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The Management of Injuries to the Medial Side of the Knee

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The Management of Injuries to the Medial Side of the Knee [ CLINICAL COMMENTARY ] ROBERT F. LAPRADE, MD, PhD1 • COEN A. WIJDICKS, PhD2 The Management of Injuries to the Medial Side of the Knee he injury incidence of the superficial medial collateral ligament 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) medial knee injuries 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- anatomy, 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 biomechanics 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 ligaments. 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, surgery, 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] journal of orthopaedic & sports physical therapy | volume 42 | number 3 | march 2012 | 221 /D3UDGHLQGG 30 [ CLINICAL COMMENTARY ] 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 joint cap- sule deep to the superficial MCL.14 Its at- tachment site on the femur is just over 1 cm distal to that of the superficial MCL. The deep MCL courses distally to attach to the medial meniscus 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 tibia.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 222 | march 2012 | volume 42 | number 3 | journal of orthopaedic & sports physical therapy /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 gastrocnemius muscle belly,14 and then attaches slightly proximal and posterior to a bony depression adjacent to the gas- trocnemius tubercle.
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