Medial Collateral Ligament Injury of the Knee

Original Editors - Sem Bras

Top Contributors - Laure-Anne Callewaert, Bianca Vander Slaghmolen, Kim Jackson, Admin, Sem Bras, Michelle Lee, Oyemi Sillo, Stan Dieleman, Jonas Vangindertael, Gwen Wyns, Matthias Steenwerckx, WikiSysop, Fasuba Ayobami, Alexander Diliën, 127.0.0.1, Uchechukwu Chukwuemeka, Wanda van Niekerk, Lucinda hampton, Evan Thomas, Shejza Mino and Naomi O'Reilly  


Definition/Description[edit | edit source]

A medial collateral ligament (MCL) injury is a torn, partial tear, or complete tear of the ligament on the inside of the knee. The MCL is one of the most frequently injured knee structure.[1] [2] The anatomy and biomechanical role of this
ligament and the associated posteromedial structures of the knee
continue to be explored.[3] It is usually injured because of valgus forces applied to the knee.[4]

Clinically Relevant Anatomy [edit | edit source]

The medial collateral ligament, also called the tibial collateral ligament, is a ligament made of tough fibrous material, functions to control excessive motion by limiting the joint mobility. The medial collateral ligament (MCL) is one of the four ligaments that are critical to maintain the stability of the knee joint. The four major ligaments of the knee-area are the cruciate ligaments (anterior and posterior), and the collateral ligaments (medial and lateral). Proximally the MCL attaches to the medial femoral condyle and distally it attaches to the metaphyseal area of the tibia. The MCL is the main medial stabilizer. [5] [6], it guides intra-articular movement (for example: roll, spin, slip and translation).

Epidemiology /Etiology[edit | edit source]

MCL injuries mostly occur after an impact on the outside of the knee. The causes of this injury are often a valgus trauma (contact/noncontact) or external tibial rotation.[7] [8] [9] The MCL on the inside of the knee becomes stretched. When the force of the impact is big enough, some or all the fibers will tear. Mostly the deep part of the ligament gets damaged first and this may lead to medial meniscal damage or anterior cruciate ligament damage. A major MCL injury may be caused by a lateral push to the lower thigh or upper leg. For example The MCL injury can appear in football from a tackle or block against the lateral aspect of the knee, a skier can also get injured to his MCL. The pathology of an MCL injury is limited to the proximal or the distal ends of the ligament.[10] [11] [12]

Characteristics/Clinical Presentation[edit | edit source]

As with all the ligament injuries, the MCL injury is graded 1, 2 or 3 (this grade is given depending on the degree of sustained) . A grade 1 tear consists of less than 10% of the collagen fibres being torn. Grade 2 tears vary in symptoms and therefore they are broken down further to grades 2- (closer to grade 1) and 2+ closer to grade 3). Obviously, this means that a grade 3 tear is a complete rupture of the MCL.
The symptoms for a grade 1 tear of the MCL are minimal. Patients complain about a mild tenderness on the inside of the knee. Usually we can’t detect a swelling over the ligament or joint laxity. Most of the patients feel pain when we apply force on the outside of a slightly bent knee.

Grade 2 injuries are also considered as incomplete tears of the MCL. Patients with a grade 2 tear mostly complain about instability when attempting to cut or pivot. The pain and swelling are more significant than with grade 1 injuries. When the knee is stressed (as for grade 1), patients complain about pain, moderate laxity in the joint and a significant tenderness on the inside of the knee.
When we speak of a grade 3 tear of the MCL, it is considered as a complete rupture of the ligament. Patients have significant pain and swelling over the MCL. Most of the time they have difficulty bending the knee. Another common finding of a grade 3 tear is instability. When we stress the knee (as described above) there is joint laxity.

Differential Diagnosis
[edit | edit source]

Differential diagnosis is necessary to exclude injuries that may cause the same symptoms as MCL injury of the knee. These injuries are:[13] [14] [15]

  • Medial meniscal tear/injury
  • Anterior cruciate ligament (ACL) tear
  • Tibial plateau fracture
  • Femur injury or fracture
  • Patellar subluxation/dislocation
  • Medial knee contusion
  • Pediatric distal femoral fracture
  • Damage to the posteromedial corner structures

A physical examination will help to ensure a correct diagnosis. A medial meniscal tear can be mistaken for an MCL sprain, because the tear causes joint tenderness like the sprain. With a valgus laxity examination a medial meniscal tear can be differentiated from a grade 2 or 3 MCL sprain. The presence of an opening on the joint line means the medial meniscus is torn. A grade 1 MCL is more difficult to differentiate from a medial meniscal tear. The differentiation can be made through an MRI or by observing the patient during several weeks. In case of an MCL sprain tenderness usually resolves, with a meniscal injury it persists.[16] [17] [18]

When there is tenderness, but no abnormal valgus laxity, it could be a case of medial knee contusion. If the tenderness is situated near the adductor tubercle or medial retinaculum adjacent to the patella, the cause is more likely to be patellar dislocation or subluxation. Patellar instability can be differentiated from an MCL sprain with the patellar apprehension test. A positive result means there is patellar instability.[19] [20] [21]

If the patient is a child, a gentle stress-testing radiograph can determine if they have a distal femoral fracture instead of an MCL sprain.[22] [23] [24]

Diagnostic Procedures[edit | edit source]

The patient’s anamnesis is important to know where the pain is located. After determining where it hurts, the therapist has to feel if there is tenderness or soft-tissue swelling. For that, he needs to palpate the knee joint. Most of the time, the pain is localized on the medial side of the knee. Soft-tissue swelling will also be present. As was explained before, there are three grades of MCL tear. The grade depends on the degree of pain or on the range of the opening of the joint space during stress tests of the patient’s knee joint.[25] [26]

Outcome Measures[edit | edit source]

  • International Knee Documentation Committee (IKDC) (Level of evidence 1)
  • Tegner function score (Level of evidence 5)
  • Lysholm knee score (Level of evidence 2)

[27]   [28]


Clinicians use different instruments to identify pain, functioning, disability and changes in the patient’s status through the treatment. They use a validated patient-reported outcome measure, a general health questionnaire, and a validated activity scale.[29] [30]

Examination[edit | edit source]

There are 2 methods to identify the range of the opening of the joint space.
The first method is manual. The therapist can test the laxity of the knee with manual stress.[31] The therapist forces the knee in terminal position. This method is highly subjective and rely on clinician experience.[32]
The second method is stress radiography. This method is objective and gives us reproducible measurements of medial compartment opening.

There are also studies who have suggested that diagnostic ultrasonography can be useful in evaluating MCL injuries.[33]

Manual method:
When pressing the lower leg sideways the patient will experience pain. The therapist has to touch on the inside of knee over joint line and on either side over thighbone and on shinbone. The patient should lie on his back with his legs apart while the therapist forces the knee joint apart by pushing the upper leg and pulling the lower leg. The patient will feel pain on the inside of the knee. Bruises may be present on the site of the pain. Clinical findings may be subtle even with complete tear.[34] [35]

Valgus stress testing is usually positive if the patient has experienced a MCL injury.[36] [37]

“The valgus stress test (Jacobson KE et al, 2011, level of evidence 2A) [38] [39] [40]
The hip has to be in abduction and the knee has to be at 30° of flexion or in extension.

  • This test is performed to measure the amount of joint-line opening of the medial compartment and to look for potential rotation of the tibia on the distal femur.
  • The leg is placed over the edge of the table and the examiner places his/her thigh against the patient's thigh to stabilise it.
  • The fingers of one hand are placed directly over the joint line to feel the amount of joint-line opening that occurs when the other hand creates valgus stress. Valgus stress can be created by pressure on the anterior aspect of the ankle.
  • The amount of joint-line opening can be quantified by the examiner between 0-5 mm (mild tear), 5-10 mm (moderate tear), and greater than 1cm (complete tear of the moderate complex).” [41]

Medical Management
[edit | edit source]

It is important to say that a physiotherapist treats a patient and not an injury. Every patient is unique, so the physiotherapist needs to adapt the therapy to his patient. The most frequently used interventions for MCL injury are:


  • Therapeutic exercises, like agility and sport-specific drills, are necessary to increase the ROM of lower extremity, the strength, the flexibility and the proprioception of the muscles. (Level of evidence 5) [42]
  • Inflammation and pain can be decreased by putting ice on the medial side of the knee, therapeutic ultrasound and high-voltage electrical stimulation. (Level of evidence 5) [43] [44]
  • Patellar/ soft tissue mobilizations and frictional massage. (Level of evidence 3B) [45] [46]
  • A hinged brace that needs to be worn for about 4 to 6 weeks. (Level of evidence 2A) [47] [48] [49]
  • Gait training is used to regain an efficient and effective pattern.
  • A home exercise program, but the patient has to understand why he needs to do these exercises and he needs to know exactly how to carry them out. (Level of evidence 5) [50] [51]

But the most important thing to do is to rest. It is important that the decrease in load-taking capacity is not neglected. The knee, and especially the MCL, needs time to recover.

In complex cases the MCL will not heal well, surgery is then required. An MRI scan can assess this. Any operation on the MCL should be performed within two weeks of injury.

Some surgeons describe a grade four injury to the MCL. This is called a medial column injury. It involves a more complex injury with different ligaments than just the MCL.


Physical Therapy Management
[edit | edit source]

The MCL have a good healing potential, for the ACL on the other hand there is a lower chance of complete healing of the structure.[23] It is preferably to treat MCL tears non-operatively.[22, 23] Some simple treatment steps, together with rehabilitation, will allow patients to return to their previous level of activity. The main goals of the rehabilitation are: reducing pain and swelling, restoring full mobility, improving strength and stability of the joint and returning to full activity.

The first step consists of self-management with the RICE-method: Rest, Ice, Compression and Elevation. (level 2) It will have an accelerating effect on the recovery, this needs to be started the day after getting injured. This phase only takes 48 to 72 hours. [52] [53] [54]


The treatment can roughly be divided into three phases (Wilk et al. Level of evidence 5):

  1. Maximal Protection Phase: In phase one the negative effects of immobilization needs to be avoided by starting almost immediately after the RICE- treatment with mobilizations, without the patient having pain. Using a functional brace (level 2) can allow early range of motion (ROM) and protect the knee from further valgus blow. [55] [56] [57] [58] Within the first week phase two of the rehabilitation starts by exercise all the muscles of the lower extremity to prevent atrophy, especially atrophy of the quadriceps. Because of the pain and risk of overload, the exercises need to be isometric and isotonic strengthening exercises. Stretching exercises are also recommended, but still without causing any further damage. [59] [60] [61]
    Phase one (first week after getting the injury) consists of reducing the swelling by applying cold therapy (1) and a compression. The first day after getting injured the patient needs to apply ice for 15 minutes every two hours. This frequency can gradually be reduced to three times a day (remember that ice burns, so it should do not be applied ice directly onto the skin). As soon as the pain allows it, the patient can start with some stretching exercises for the hamstring and quadriceps muscles and light static strengthening exercises. After each stretch/strengthening session, make sure the patient should apply cold therapy.
  1. Moderate Protecting Phase:
    After one week phase two can start. The main goal of this phase is to eliminate any swelling completely and to regain full ROM, still by using a brace (Level 2). [62] [63] [64] The patient still need to continue itself with the strength and stretch exercises from phase one (after each session, apply cold therapy).. Now dynamic strengthening exercises can be introduced. Each strengthening session can be introduced by dynamic strengthening exercises, for example: knee extension/flexion, half squats and step ups.[30] On alternate days, deep friction massage can be added (on alternate days). [65]
  2. Minimal Protecting Phase and Maintenance Program:
    The third phase (starting after two weeks) consists of maintaining full range of motion, equaling strength of both legs and returning to running. The patient continues the stretch- and strengthening-sessions (after each session, apply cold therapy). Building on the dynamic strengthening exercises is one of the major goals of this phase. The intensity and number of repetitions (between 10 and 20 reps) need to be increased until the strength is the same for both legs is equal. [66] [67]

Surgery can be necessary for a grade III injury, but it’s preferably to opt for non-operative treatment/healing. [68] [69] [70] [71]

Clinical Botom Line[edit | edit source]

A medial collateral ligament (MCL) injury is a stretch, partial tear, or complete tear of the ligament on the inside of the knee. A valgus trauma or external tibia rotation are the causes of this injury. This injury is categorized in 3 grades: I, II and III. The category depends on the degree of pain or degradation of the knee joint. The therapist can use the valgus stress test to see if the diagnosis is correct. There are several rehabilitation methods for an MCL injury, rest is the most important though. While resting, the MCL has time to recover. There are other rehabilitation techniques as well, like patellar/soft tissue mobilizations and frictional massage, gait training, cold therapy etc. In rare situations, surgical intervention is necessary.

Key Research[edit | edit source]

  1. Irrgang JJ, Fitzgerald GK ( 2000 ),Rehabilitation of the multiple-ligament-injured knee
  2. Yastrebov O., Lobenhoffer P. ( 2009 ), Treatment of isolated and multiple ligament injuries of the knee: anatomy, biomechanics, diagnosis, indications for repair, surgery
  3. Swenson TM (2000), Physical diagnosis of the multiple-ligament-injured knee
  4. Scheidt DK (2003), Treatment of the multiple ligament injured knee and dislocations : a trauma perspective

Resources
[edit | edit source]

  1. Roald Bahr – Sverre Maehlum- Tommy Bolic (2002), Clinical guide to sports injuries : an illustrated guide to the management of injuries in physical activity, p. 321-324 + p.328-329
  2. Paul K. Canavan (1998), Rehabilitation in sports medecine : a comprehensive guide, p. 293-295 + p. 301-304
  3. Patrick J. – Macmahon MD (2007), Current diagnosis and treatment in sports medecine, p. 77-82
  4. Francis A. Burgener (2006), Differential diagnosis in magnetic resonance imaging, p.396
  5. David E. Brown – Randall D. Neumann (2004), Orthopedic secrets, p. 328-332
  6.  

Recent Related Research (from Pubmed)
[edit | edit source]

Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=18WX1aNNAKMuvn_2wRetqhTQOVj_03DcO2vUhbyvb-Nytf0c7C|charset=UTF-8|short|max=10: Error parsing XML for RSS

References
[edit | edit source]

  1. ↑ PHISITKUL, P., et al., “MCL Injuries of the Knee: Current Concepts Review”, The Iowa Orthopaedic journal, 2006. (used on 18 December 2014) (Level of evidence 2A)
  2. ↑ CHEN, L., et al., “Medial collateral ligament injuries of the knee: current treatment concepts”, Curr Rev Musculoskelet Med., June 2008. (used on 18 December 2014) (Level of evidence 5)
  3. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  4. ↑ CHEN, L., et al., “Medial collateral ligament injuries of the knee: current treatment concepts”, Curr Rev Musculoskelet Med., June 2008. (used on 18 December 2014) (Level of evidence 5)
  5. ↑ PHISITKUL, P., et al., “MCL Injuries of the Knee: Current Concepts Review”, The Iowa Orthopaedic journal, 2006. (used on 18 December 2014) (Level of evidence 2A)
  6. ↑ INDELICATO P., “Isolated Medial Collateral Ligament Injuries In The Knee”, J Am Acad Orthop Surg, 1995. (Level of evidence 5)
  7. ↑ PHISITKUL, P., et al., “MCL Injuries of the Knee: Current Concepts Review”, The Iowa Orthopaedic journal, 2006. (used on 18 December 2014) (Level of evidence 2A)
  8. ↑ BAHR, R., et al., Clinical guide to sports injuries, Human kinetics, 2004, p.328-329. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  9. ↑ BIRRER, R., et al., Sports medicine for the primary care physician, Boca Raton, 2004, p. 632-633. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  10. ↑ PHISITKUL, P., et al., “MCL Injuries of the Knee: Current Concepts Review”, The Iowa Orthopaedic journal, 2006. (used on 18 December 2014) (Level of evidence 2A)
  11. ↑ PETERSON, L., et al., Sports injuries: their prevention and treatment, Dunitz, 2003, p. 282-285. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  12. ↑ ROACH, C., et al., “The Epidemiology of Medial Collateral Ligament Sprains in Young Athletes”,TheAmericanjournalofsportsmedicine, 2014. (used on 18 December 2014) (Level of evidence 1B)
  13. ↑ DELEE & DREZ’S, “Orthopaedic Sports Medicine”, 3th ed., 2009 fckLRLARSON RV, in “Delee and Drez Orthopedic Sports Medicine”, 2nd ed., 2003 fckLRINDELICATO P., “Isolated Medial Collateral Ligament Injuries In The Knee”, J Am Acad Orthop Surg, 1995. (internet, http://www.eorif.com/KneeLeg/MCL.html) (used on 8 October 2014)
  14. ↑ SIMS, W. F., et al., “The Posteromedial Corner of the Knee Medial-Sided Injury Patterns Revisited”, 2004. (used on 18 December 2014) (Level of evidence 2A)
  15. ↑ SCHEIN, A., et al., “Structure and function, injury, pathology, and treatmentfckLRof the medial collateral ligament of the knee”, Am Soc Emergency Radiol, 2012. (used on 19 December 2014) (Level of evidence 2A)
  16. ↑ BROTSMAN, B., “Diagnosis and Examination of MCL Injuries”, North Austin Sports Medicine, (internet, www.northaustinsportsmedicine.com/austin-sports-medicine-blog/466/diagnosis-and-examination-of-mcl-injuries/) (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  17. ↑ BAHR, R., et al., Clinical guide to sports injuries, Human kinetics, 2004, p.328-329. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  18. ↑ BIRRER, R., et al., Sports medicine for the primary care physician, Boca Raton, 2004, p. 632-633. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  19. ↑ BROTSMAN, B., “Diagnosis and Examination of MCL Injuries”, North Austin Sports Medicine, (internet, www.northaustinsportsmedicine.com/austin-sports-medicine-blog/466/diagnosis-and-examination-of-mcl-injuries/) (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  20. ↑ BAHR, R., et al., Clinical guide to sports injuries, Human kinetics, 2004, p.328-329. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  21. ↑ BIRRER, R., et al., Sports medicine for the primary care physician, Boca Raton, 2004, p. 632-633. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  22. ↑ BROTSMAN, B., “Diagnosis and Examination of MCL Injuries”, North Austin Sports Medicine, (internet, www.northaustinsportsmedicine.com/austin-sports-medicine-blog/466/diagnosis-and-examination-of-mcl-injuries/) (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  23. ↑ BAHR, R., et al., Clinical guide to sports injuries, Human kinetics, 2004, p.328-329. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  24. ↑ BIRRER, R., et al., Sports medicine for the primary care physician, Boca Raton, 2004, p. 632-633. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  25. ↑ ROACH, C., et al., “The Epidemiology of Medial Collateral Ligament Sprains in Young Athletes”,TheAmericanjournalofsportsmedicine, 2014. (used on 18 December 2014) (Level of evidence 1B)
  26. ↑ WILLACY, H., et al., “Knee ligament injuries”, Patient.co.uk, 2014 (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  27. ↑ LOGERSTEDT, D., et al., “Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain”, Journal of Orthopaedic & Sports Physical Therapy, 2010. (used on 30 October 2014 and 3 November 2014) (Level of Evidence see table 1 in article)
  28. ↑ WAGEMAKERS, H., et al., “Outcome of knee injuries in general practice: 1-year follow-up”, The British Journal of General Practice, 1 februari 2010. (used on 30 October 2014 and 3 November 2014) (Level of Evidence 1B)
  29. ↑ WILLACY, H., et al., “Knee ligament injuries”, Patient.co.uk, 2014 (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  30. ↑ LOGERSTEDT, D., et al., “Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain”, Journal of Orthopaedic & Sports Physical Therapy, 2010. (used on 30 October 2014 and 3 November 2014) (Level of Evidence see table 1 in article)
  31. ↑ DEBERANDINO, T. et al., “Medial Collateral Knee Ligament Injury Clinical Presentation”, medscapefckLR(internet, http://emedicine.medscape.com/article/89890-clinical#a0217) (used on 18 December 2014) (Level of evidence 5)
  32. ↑ RUSSELL, D., et al., “Non-invasive quantification of lower limb mechanical alignment in flexion”, informahealthcare, (used on 18 December 2014) (Level of evidence 3B)
  33. ↑ GROOD E S, et al., “Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees”, thejournalofboneandjointsurgery, 1989. (used on 18 December 2014) (Level of evidence 3B)
  34. ↑ WILLACY, H., et al., “Knee ligament injuries”, Patient.co.uk, 2014 (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  35. ↑ PETERSON, L., et al., Sports injuries: their prevention and treatment, Dunitz, 2003, p. 282-285. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  36. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  37. ↑ MARCHANT, M., et al., “Management of Medial-Sided Knee Injuries, Part 1: Medial Collateral Ligament” The American Journal of Sports Medecine, 2010. (used on 18 December 2014) (Level of evidence 5)
  38. ↑ CHEN, L., et al., “Medial collateral ligament injuries of the knee: current treatment concepts”, Curr Rev Musculoskelet Med., June 2008. (used on 18 December 2014) (Level of evidence 5)
  39. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  40. ↑ JAYANT, J. et al., Essentials Of Orthopaedics & Applied Physiotherapy, 1999, p. 533-534. (used on 19 December 2014) (Level of evidence 5)
  41. ↑ WILLACY, H., et al., “Knee ligament injuries”, Patient.co.uk, 2014 (used on 30 October 2014 and 3 November 2014) (Level of Evidence 5)
  42. ↑ PALETTA, G.A., et al., “Knee Injuries and Alpine Skiing. Treatment and Rehabilitation.”, Sports Medicine, 1994. (used on 18 December 2014) (Level of evidence 2A)
  43. ↑ WATSON, “Ultrasound therapy”, Physiopedia (used on 18 december 2014) (Level of evidence 5)
  44. ↑ READ, M., et al., Sports injuries: a unique guide to self-diagnosis and rehabilitation, Churchill Livingstone, 2009, p. 127-128. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  45. ↑ LOGHMANI, et al., Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing, Journal of Orthopaedic & Sports Physical Therapy, 2009. (used on 18 December 2014) (Level of evidence 3B)
  46. ↑ READ, M., et al., Sports injuries: a unique guide to self-diagnosis and rehabilitation, Churchill Livingstone, 2009, p. 127-128. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  47. ↑ CHEN, L., et al., “Medial collateral ligament injuries of the knee: current treatment concepts”, Curr Rev Musculoskelet Med., June 2008. (used on 18 December 2014) (Level of evidence 5)
  48. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  49. ↑ READ, M., et al., Sports injuries: a unique guide to self-diagnosis and rehabilitation, Churchill Livingstone, 2009, p. 127-128. (used on 16 and 30 October 2014, 10 November 2014) (Level of evidence 5)
  50. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  51. ↑ PARIS, M.J., “Standard of Care: Medial Collateral Ligament Sprain”, Brigham and women’s hospital Department of Rehabilitation Services, April 2008. (used on 30 October 2014 and 3 November 2014) (Level of evidence 5)
  52. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  53. ↑ ADAMS, N., “Knee Injuries”, Emergency Nurse, 2004. (used on 19 December 2014) (Level of evidence 5)
  54. ↑ SCHEIN, A., et al., “Structure and function, injury, pathology, and treatmentfckLRof the medial collateral ligament of the knee”, Am Soc Emergency Radiol, 2012. (used on 19 December 2014) (Level of evidence 2A)
  55. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  56. ↑ MARCHANT, M., et al., “Management of Medial-Sided Knee Injuries, Part 1: Medial Collateral Ligament” The American Journal of Sports Medecine, 2010. (used on 18 December 2014) (Level of evidence 5)
  57. ↑ SCHEIN, A., et al., “Structure and function, injury, pathology, and treatmentfckLRof the medial collateral ligament of the knee”, Am Soc Emergency Radiol, 2012. (used on 19 December 2014) (Level of evidence 2A)
  58. ↑ WILK, K. E., e.a., Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee, Operative Techniques in Sports Medicine, vol. 4, No 3, 1996, pp.192-201 (used on 19 December 2014) (Level of evidence 5)
  59. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  60. ↑ MARCHANT, M., et al., “Management of Medial-Sided Knee Injuries, Part 1: Medial Collateral Ligament” The American Journal of Sports Medecine, 2010. (used on 18 December 2014) (Level of evidence 5)
  61. ↑ WILK, K. E., e.a., Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee, Operative Techniques in Sports Medicine, vol. 4, No 3, 1996, pp.192-201 (used on 19 December 2014) (Level of evidence 5)
  62. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  63. ↑ SCHEIN, A., et al., “Structure and function, injury, pathology, and treatmentfckLRof the medial collateral ligament of the knee”, Am Soc Emergency Radiol, 2012. (used on 19 December 2014) (Level of evidence 2A)
  64. ↑ WILK, K. E., e.a., Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee, Operative Techniques in Sports Medicine, vol. 4, No 3, 1996, pp.192-201 (used on 19 December 2014) (Level of evidence 5)
  65. ↑ DEBERARDINO,T., et al., “Medial Collateral Knee Ligament Injury Treatment and Management”, medscapefckLR(internet, http://emedicine.medscape.com/article/89890-treatment) (used on 18 December 2014) (Level of evidence 5)
  66. ↑ DEBERARDINO,T., et al., “Medial Collateral Knee Ligament Injury Treatment and Management”, medscapefckLR(internet, http://emedicine.medscape.com/article/89890-treatment) (used on 18 December 2014) (Level of evidence 5)
  67. ↑ WILK, K. E., e.a., Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee, Operative Techniques in Sports Medicine, vol. 4, No 3, 1996, pp.192-201 (used on 19 December 2014) (Level of evidence 5)
  68. ↑ MIYAMOTO, R., et al., “Treatment of Medial Collateral Ligament Injuries”, Journal of the American Academy of Orthopaedic Surgeons. (used on 18 December 2014) (Level of evidence 2A )
  69. ↑ ADAMS, N., “Knee Injuries”, Emergency Nurse, 2004. (used on 19 December 2014) (Level of evidence 5)
  70. ↑ GABRIEL, Y. F., “Ligament Injury and Repair: Current Concepts”, Hong Kong Physiotherapy Journal, 2002. (used on 19 December 2014) (Level of evidence 5)
  71. ↑ SCHEIN, A., et al., “Structure and function, injury, pathology, and treatmentfckLRof the medial collateral ligament of the knee”, Am Soc Emergency Radiol, 2012. (used on 19 December 2014) (Level of evidence 2A)
Retrieved from "https://www.physio-pedia.com/index.php?title=Medial_Collateral_Ligament_Injury_of_the_Knee&oldid=143354"