The Knee 16 (2009) 64–68

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The Knee

Persistent symptoms following non operative management in low grade MCL injuryof the knee — The role of the deep MCL

Luke Jones a,⁎, Quamar Bismil b, Faisal Alyas c, David Connell c, Jonathan Bell d

a Oxford Deanery, 38 College Court, Queen Caroline Street, London, W6 9DZ, United Kingdomb South-West Thames, Apartment 62, Juniper Drive, Battersea Reach, London, SW18 1TZ, United Kingdomc Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, United Kingdomd Department of Orthopaedics, Kingston Hospital NHS Trust, Galsworthy Road Kingston upon Thames Surrey, KT2 7QB, United Kingdom

⁎ Corresponding author. Tel.: +44 7967 37 44 55.E-mail address: lukejones@doctors.org.uk (L. Jones).

0968-0160/$ – see front matter © 2008 Elsevier B.V. Aldoi:10.1016/j.knee.2008.09.002

a b s t r a c t

a r t i c l e i n f o

Article history:

Incomplete injuries (grade Received 21 April 2008Received in revised form 7 September 2008Accepted 9 September 2008

Keywords:Level Four evidenceCase series

I or II) to the medial collateral ligament (MCL) of the knee are common andusually self limiting. Some patients complain of chronic medial knee pain following injury. We highlight theimportance of anatomical investigation of these patients and evaluate a successful treatment technique.A consecutive case series of 34 patients with chronic pain following grade I/II MCL injury were reviewed. Injuryprevented sporting activity, and examination revealed thickening and tenderness of the MCL. The knee wasassessedbyMRI. All patients had radiological evidenceof injury to the superficial anddeepMCL,with thickening,scarring and tearing. Patients were treatedwith ultrasound guided injection of local anaesthetic and steroid intothe deep MCL and clinically reassessed. They were allowed to return to sport immediately. They were assessedfor recurrence of symptoms with a postal questionnaire. Four were excluded from follow up. Four were lost.All patients reported an immediate and sustained resolution their medial knee pain.At mean follow up of 20.4 months (range 11–38months) all were back to their pre-injury level of work. Twentyfive (96%) had immediate and sustained return to sporting activity. Twenty one (81%) reportedno change in levelof sporting function.In patients with persistent medial joint pain following grade I/II MCL sprain, pain from the deep MCL must beconsidered. MRIwill confirm the diagnosis, exclude coexistent pathology and localise the lesionwithin the deepMCL. A single corticosteroid injection provides an excellent clinical outcome 20 months post injection.

© 2008 Elsevier B.V. All rights reserved.

1. Introduction

The medial collateral ligament (MCL) functions as a stabilizer tovalgus stress and external rotation particularly in flexion [1,2]. Much ofthe literature describes the MCL as a three-layered structure [3–5].Layer I (themost superficial) is a continuation of the deep fascia (fascialata), layer II is the superficial MCL; layer III is the deep MCL. Layer I iscontinuous with the deep fascia of the lower limb and as such not astructure specific to the MCL [6].

Clinically, the MCL is best considered as a two-layered structurewith deep and superficial components. Robinson et al. [7] describe thedeep MCL as distinct but inseparable from the joint capsule. It isattached to themedialmeniscus and consists of parallel fibres of widthof 0.5–0.9 cm and 2.9–3.3 cm long. Posteriorly, the proximal portionblends with the posteromedial capsule. The attachments of the deepMCL to the femur and tibia are termed the meniscotibial ligament(MTL) and meniscofemoral ligament (MFL). The MTL arises from the

l rights reserved.

peripheral inferior aspect of the body of the medial meniscus andattaches 0.2–0.3 cm below the tibial articular cartilage. The MFL arises1.5–1.7 cm proximal to the femoral articular cartilage, immediatelydistal and posterior to the attachment of the superficial MCL, on theinferior aspect of the femoral epicondyle. MRI and ultrasound havebeen shown to accurately identify the deep components of the MCL[8,9] (Fig. 1).

MCL injuries are common. They are classified according to thecriteria of Bergfield [10] with grade I strains consisting of tendernessover the MCL with no instability to valgus stress in full extension or at25–30 degrees of flexion, and grade II consisting of tenderness overthe MCL with no instability in extension, but greater than 10 degreesin 25–30 degrees flexion with a definite end point.

Patients with grade I/II MCL sprains should be back to their normalactivities and sport three to four weeks following injury with a wellstructured conservative management strategy [3,10–12].

Our experience indicates a small subset of patients who do notrespond to conservative measures, and can experience chronicsymptoms, presenting to the clinic up to 18 months post injury withsymptoms preventing sporting activity. Chronic injury to the deeppart of the MCL has been previously described by Bollen and

Fig. 1. Coronal proton density weighted MRI image demonstrating the components ofthe medial collateral ligament (MCL) in a 30 year old male. Small black arrowhead –

femoral insertion of the meniscofemoral ligament (MFL). Long black arrow – Superiorfluid recess (sulcus). Short black arrow MFL. White arrowhead – fat filled recessbetween the deep and superficial components. Short white arrow – meniscotibialligament (MTL). Long white arrow inferior fluid recess (sulcus). Large arrow head.Superficial medial collateral ligament.

Fig. 2. MRI of 45 year old male with a 4 month history of chronic medial knee paindemonstrating a chronic injury of theMFL. Coronal PDW image demonstrates thickenedirregular MFL with intermediate low signal (arrow), consistent with hypertropic scartissue. In addition there is some thickening of the superficial MCL (arrowhead).

65L. Jones et al. / The Knee 16 (2009) 64–68

demonstrated arthroscopically [13]. It is uncommon [14], but has beendescribed in up to 20% of patients following an acute injury [15]. Thesymptoms can be clinically difficult to differentiate from a medialmeniscus injury [16–18].

We believe the key to the clinical examination of the deep MCL islocating the deep MCL sulcus (Fig. 1). This sulcus relates to theproximal portion of the meniscofemoral component of the deep MCL,where this traverses the joint line. Invariably patients with this injuryhave tenderness and thickening of the deep MCL in this sulcus.

We hypothesised that many patients do not have medial meniscustears but chronic symptoms arising from the deep part of the MCL.This abnormality would be identified with imaging and may respondto ultrasound guided steroid injection.

2. Materials and methods

Between 2004 and 2006, 34 patients were seen in the SportsMedicine Clinic following grade I/II MCL injuries with a consistentclinical picture. The mean age was 37 years (range 11–54); 11 (32%)patients were female; mean follow up was 20.4 months (11–38).

All complained of ongoingmedial joint line pain at a minimum of 3months (range 3–18 months) following injury and were thusconsidered to be chronic injuries [19]. In all patients their medialknee pain prevented sporting activity. They had localized tendernessand thickening of the deep MCL, and active resisted knee movementprovoked their medial knee pain. The inclusion criteria were:

1. Diagnosis of grade I/IIMCL injury on the basis of clinical examinationand MRI;

2. Tenderness and thickening localized to the deep MCL;3. Failure to respond to a period of non operative treatment which

included rest, ice, non-steroidal anti-inflammatory medicationsand physiotherapy;

4. Failure to settle within 3 months of injury;

Patients were excluded from the study if they exhibited clinical orMRI evidence of another intra-articular (such as medial meniscus,chondral defect, bone contusion) or ligamentous injury.

All 34 athletes fulfilled the criteria and were diagnosed with deepMCL pain.

They were offered imaging and consented to receive an injection ifthe suspected pathology was identified. All patients were managed inthe same way.

The subjects underwentMRI of the knee using a SiemensMAGNETOMSymphony 1.5 T scanner. Three plane fast spin echo proton densitysequences together with sagittal and coronal proton density fatsuppressed sequences were reviewed specifically for deep extension/ligament tears. Scans were read in consensus by two experiencedmusculoskeletal radiologists.

The key imaging finding was the demonstration of thickenedtissue of intermediate signal on MRI or slightly echogenic onultrasound consistent with solid scar tissue in the region of the deepMCL (Figs. 2 and 3). The adjacent deep ligament injurieswere classifiedusing MRI as:

1. Low – intact ligament but thickened N1 mm with surroundingintermediate signal consistent with scar tissue (32.3% – MTL=1,MFL=10)

2. Moderate – partial thinning or discontinuity of the ligament withsurrounding intermediate signal consistentwith scar tissue (41.2% –

MTL=2, MFL=12)3. High – complete discontinuity of the ligament, or no visible ligament

identifiedwith surrounding intermediate signal consistentwith scartissue (26.5% – MTL=1 MFL=8)

Identification of the lesion was undertaken with sonography(Philips HDI, 12 mHz linear transducer) prior to guided injection of

Fig. 3.MRI of 25 year old female with chronic medial joint pain demonstrating a chronic deep MFL. (a) Coronal ultrasound of the knee demonstrates a thickened echogenic deep MFL(arrow), compared to the normal MTL (large arrowhead). In addition the superficial MCL is thickened and echogenic towards the femoral side (arrowhead). (b) Coronal ultrasound ofthe knee demonstrates neovascularisation (within white box). (F = Femur, T = Tibia.).

Table 2The Tegner and Lysholm scoring system

Level 10 Competitive sports – soccer, football, rugby (national elite)Level 9 Competitive sports – soccer, football, rugby (lower divisions), ice hockey,

wrestling, gymnastics, basketballLevel 8 Competitive sports – squash or badminton, track and field athletics (jumping,

etc.), down-hill skiingLevel 7 Competitive sports – tennis, running, motorcars speedway, handball soccer,

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local anaesthetic [20–22] (bupivicaine, 2 ml of 0.5%) and steroid(Triamcinolone acetonide, 40 mg in 1 ml) [23] superficial and deep tothe deep MCL.

This was followed by repeated needling of the affected ligament[24–26].

Ultrasound can be used to guide injection more accurately thanusing surface anatomy alone, directly into the area of hypertrophicscar formation response [8,9].

The injection was performed by a solitary musculoskeletalradiologist. Clinical re-assessment was performed 5 mins after theinjection. This again consisted of palpation over the deep MCL andactive resisted knee movement.

The patientswere providedwith a programmeof resistive exercises:progressing through isometric, isotonic, and eventually isokinetic.Patients were advised to return to full activities and sport followinginjection as comfort allowed, with no limitations or precautions.

Four patients were lost to long term follow up as they had left thecountry.

Four patients were excluded at long term follow up as theyreported new pain arising from structures distant to the medialcollateral ligament, or had subsequently suffered a separate kneeinjury and could thus not be considered to reliably report their medialknee pain.

Thus although 34 underwent initial imaging and treatment, 26were followed up by questionnaire.

Table 1Activity-related symptoms

Yes No If pain:level

1 2 3 4 5 6 7 8 9 10

1. Do you get pain fromsporting activities? If sowhat level?

11 15 4 2 2 1 1 1

2. Can you squat pain free? 20 (77%) 6 2 3 13. Can you run pain free? 20 (77%) 6 2 2 24. Can you twist and turnpain free?

16 (62%) 10 5 5

5. If applicable, can you kicka football pain free?

15 (71%) 6 1 4 1

The patients were reassessedwith a postal questionnaire at amean20.4 months (11–38) following their injection. Patients were asked ifthey:

1) Were back to full sports activity.2) Were able to play pain-free, with slight pain or severe pain.

They were then asked to rate their pain on a scale from 0 (no pain)to 10 (worst pain imaginable) during: (1) sporting activities; (2)squatting; (3) running; (4) twisting/turning and (5) kicking a soccerball (Table 1). Functional sporting level was formally assessed usingthe scoring system of Tegner and Lysolm (Table 2) [27].

3. Results

3.1. Radiographic

In all patients the MRI showed abnormality of the deep MCL. Findings includedthickening, partial disruption, attenuation and scarring (Fig. 2).

football, rugby, bandy, ice hockey, basketball, squash, racquetball, runningRecreational sports – soccer, football, rugby, bandy, ice hockey, basketball,squash, racquetball, running

Level 6 Recreational sports – tennis and badminton, racquetball, down-hill skiing,jogging at least 5 times per week

Level 5 Work – heavy labor (construction, etc.) cycling, crosscountry skiing,Recreational sports jogging on uneven ground at least twice weeklyCompetitive sports – cycling, cross-country skiingRecreational sports – jogging on uneven ground at least twice weekly

Level 4 Work – moderately heavy labor (e.g. truck driving, etc.)Level 3 Work – light labor (nursing, etc.)Level 2 Work – light laborWalking on uneven ground possible, but impossible to back

pack or hikeWalking on uneven ground possible, but impossible to back pack or hike

Level 1 Work – sedentary (secretarial, etc.)Level 0 Sick leave or disability pension because of knee problems

67L. Jones et al. / The Knee 16 (2009) 64–68

Ultrasound showed thickened echogenic scar tissue formation often withneovascularisation on colour Doppler (Fig. 3 a,b).

Of the34patients 30 (89.5%C.I. 75.2–97.1%) had injuriesof theMFL, four (10.5%,C.I. 2.9–24.8%) of the MTL.

3.2. Post injection results

3.2.1. Immediate (5 mins) reassessmentAll 34 patients reported resolution of their pain when clinically re-assessed 5 mins

following the injection of local anesthetic and steroid. In all patients palpation of thedeep MCL and active resisted movement did not provoke pain at the 5 minsreassessment.

3.2.2. Final follow upPatients reported no complications as a result of the steroid injection.

3.2.2.1. Return to sport. All patients were unable to participate in sport prior totreatment. All patients were encouraged to return to sport immediately followinginjection as pain allowed.

Twenty five of 26 patients that were included in the long term follow up (96%) wereback to sports immediately and maintained this return to sporting activity at follow up.Of the eleven patients (42%) who reported slight pain with sporting activities, nine(34%) were at a level of 4/10 (mild pain) or less. The only patient who had not returnedto sport attributed this to anxiety over using the knee following the injury rather thanpain restricting activity.

3.2.2.2. Activity-related symptoms. Table 1 illustrates the level of symptoms with regardto (1) pain during sporting activities (2) squatting (3) running (4) twisting/turning(5) kicking a ball.

3.2.2.3. Tegner and Lysolm score. Twenty one patients (81%) returned to their previouslevel of sporting function according to their Tegner score. The five patients (19%) whoselevel of sporting activity had dropped reported a decrease in Tegner score of two or less.

4. Discussion

This case series defines a subset of patients with incomplete MCLinjuries who fail to respond to non operative treatment, with clinicaland radiographic evidence that the deep MCL is the source of ongoingsymptoms. All patients presented following a grade I/II MCL injurywith persistent medial knee pain that prevented sporting activity, andconsistent imaging findings with the meniscofemoral ligament beingaffected more commonly then the meniscotibial ligament. Followinginjection of local anaesthetic and steroid 96% of these chronic MCLinjury patients had an immediate and sustained return to sport with81% maintaining their pre-injury level of function and the remaining19% decreasing their Tegner score by only two or less at an averagefollow up of 20.4 months.

The index injury was usually a minor valgus injury resulting inpersistent pain but no locking. They complained of pain on running,changing direction, pivoting, catching the foot (external rotation) andpassing the soccer ball with the instep. Whilst these patients did nothave frank locking, many other features were consistent with a medialmeniscal tear [16,17]. This can lead to considerable clinical confusionon examination. Deep MCL injuries can be misdiagnosed as medialmeniscus injuries [13].

The reason for the ongoing pain from the deepMCL remains unclear.Possibilities include chemicalmediators, neovascularisation, associatedsynovitis, or associated joint instability following injury. Loss of softtissue and osseous homeostasis within these chronic patients mayrepresent an alternative possibility. In our study the deep MCLunderwent needling following injection of steroid and local anaes-thetic. This involved the repeated lancing of the area, leading todisruption of collagen fibres and the induction of formation ofgranulation tissue that strengthens the ligament. Although our studydesign does not allow comment on the method of action of thistechnique, others have postulated on the possiblemechanismsof action[25,28,29].

We conclude that localised injection of local anaesthetic andsteroid into a chronically injured deep MCL leads to an immediate andsustained relief of pain that allows and immediate and sustainedreturn to sport. A follow up study comparing this to placebo injection

would add further evidence of the efficacy of this treatment. Our studyis limited by the length of its follow up, although some were followedfor over three years. Our postal questionnaire allowed both objectiveand subjective assessment of symptoms and function; however theretrospective nature of our study and the questionnaire follow up doesallow the possibility of reporting bias. It is possible that blindedclinical follow up and assessment of outcome may have lead to worseclinical results being identified. Although a control group was notused, previous studies have extensively documented the naturalhistory of the Grade I/II MCL injuries, and have highlighted thepotentially chronic nature of these injuries [3,10,12,15].

Clinicians whomanage patients following incomplete MCL injuriesshould be aware that the deep MCL is a potential cause of chronicsymptoms. We suggest that ongoing symptoms following such aninjury could easily be attributed to a medial musical tear that maythen lead to unnecessary arthroscopy. In this series we demonstratethat with a single corticosteroid injection into the deep MCL, patientswith a chronic grade I or II deep MCL injury can expect a good clinical,and excellent functional recovery.

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