Medial Collateral Ligament Tear with Avulsion
Fracture at Tibial Plateau
Scott Bryson
Pathology & Evaluation of Athletic Injuries
Dr. Robert Sterner
Objective: to discuss a Medial Collateral Ligament tear resulting in an avulsion fracture to the
insertion site of the MCL from a valgus force.
Background: the cause of an MCL sprain is done a few different ways. You could have a valgus
force coming from the lateral side of the knee over stretching the ligament. Another possible
way to tear the ligament is a torsion force on the knee with the foot planted and the upper
body turning away from the lower body.
Differential Diagnosis: avulsion fracture to the medial tibial plateau from a medial collateral
ligament sprain.
Treatments: surgery to tack down the avulsed piece of bone using a suture anchor. After
surgery rehabilitation is required to get the patient back to full strength and full range of
motion.
Uniqueness: usually with MCL tears there generally isn’t an avulsion fracture but this sprain
avulsed a piece of the tibial plateau.
Conclusion: having a piece of the tibia avulse off with an MCL tear is rare in sports. It is a violent
action to happen and can occur in motor vehicle accidents.
Key terms: MCL sprain, avulsion, fracture, valgus force, acute injuries, suture anchor
Personal Data:
The patient is a 21 year old male who plays basketball for his school league. He is a
about 5 foot 8 inches tall and plays point guard for his team. He works at the school in the
tutoring center so his job limits him on his feet so he will still be able to work through this
whole process.
Chief Complaint:
The history of the injury is he was playing in a game, he went up for a rebound and on
his way down he landed on a player on the opposing team who was knocked down somehow
and fell into his leg causing a valgus force on his knee as soon as he landed. The opposing player
rolled on top of his leg causing more of a valgus force and putting more of his weight onto his
knee. He said upon impact he felt a sharp pain on the medial aspect of his knee and heard a
pop. The swelling started up almost instantly and guarding had started a few minutes after he
was moved off of the court due to the severity of the injury and him being moved and not
feeling comfortable anymore. He now has some swelling and is in the rehabilitation stages after
his surgery. He hasn’t had any previous injury to his knees or any major injuries too note just
some bumps and bruises due to sports and working out.
Result of Physical Examination:
Upon observation of the injury he had medial swelling and some ecchymosis but not
much, just swelling upon initial injury. He had a much altered gait due to pain on his left knee so
he used crutches to get around. There was no visible deformity or deformity felt with palpation
due to the large amount of swelling and his apprehension for us to really touch it at all. What
little palpation was done he was tender too palpation over the medial aspect of his knee
especially over the insertion at the tibial plateau and less as you go along the medial collateral
ligament towards the thigh. He says it’s about a 7 or 8 out of 10 when palpating over the tibial
plateau because of the avulsion. His range of motion was limited in flexion due to swelling and
pain. Passive he can get a little more flexion but not much and resistive range of motion is very
limited due to pain on flexion and extension. With manual muscle testing he was at a 3 for
rectus femoris for knee extension due to pain and apprehension. I also tested semi- tendonosis
and semi- membranosus and they were also at a 3 due to pain and just overall discomfort over
the medial aspect of his knee. The patient’s neurological examination was normal with no
dermatome functional loss. He did have some myotome weakness with L-3 and S-3 with
discomfort again over the medial aspect of his knee. The special tests the initial examiner did
was a Lochman’s which was negative, they did a valgus stress test and at 0 degrees he had
laxity and gapping and at 30 degrees he had a large amount of gapping, they also did a varus
stress test which was negative. As his teammates helped him off the court they did more tests
in the locker room. The examiner did an anterior drawer for the knee and it was positive on the
medial side for a MCL sprain. The Slocum test was negative because by this time he had started
guarding and not getting positive tests anymore.
Results of Medical History
The day after his injury he received an MRI that revealed the medial collateral ligament
tear at the tibial plateau and a few days later received an x-ray that revealed the piece of the
tibial plateau that was avulsed off from the MCL tearing off. About 10 days after the initial
injury he was signed up for surgery which is the optimal time to receive surgery with an avulsed
piece of bone so it will be able to heal better and quicker. The less time waiting the better for
the bone. (Wymenga A, Kats J, Kooloos J, Hillen B.)
Usually with MCL tears they scars down well without surgery but this is a unique case in
which the insertion site at the tibial plateau was avulsed off and took a piece of bone off along
with it. (Oakes, Elizabeth H.) The procedure of the surgery starts with the patient getting put
under anesthesia as this is a pretty invasive surgery. An incision is then made over the medial
aspect of the knee where the site of the injury is suspected, in this case more towards the tibial
plateau. After the surgeon assesses the extent of the injury they then place the knee in
extension and slightly varus to take some of the slack off of the medial side of the knee. Then
the anchor is placed on the tibia, the surgeon drills a tiny hole into the bone and puts the
anchor into the tibia. Next the surgeon will then suture the avulsed piece of bone down to the
tibia where it was avulsed from. After the surgeon is sure it is tacked down and does some
functional tests like applying slight valgus force on the knee they then close everything up and
stitch internally as the suture and anchor will either dissolve and become part of the bone
tissue or they will have a tiny metal screw in their knee holding it down as bone heals around it
securing it down to the tibia. The patient is then placed in a knee brace giving them about 30-90
degrees of flexion so he is never in full extension where the MCL is tightest and also at full
flexion when it is again at its tightest. The patient was also given crutches too get around in so
he wouldn’t put any pressure on it for at least 3 weeks when he started being able to bear
weight on his leg. (Wymenga A, Kats J, Kooloos J, Hillen B.)
The operation was a success with no complications afterward. The avulsed piece of
bone reattached with no problems. Infection of the incision or on the opened area was not a
problem either.
Diagnosis
The overall diagnosis of this injury was a grade three medial collateral sprain of the left
knee with an avulsion fracture of the insertion site at the tibial plateau. The mechanism of the
injury says it all, at least for the torn MCL part of the injury. With the strong valgus force of
someone falling onto his leg and having the person roll onto the leg also just causing more
damage possibly, the MCL tear was the obvious injury. After the special test confirmed the tear
with a positive valgus stress test gapping at both 0 degrees and also 30 degrees of flexion the
next step was to see if there was any other structural damage with an MRI and X-ray. The MRI
came as no surprise with the MCL being torn and showed that everyones assessment was
correct, but with it torn at the insertion site there was some concern. When he received his Xrays it showed a relatively large piece of the tibial plateau where the MCL inserts was avulsed
off which meant he needed surgery too tack the avulsed bone back down to the tibia. (Oakes,
Elizabeth H.)
Treatment and Clinical Course
The treatment process has been going through stages. At first after the surgery the
patient was really only allowed to be in about 30 degrees of flexion to avoid full extension
where the medial collateral ligament is at its tightest. About 2-3 weeks after surgery the patient
will then start working on their range of motion starting to extend their knee to about 15-20
degrees of flexion instead of staying in 30 dgrees of flexion and also working on flexion trying to
get too about 90 degrees of flexion (Wymenga A, Kats J, Kooloos J, Hillen B.). Depending on
how the patient is feeling he then started working on some extension exercises like dragging his
foot up and down the wall to get some strength back. He also was starting doing weighted leg
extensions starting with a 5 pound weight moving his way up to 20 pounds within a few weeks.
Throughout the whole rehabilitation process the main goal has been for him to get a full
range of motion back in his knee, full strength back in his leg, and to get him back to playing as
quickly as possible without any setbacks. He was very cooperative throughout the whole
process and so far has been progress slightly ahead of schedule. He is about 6 weeks out of
surgery and still has not been able to start playing since the avulsion takes alittle longer too
heal than a normal MCL tear but he is now walking with limited limping and pain and has
started getting more and more strength in the leg every few days. Almost every other day he
receives friction massage to He can now do single leg squats at about 90 degrees of flexion
going down but not fully. He has progressed well since his surgery going to his rehab everyday
and doing everything that is asked of him throughout the whole process.(Sportex Medicine)
Criteria for Return
To determine the patients return to activity the athletic trainer in charge will have to put
him through basketball skill tests such as cutting and jumping and landing without any pain or
discomfort to the area of surgery. He will need to be honest with us and if can do all of the
sport related tests without any symptoms returning than he will be ready to return to activity.
He will also need to have 90 percent of normal strength or more in the affected leg compared
to what it was before (Meislin R.).So far along in his rehabilitation process he is about 2-3weeks
away from being able to try these types of tests.
DiscussionThis particular case study is important because of the rarity it happens and also the fact
that some people may look over avulsion part and just concentrate on the MCL tear. If the
avulsed piece of bone was over looked than it could have caused a lot more damage in the knee
capsule. Usually when there is a tear or even a suspected tear the patient will generally get
either an X-ray or an MRI or both too rule out any more structural damage so this type of thing
usually doesn’t go unnoticed.
This injury is unique because it just really doesn’t happen too often. If the MCL is going
to tear off it is generally at the femoral end where it originates not generally at the end where it
inserts. Avulsion fractures in themselves are relatively rare but do happen and need to be
noticed so no more structural damage can be done. The medial collateral ligament is the most
common ligament in the knee to be injured, but the avulsion fracture at the tibial plateau
makes this injury unique and rarely seen in sports.
Conclusion
Throughout this assignment I learned how the surgery process of an avulsion fracture is
done and how uncommon these types of injuries do happen. Before I would have thought that
the tibial insertion would be the most common way to avulse a piece of bone off but doing this
case study I have learned that it is actually rare to have the insertion and the origin along the
femur is the most common. This was an interesting and intriguing case study and I learned a lot
of new information on medial collateral ligament sprains, tears and avulsion fractures.
References
1.Oakes, Elizabeth H. "medial collateral knee ligament (MCL) injury." Health Reference Center.
Facts On File, Inc. Web. 2 Dec. 2012.
<http://www.fofweb.com/activelink2.asp?ItemID=WE48&SID=5&iPin=ESM0096&SingleRecord
=True>.
2.Wymenga A, Kats J, Kooloos J, Hillen B. Surgical anatomy of the medial collateral ligament and
the posteromedial capsule of the knee. Knee Surgery, Sports Traumatology, Arthroscopy [serial
online]. March 2006;14(3):229-234. Available from: SPORTDiscus with Full Text, Ipswich, MA.
Accessed December 2, 2012
3.AMIN D. REHABILITATION OF A MEDIAL COLLATERAL LIGAMENT TEAR: A STRUCTURED CASE
ANALYSIS. Sportex Medicine [serial online]. October 2011;(50):25-29. Available from: SPORTDiscus
with Full Text, Ipswich, MA. Accessed December 3, 2012.
4.Meislin R. Managing collateral ligament tears of the knee. / Soigner les dechirures collaterales
du ligament du genou. Physician & Sportsmedicine [serial online]. March 1996;24(3):67-70;7374;79-80. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed December 6, 2012