Medial Collateral Ligament Sprain
1. Introduction
There are two collateral ligaments, one either side of the knee, which act to stop side-to-side movement of the knee. The medial collateral ligament is the most commonly injured. It lies on the inner side of your knee joint, connecting your thigh bone (Femur) to your shin bone (Tibia) and provides stability to the knee (2).
Injuries to this ligament tend to occur when the knee is forced inwards, either by direct trauma or twisting during a fall, or when playing sports. A medial collateral ligament injury can vary in grades.
A sprain is an injury to a ligament. They are classified as follows (1):
- Grade I: mild sprain with ligaments stretched but not torn.
- Grade II: moderate sprain with some ligaments torn.
- Grade III: severe sprain with complete tear of ligaments.
Complete tears (ruptures) were traditionally always surgically repaired, however more recent evidence has demonstrated that most people who are treated with conservative methods successfully return to previous activities (9).
Frequently Asked Questions
The medial collateral ligament is on the inner side of the knee. It provides stability to the joint by preventing excessive side–to–side movement. It is possible to injure this ligament when a person is bearing weight, and the knee is forced inwards (1).Â
- Common
- Ligament injuries of the knee account for approximately 40% of all knee injuries.
- Medial collateral ligament injuries are the most common (2).
- No
- The majority of medial collateral ligament sprains can be treated without surgery. With the correct rehabilitation protocol even a significant tear should completely heal as the medial collateral ligament has a strong blood supply (3).
- Conservative treatment has shown to be effective in 98% of smaller tears of the ligament (4).
- Those who take part in contact sports. (5, 6).
- Skiers: 60% of all skiing injuries involve the medial collateral ligament (7).
- People with a high risk of falls.
- Males are at greater risk than females (5).
- Pain and swelling on the inside of the knee, especially with twisting movements.
- The knee may feel unstable depending on the grade of the injury (5).
- May hear or feel a popping sensation at the time of injury.
- In the early stage of management, good practice now involves use of the ‘Peace & Love’ protocol.
- Pain free cardiovascular exercise can increase blood flow and optimise the healing process.
- Begin to progressive load and exercise the knee in order to gradually return to previous activities. A physiotherapist can guide you with this.
- This depends on the severity of the injury. With mild symptoms taking a few weeks and more profound symptoms taking a few months (5).
- Lifestyle factors such as BMI, diet, alcohol intake and smoking can also affect recovery.
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
- Pain in the knee, especially on the medial (inner) aspect, particularly with twisting or cutting movements.
- Oedema (swelling) and haematoma (bruising) with higher grade sprains.
- Instability and feelings of giving way with higher grade sprains.
3. Causes
Injuries to this ligament tend to occur when a person is bearing weight and the knee is forced inwards. This may involve abrupt turning, cutting or twisting. Medial collateral ligament injuries can also result from direct blows to the outside of the knee.
4. Risk Factors
These factors could increase the likelihood of someone developing a medial collateral ligament sprain. It does not mean everyone with these risk factors will develop symptoms.
- Gender – medial collateral ligament sprain is more common in males.
- Sport – those that take part in sports that involve quickly changing direction such as skiing and football, as well as contact sports such as rugby.
- Lower limb weakness – reduced strength can lead to increased stress on the medial collateral ligament.
5. Prevalence
In the general population medial collateral ligament sprains affect less than 1% of the population. They are more common in athletic populations and account for around 40% of all knee injuries (9).Â
6. Assessment & Diagnosis
Physiotherapists and other musculoskeletal professionals can diagnose a medial collateral ligament injury following detailed history taking and a thorough examination.
In very rare cases where conservative management does not improve symptoms, further imaging such as MRI (magnetic resonance imaging) can be used to assess and diagnose knee injuries further (10).
7. Self-Management
In the early stage of management, good practice now involves use of the ‘Peace & Love’ protocol:
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your injury. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as advised to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
There is strong evidence between physiotherapist-led rehabilitation and improved medium and long-term outcome (11).
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing ligament sprains. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Medial Collateral Ligament Sprain
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on regaining or maintaining range of movement within the knee, and appropriate loading of the knee to maintain lower limb strength without aggravating symptoms. We can work into pain during these exercises but ideally this should not exceed any more than 4 out of 10 on your self-perceived pain scale.
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This is the next progression. More focus is given to progressive loading of the knee as well as proprioception (perception or awareness of the position and movement of the body) and stability exercise. As with the early programme, some pain is to be expected but ideally, we do not want this to be any more than 4 out of 10. Â
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This phase looks to incorporate more challenging strength and movement-based exercises to try and progress the function of the knee and help towards a return to activity. Â
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10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport, a rehabilitation programme should incorporate plyometric based exercises; this might include things like bounding, cutting and sprinting exercises (5,7).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice may allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Grade III sprains are often treated operatively in athletic populations (13). This is because the severity of the injury can lead to lasting rotational instability.
There is also emerging evidence suggesting shockwave therapy may be a useful adjunct alongside exercise (4).
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References
- Desai VS, Wu IT, Camp CL, Levy BA, Stuart MJ, Krych AJ. Midterm Outcomes following Acute Repair of Grade III Distal MCL Avulsions in Multiligamentous Knee Injuries. J Knee Surg. 2020 Aug;33(8):785-791.
- Loughran GJ, Vulpis CT, Murphy JP, Weiner DA, Svoboda SJ, Hinton RY, Milzman DP. Incidence of Knee Injuries on Artificial Turf Versus Natural Grass in National Collegiate Athletic Association American Football: 2004-2005 Through 2013-2014 Seasons. Am J Sports Med. 2019 May;47(6):1294-1301.
- Lundblad M, Hägglund M, Thomeé C, Hamrin Senorski E, Ekstrand J, Karlsson J, Waldén M. Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3692-3698.
- Elkin JL, Zamora E, Gallo RA. Combined Anterior Cruciate Ligament and Medial Collateral Ligament Knee Injuries: Anatomy, Diagnosis, Management Recommendations, and Return to Sport. Curr Rev Musculoskelet Med. 2019 Jun;12(2):239-244.
- Jung KH, Youm YS, Cho SD, Jin WY, Kwon SH. Iatrogenic Medial Collateral Ligament Injury by Valgus Stress During Arthroscopic Surgery of the Knee. Arthroscopy. 2019 May;35(5):1520-1524.
- Westermann RW, Spindler KP, Huston LJ, MOON Knee Group. Wolf BR. Outcomes of Grade III Medial Collateral Ligament Injuries Treated Concurrently With Anterior Cruciate Ligament Reconstruction: A Multicenter Study. Arthroscopy. 2019 May;35(5):1466-1472.
- Posch M, Schranz A, Lener M, Tecklenburg K, Burtscher M, Ruedl G. In recreational alpine skiing, the ACL is predominantly injured in all knee injuries needing hospitalisation. Knee Surg Sports Traumatol Arthrosc. 2020 Aug 14;
- 8.Mack CD, Kent RW, Coughlin MJ, Shiue KY, Weiss LJ, Jastifer JR, Wojtys EM, Anderson RB. Incidence of Lower Extremity Injury in the National Football League: 2015 to 2018. Am J Sports Med. 2020 Jul;48(9):2287-2294.
- Albtoush OM, Horger M, Springer F, Fritz J. Avulsion fracture of the medial collateral ligament association with Segond fracture. Clin Imaging. 2019 Jan – Feb;53:32-34.
- DeFroda SF, Bokshan SL, Vutescu ES, Sullivan K, Owens BD. Accuracy of internet images of ligamentous knee injuries. Phys Sportsmed. 2019 Feb;47(1):129-131.
- Encinas-Ullán CA, RodrÃguez-Merchán EC. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev. 2018 Jul;3(7):398-407.
- Goff AJ, Page WS, Clark NC. Reporting of acute programme variables and exercise descriptors in rehabilitation strength training for tibiofemoral joint soft tissue injury: A systematic review. Phys Ther Sport. 2018 Nov;34:227-237. [PubMed]
- Logan CA, Murphy CP, Sanchez A, Dornan GJ, Whalen JM, Price MD, Bradley JP, LaPrade RF, Provencher MT. Medial Collateral Ligament Injuries Identified at the National Football League Scouting Combine: Assessment of Epidemiological Characteristics, Imaging Findings, and Initial Career Performance. Orthop J Sports Med. 2018 Jul;6(7):2325967118787182.
Other Conditions in
Knees
Patellofemoral Pain Syndrome (PFPS)
Knee pain around the kneecap usually worse in static positions, squatting or kneeling.
Patellar Tendinopathy
Knee pain at the lower border of the kneecap which is also known as ‘jumper’s knee’.
Osgood-Schlatter Disease
Pain in an area just below the knee on the shin bone, often with a lump.
Meniscus Injury
Structural knee injury, triggered either by a tear or through wear and tear.
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hamstring Strain/Tear
An over-stretch or tear to one or more of the muscles located at the back of the thigh. Â
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Fat Pad Impingement
A rare condition affecting the adipose (fat) tissue that sits under the kneecap (patella) between the joint spaces of the knee.
Degenerative Meniscus
Seen to be normal as we age, but in some situations can result in knee aches, pain or joint swelling.
Bowed Knees
A condition in which the legs are bowed outwards leaving a greater space in between your knees.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Anterior Cruciate Ligament (ACL) Injury
Injury to a major stability ligmant in the knee, normally occuring following a significant twisting injury.