A 24-year-old male player presented following an injury sustained when landing from a heading duel. He reported landing awkwardly on his left leg and feeling his left knee “buckle” under him. There was immediate pain, some swelling and an inability to continue to play.
A week after his injury, he could stand and mobilise with crutches. He had a small effusion, could achieve full extension and could flex to just beyond 90 degrees. There was gross laxity with Lachman test. There was high grade laxity with a MCL stress test in 30 degrees of knee flexion but minor laxity only when assessed in full extension. His PCL and LCL appeared clinically normal.
An x-ray series of the knee was normal. The MRI confirms a ruptured anterior cruciate ligament with high signal and a loss of the normal fibrillar pattern. There is a severe grade two injury bordering on rupture of the medial collateral ligament. This ligament is also thickened, irregular and contains high signal. In addition to this, the images show a moderate grade interstitial tear of the posterior cruciate. Other images (not shown here) suggest a minor sprain of the proximal fibular collateral ligament.
This payer was managed with a four-week period of immobilisation in a range of motion brace. During this period he was allowed to perform ROM exercises and quadriceps activation exercises. After this period of bracing his knee function and MCL laxity had improved significantly. He then underwent an uncomplicated ACL reconstruction (with a patellar tendon graft) and was able to return to play approximately nine months following his surgery. At the time of his return to play he had mild residual laxity of his MCL when assessed in 30 degrees of flexion. This was entirely asymptomatic.
In general, multi-ligament injuries of the knee are usually best treated with early surgical stabilisation. Combined ACL and MCL injuries are a good example of this although a variety of treatment protocols have been described. As illustrated in this case, one option is to delay surgery to try to allow the MCL to heal. This allows the patient to recover from the initial trauma and to regain some function prior to surgery. This may allow them to progress their rehabilitation more successfully post-operatively. Another strategy is to proceed with early surgery. In this case both the ACL and MCL are reconstructed (or the MCL is repaired). This may provide a more predictable outcome in terms of reducing ligamentous laxity and is often preferred when the injury to the MCL is more significant (and there is more laxity).
With the increasing use of MRI scans to evaluate knee injuries, and with better quality imaging protocols, it is now very common to see abnormalities involving multiple knee ligaments. It is always important to correlate these radiological findings with the player’s clinical findings. In many cases these radiological findings are not clinically relevant. This is illustrated well in this case. The reported MRI abnormalities relating to the PCL and LCL were not associated with any clinical laxity, either when assessed in clinic or under anaesthetic. As a result, they do not require any specific treatment.
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