Medial collateral ligament( superficial fibres) – tibial collateral ligament

Findings

There is a history of forced abduction of the tibia, during a fall, twist, wrench or blocked adduction.

Cause

An abduction strain of the knee, strains or tears of the medial collateral ligament.

Grade 1

a)      No bruising.

b)      Passive abduction is painful.

c)      There is tenderness to palpation, usually over the femoral attachment.

d)     The pain is exacerbated by turning over in bed, and lying on one side with the bad leg uppermost.

e)      McMurray’s manoeuvre may be painful, without the clunk.

Grade 2

As for grade 1, but local bruising and puffiness can be seen.

Grade 3

Bruising, with passive abduction being pain free, or relatively pain free. There may be gapping of the knee joint, even with the knee held straight, and crutches are required as the knee is unstable. There is tenderness over the femoral and tibial attachment.

Chronic

The findings are similar to the grade 1, but without an acute episode. Examination shows anatomical or functional valgus at the knees and, frequently, overpronation at the feet.

Treatment

Grade 1

a)      Limit oedema and inflammation with RICE for 48 hours. A pillow placed between the knees, when in bed, will reduce the abduction strains across the knee.

b)      Settle inflammation and organize scar tissue with electrotherapeutic modalities and massage, plus passive flexion/extension of the knees.

c)      Maintain static quadriceps exercises then, when possible, add active knee flexion/extension exercises.

d)     Closed chain knee exercises, with a brace or knee support.

e)      Cross-train, non- impact, e.g. cycling, rowing or swimming, but not breaststroke.

f)       Knee ladders

g)      Add side steps, figure-of-eight runs and cross-over steps before testing for match fitness.

h)      Use a knee support for 4-6 weeks when playing in matches.

Grade 2

a)      There is therapeutic balance between immobility, to heal the ligament, and mobility, to maintain joint movement.

b)      A long length, hinged knee brace, with a lockable adjustable hinge range, is most effective as it helps balance mobility and stability.

c)      Maintain static quadriceps. The quadriceps and hamstrings can be worked against a brace. Straight leg raises and hamstring isometrics are used in the early stages.

d)     Continue as for grade 1- with, and then without, a brace.

Grade 3

Splint the knee in the acute stage. The ruptured ligaments require surgical repair, preferably within 2 weeks. The knee should be examined to exclude further damage – to meniscus, cruciates and popliteal artery. Rehabilitate as described for grade 2.

Chronic

Treat as for grade 1,but correct the causes of the genu valgum.

Sports

This is an important ligament for knee stability. Proprioception is improved by pressure from any support on the skin. A hinged knee brace may be of mechanical value in sports where this is permitted. Problem sports include:

a)      Breaststroke – reduce the frog kick to a narrow wedge kick

b)      Snow skiers who cannot parallel and have to use edging and snow plough techniques will strain the ligament

c)      Twisting, turning and checking, at any sport

d)     Soccer and football – side foot kick and side foot tackle

e)      Martial arts – side, and round the head, kicks

This is fairly common injury. The superficial fibres of the medial collateral ligament are tender on the bone of the femur and/or the tibia and should not be injected.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English