daily • Progress isokinetics • Sidelying hip abduction, 10 sets of 10 repetitions daily • Step-ups • Standing hip extension, 10 sets of 10 repetitions daily • Progress walk-to-run, as tolerated, once cleared by surgeon • Standing hamstring curls, as tolerated; if painful, discontinue • Progress agilities from balanced to unilateral exercises (single-leg hop- • Bike, as comfortable, 10 to 20 minutes, low resistance, start as soon scotch jumps, etc) as possible Precautions: • No limits on upper extremity workouts that do not a!ect the injured • Verify healing by physician at 5 to 6 weeks to progress to next level knee • Verify with stress radiographs as needed

Phase 2: 3 to 4 Weeks Weight bearing: Phase 4: 6 Weeks • As tolerated with hinged brace Brace: Range of motion: • Discontinue brace with gait, wear for competition through competitive • Full extension season or for at least 3 months • Progressive flexion as tolerated • Protective use when out of home, hinged brace open per quadriceps Therapeutic exercises: control • Progress above exercises as tolerated to 5 to 10 lb (2-4 kg) Range of motion: • Progress to 20 minutes of exercise biking daily; increase resistance as • Full, symmetrical tolerated. This is the key exercise to promote healing, rebuild strength, Therapeutic exercises: and maintain aerobic conditioning • Continue daily exercise bike use through 12 weeks after injury (at least • Progress to weight-room exercises. Limit the injured knee’s range of motion to between 0° and 90° of knee flexion when lifting weights (in 20 minutes per day) the brace) • Progress sport-specific exercises • Hamstring curls Precaution: • Leg presses: double-leg press and single-leg press on injured side • Return to competition once full motion and strength return and the • Progress isokinetics patient passes a sport functional test and is cleared by the physician

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APPENDIX B

POSTOPERATIVE REHABILITATION PRINCIPLES FOR ANATOMIC MEDIAL KNEE RECONSTRUCTION

Phase 1: 0 to 2 Weeks Phase 3: 6 to 8 Weeks Goals Goals • Control e!usion and pain • Range of motion with no knee extension lag • Flexion range of motion (within safe zone) to 90° of knee flexion • Quadriceps girth returning • Maintain full extension • Normal gait mechanics performed • Reactivate quadriceps muscle Weight bearing: • Straight leg raises with no knee extension lag • As tolerated with bilateral crutches • Patellofemoral mobility • Progress to full weight bearing per quadriceps control with no gait Weight bearing: deviation • Non–weight bearing Brace: Brace: • Gradually open fully per quadriceps control • Wear brace at full extension at all times, except for passive motion for • Discontinue use when ambulating with full weight bearing and no gait therapy deviation Range of motion: Range of motion: • Emphasize full extension • Full, symmetrical • Knee flexion from 0° to 90° Therapeutic exercises: Therapeutic exercises: • Initiate closed-kinetic-chain strengthening in bilateral support (୏70° of • Cryotherapy for edema control knee flexion) • Range-of-motion exercises • Continue to progress to intermediate core and proximal hip strengthen- ing exercises • Quadriceps and hamstring strengthening • Initiate basic lower extremity proprioception and balance drills with Precaution: bilateral support • Avoid valgus and internal and external rotation through the knee joint Precautions: • Limit bilateral squats to ୏70° of knee flexion Phase 2: 2 to 6 Weeks • No pivoting on a planted foot Goals • Observe and correct for knee/hip alignment with closed-kinetic-chain • E!usion resolved drills • Knee flexion range of motion ୑115° • Observe for continued e!usion, pain with weight bearing, and home • Preserve full knee extension exercise program progression • Quadriceps and straight leg raises with no extension lag Weight bearing: Phase 4: 8 to 12 Weeks • Non–weight bearing Goals Brace: • Restore normal gait mechanics with closed-kinetic-chain lower extrem- • Wear brace when up and about and while sleeping ity activities • Hinged brace open into flexion per quadriceps functional control • Resume normal stair climbing Range of motion: • Normalization of walking speed and distance • Full extension • Able to perform single-leg squat ୑45° of knee flexion with normal • Progressive flexion as tolerated mechanics Therapeutic exercises: Weight bearing: • Continue per phase 1 • Full weight bearing, no restrictions • Initiate upright stationary bike at week 4 with no resistance Brace: • Progress to intermediate core and proximal hip strengthening exercises • Protective use for dynamic activities when out of home, hinged brace • Initiate prone or standing hamstring curls (active flexion, passive open per quadriceps control extension) Range of motion: Precaution: • Full, symmetrical • Continue to avoid valgus and internal and external rotation strain Therapeutic exercises: through the knee joint • Progress closed-kinetic-chain strength drills to single-leg

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• Progress lower extremity proprioception and balance drills to single-leg Range of motion: • Initiate light cardiovascular exercise with bike • Full, symmetrical • Add bilateral support for large muscle group weight training Therapeutic exercises: Precautions: • Directional lunging • Continue to observe for proper lower extremity alignment and • Interval jogging (straight line, no hills) mechanics with closed-kinetic-chain exercise • Initiate basic agility/footwork drills • No use of knee extension machine • Initiate basic double-leg plyometric drills • Dynamic and directional challenge to lower extremity proprioception Phase 5: 12 to 16 Weeks and balance drills Goal Precautions: • Able to perform single-leg squat ୑60° of knee flexion with normal • Continue to observe for proper lower extremity alignment and mechanics mechanics with closed kinetic chain Weight bearing: • Observe for continued e!usion and pain control with initiation of • Full weight bearing, no restrictions impact activity Brace: • No brace Range of motion: Phase 7: 20+ Weeks • Full, symmetrical Goals Therapeutic exercises: • Patient to become independent with exercise program and demon- • Continue per phase 4 strate good self-awareness of proper lower extremity alignment during • Progress cardiovascular activity with bike, elliptical, walking, and high-level drills flutter-kick swimming • Return to sport once strength returns and clinical/objective stability is • Progress weight training to single-leg verified • Progress lower extremity proprioception and balance drills with Weight bearing: surface challenge: BOSU (BOSU, Canton, OH), Airex (Airex AG, Sins, • Full weight bearing, no restrictions Switzerland), and DynaDisc (Exertools Inc, Petaluma, CA) Brace: Precautions: • No brace except for sports • Patient demonstrates good control in concentric and eccentric phases with weight-training exercises Range of motion: • Able to preserve proper lower extremity alignment with proprioception, • Full, symmetrical balance, and closed-kinetic-chain drills Therapeutic exercises: • Continue with weight-room strength training • Progress plyometric drills Phase 6: 16 to 20 Weeks Goal • Progress speed/intensity of agility drills • Patient demonstrates good self-awareness of proper lower extremity • Initiate acceleration/deceleration drills alignment with closed-kinetic-chain and impact drills • Initiate cutting drills Weight bearing: • Initiate sport-specific drills • Full weight bearing, no restrictions Precaution: Brace: • Avoid functional valgus at knee with deceleration, cutting, and jumping • No brace except for dynamic activities drills

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