Collateral Ligament and Multiple Ligament Injury

Andrea Tychanski, PT, DPT, SCS, ATC, CSCS

John Cavanaugh, PT, ATC, SCS

Anil S. Ranawat, MD

Dr. Ranawat or an immediate family member has received royalties from Conformis; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, CONMED Linvatec, DePuy Mitek, and Stryker MAKO; serves as a paid consultant to Arthrex, CONMED Linvatec, DePuy Mitek, and Stryker MAKO; has stock or stock options held in Conformis; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Saunders/Mosby-Elsevier and Springer; and serves as a board member, owner, officer, or committee member of Current Trends in Musculoskeletal Medicine and the EOA. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Cavanaugh and Dr. Tychanski.

Introduction

Stable motion of the knee requires the coordinated function of the ligaments, menisci, muscles and bone structure. The knee has four major ligaments: the 2 cruciates controlling anterior posterior motion and the 2 collaterals, which control varus and valgus stability. Detailed biomechanical evaluation has shown a more complex function in controlling rotational movement by these ligaments and other structures, especially in the posterolateral corner. Injuries to these ligaments occur as a result of sports activities, falls, and motor vehicle crashes. They mostly occur as single-ligament injuries, but also occur in combination with one another. The medial collateral ligament (MCL) is often injured with the anterior cruciate ligament (ACL) while the lateral collateral ligament (LCL) in combination with the posterior cruciate ligament (PCL) and posterolateral corner (PLC).

Collateral Ligament Injuries

Collateral ligament injuries can range from a minor isolated grade 1 sprain to a complete grade 3 tear, often in the setting of multiple ligament knee injuries (MLKIs). Isolated collateral ligament sprains are commonly managed nonoperatively with a progressive rehabilitation program. Initial treatment for an isolated grade 1, 2, or 3 collateral injury includes rest, ice, and compression to limit edema and permit healing of the injured ligament. Grades 2 and 3 collateral ligament injuries are initially managed with the protection of a hinged brace. Weight bearing will be restricted for 2 to 4 weeks for grade 2 injuries and 4 to 6 weeks for grade 3 injuries. Typically, the higher the grade of ligament damage, the longer the recovery period, ranging from days to multiple weeks. Rehabilitation for an isolated collateral ligament injury follows a symptom-based range of motion (ROM) and lower extremity strengthening progression. In the early phases of rehabilitation, the clinician should be cautious when incorporating exercises in the frontal and transverse planes in order to protect the collateral ligaments from excess stress. Proprioceptive training exercises are incorporated throughout the rehabilitation program. Following a criteria-based rehabilitation program, the injured ligament is then reevaluated and the final decision to return to play is determined.

Collateral injuries are often combined with ACL injuries. Should the healing response not be effective in the preoperative phase, the collateral ligament is often surgically augmented concomitantly with an ACL reconstruction.

Multiligament Knee Injury

With larger traumatic forces, such as those occurring in motor vehicle accidents and sporting event collisions, MLKIs inclusive of the cruciate ligaments are common. Knowing the mechanism of injury is often helpful to the examiner to determine what side of the knee was in tension versus compression. Evaluation of an MLKI begins with a thorough neurovascular examination followed by a physical examination, including assessment of ligaments and the extensor mechanism. Arterial compromise and nerve disruptions are known to occur with these injuries. Radiographs and MRI can assist in assessing the degree and location of soft-tissue damage. Aside from assessment of ligamentous structures, MRI permits assessment of other structures, including menisci, articular cartilage, and bone.

More extensive injuries involving multiple ligaments commonly require surgical intervention. The goal of treatment is to anatomically repair and/or reconstruct all necessary ligamentous and other associated injuries. In low-demand patients,
there is a role for nonsurgical treatment for MLKI. Excluding neurovascular injury, initial treatment for an MLKI is brace immobilization in extension. If there is more extensive injury, such as a knee dislocation, prompt imaging and reduction is paramount. Emergency surgery is usually not necessary unless there is vascular injury, irreducible knee, or traumatic arthrotomy. In most cases, surgery is delayed 1 to 3 weeks to permit reduction of effusion, capsular healing, establishment of ROM, and time for surgical planning. There is debate regarding the optimal time to proceed with surgery. Early surgery affords the best chance for primary repairs, but increases chances for postoperative stiffness. The decision to operate with MLKI is usually dependent on multiple factors, including the patient, affected structures, and surgeon preference.

Early surgery allows primary repair of some injuries, but may use augmentation procedures. Early surgery is commonly indicated for cruciate injuries with repairable PLC injuries. With lateral side involvement, surgery is performed at 2 weeks postinjury. The cruciate ligaments are usually reconstructed and the lateral structures are primarily repaired with or without augmentation. However, in certain cases, these surgeries may be delayed if the risk of stiffness is felt to be too high. With injury on the medial side of the knee, there is a tendency to be more conservative and delay surgery. Likewise, many low-grade MCL sprains with bicruciate injuries are often rehabilitated first to restore knee motion and then undergo delayed surgical reconstructions. Certain high-grade medial injuries that are tibial sided benefit from early surgery. The cruciates can be reconstructed simultaneously or staged depending on the risk of stiffness.

Surgical Technique

There are numerous surgical techniques for these injuries. For the most part, cruciates are reconstructed and collateral ligaments are repaired if the injury is acute. However, they are reconstructed (vs. repaired) when the injury is chronic or the quality of the tissue is too compromised for repair. There are numerous cruciate reconstruction techniques utilizing a single- or double-bundle ACL, but a single-bundle ACL and PCL is the gold standard with multiligament knee. These involve drilling bone tunnels in the femur and tibia, and passage of the graft, as described in the ACL Reconstruction chapter (Chapter 48). Given the number of tunnels, attention must be paid to their trajectory to limit the risk of fracture. For collateral reconstruction, there exists multiple techniques as well, such as Larson, LaPrade, Bosworth, and others, but no technique has been found to be superior; therefore; the surgeon uses one’s preferred technique. Stability is restored through accurate graft placement and secure fixation.

Optimal order for tissue repair takes an inside out approach, which includes open meniscal repair, capsular repair followed by collateral ligament repair/augmentation. Cruciate reconstruction or repairs are also performed. Grafts are chosen based on preference and availability; however, with an MLKI, allograft tissue is commonly used. Autograft choices include ipsilateral or contralateral bone–patellar tendon–bone, hamstrings, and quadriceps tendon. Allograft options include Achilles tendon, bone–patellar tendon–bone, hamstrings and tibialis anterior. Optimal order for tissue repair includes open meniscal repair, cruciate ligament reconstruction, capsular repair, and, last, collateral ligament repair or reconstruction.

Following surgery, achieving a balance between motion and protection is important in healing and recovery. Although a hinged brace is often sufficient, in certain cases, some surgeons use a hinged external fixator during the initial postoperative phase.

Rehabilitation

The pace and intensity of rehabilitation is governed by many factors, but particularly the degree of injury and patient goals. More complex injury and higher patient goals require greater involvement of the patient, therapist, and surgeon. The rehabilitation is consequently tailored to each individual.

Collateral and Cruciate Rehabilitation

Phase 1: Early Protection Period

Rehabilitation of a cruciate reconstruction with a collateral ligament injury is similar to isolated cruciate reconstruction. Postoperative weight bearing is protected for 6 weeks utilizing a long-leg brace locked in extension. Restoring knee extension is an important early postoperative goal. Knee extension is best restored by placing a towel roll under the patient’s ankle and allowing gravity to passively stretch the knee into extension (Figure 51.1). To encourage quadriceps re-education, the patient is encouraged to perform isometric quadriceps sets with a towel roll under the knee multiple times per day (Figure 51.2). If the patient demonstrates inhibition of the quadriceps muscle, a neuromuscular electrical stimulation (NMES) unit is utilized to facilitate quadriceps activation. Once the patient demonstrates adequate quadriceps activation, supine straight leg raises are initiated with the brace locked
in extension. Straight leg raises in all other planes are also performed to strengthen the hip musculature. Distal lower extremity strengthening and flexibility begins in the first phase; this typically includes ankle plantarflexion with a resistance band (Figure 51.3) and seated calf stretching with a strap. In addition, the hamstring muscles are stretched in the supine position with a strap; caution is advised if the hamstring tendon was harvested for ligament reconstruction.

Figure 51.1 Photograph of passive knee extension with a towel roll under the ankle.

Figure 51.2 Photograph of isometric quadriceps activation with a towel roll under the ankle. Hold each contraction for 10 seconds for 10 repetitions, 5 or more times per day.

Phase 2: Gait Restoration

Following the immediate protection phase, the brace may be unlocked as the patient demonstrates the ability to perform a straight leg raise without a lag. Gait re-education with crutches is emphasized to facilitate a normal gait pattern. The patient is then gradually weaned from two crutches to one crutch or cane, then eventually to no assistive device. Criteria for advancement include a nonantalgic gait, the ability to perform straight leg raises without a lag, and no pain with ambulation. Retrograde ambulation on a treadmill with 0% incline and upper extremity support may be performed to assist in normalizing gait (Figure 51.4). Ambulation in a therapeutic pool or underwater treadmill (Figure 51.5) can also assist with gait re-education. Water aids with support of body weight and decreases loads on the lower extremities to facilitate normalization of movement patterns. With demonstration of a normalized gait, the patient will transition to use an off-the-shelf functional brace to protect the injured ligaments.

Figure 51.3 Photograph of ankle plantarflexion with a resistance band.

Figure 51.4 Photograph of retrograde ambulation on a treadmill, initiated at 0% incline and performed at a slow speed to encourage lower extremity control.

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