1. MCL and LCL Injuries

2. Normal Anatomy

4. Mechanism of Injury MCL Valgus stress Most commonly s-MCL d-MCL injuries rare although possible with only low grade s-MCL injuries LCL Severe, high-energy, direct varus stress Uncommon due to relative flexibility of LCL and decreased incidence of lateral stress

5. Classification Grade 1 Clinical - Local pain on no significant gapping on varus / valgus stress MRI - Microscopic tears of individual fibers with associated swelling Grade 2 Clinical – Broader area of pain, significant gapping on varus / valgus stress with firm end feel MRI - Macroscopic partial tears with high signal in the ligament or morphological changes on MRI Grade 3 Clinical – No definitive end point on varus / valgus stress MRI - Complete ligamentous discontinuity

6. Associated Pathologies ACL injuries PCL injuries Avulsion fractures Medial meniscus tears Meniscocapsular separations Bone bruising

7. Subjective History of varus / valgus or rotational stress injury Pain over lateral or medial knee Instant swelling Pain when weight bearing

8. Objective Pain on palpation of injured site MCL – Pain end of range flexion Varus / valgus stress painful and/or laxity – Grade I – No movement – Grade II – 3-5mm joint opening – Grade III - >5mm joint opening

9. Special Tests Varus stress test (LCL) Valgus stress test (MCL)

10. Further Investigation Varus / valgus stress radiographs MRI Ultrasound imaging

11. Management Conservative Grade I-II injuries Isolated s-MCL grade III injuries Surgery Isolated grade III injuries which do not respond to conservative management Grade III injuries with associated pathology

12. Conservative - Management Decrease weight bearing to allow pain free ambulation Hinged knee brace to prevent varus / valgus stress Maintain full ROM Maintain quads strength Maintain adductor strength (adductor longus insertion lies in close proximity to MCL) Progress to full weight bearing once limp has disappeared Stationary bike as soon as tolerated (has been shown to improve healing times) Return to play within 3 weeks (mild injuries) or 5-10 weeks (severe injuries)

13. Conservative – Management - Mild

14. Conservative – Management- Severe

15. Surgical - Management Reconstruction – MCL: Two separate grafts, four insertions