RICE & MICE will periodically review injuries that are common, uncommon or just plain unique in hockey. I hope to provide some insight to the “how’s, why’s, and when’s” of the injuries that might keep players out of the lineup.
The medial collateral ligament or MCL is one of the oft injured ligaments in contact sports, especially ice hockey and football. As its name indicates, the MCL is on the medial or inside part of each knee. It is most often injured when contact is made to the lateral or outer portion of the knee, however the injury can also occur during hyper-extending or twisting movements. The MCL mainly functions to provide stability, along with the three other “main” ligaments of the knee. The other ligaments are the lateral collateral ligament (LCL), the anterior cruciate ligament (ACL), and the posterior cruciate ligament (PCL). Of these four ligaments, the MCL and the ACL are most often injured and are commonly injured at the same time, though in these cases the injury to the ACL is more severe and debilitating.
The MCL is composed of deep and superficial layers. The superficial layer is the strongest and is further separated into anterior (towards the front) and posterior (towards the back) portions. When the knee is bent, the front edge of the MCL tightens, while the back portion is relaxed. This particular ligament is unique in that it also has a decent blood supply which allows for a faster recovery time than other ligament injuries. The deep portion of the ligament is less involved with support and protecting the knee during hits to the outside of the knee or twisting, but it is attached to part of the medial meniscus.
As with other types of ligament sprains, there are 3 grades of MCL sprains. A grade 1 sprain involves stretching or tearing of some of the fibers in the ligament. Pain and tenderness are mild and there is very little swelling. Grade 2 sprains involve more tearing of the ligament and with that come more pain, swelling and instability of the ligament. There may be mild to moderate bruising of the skin on the inner part of the knee. A grade 3 sprain is a complete tear of the ligament and can be devastating if it were any other ligament. This is one of the rare instances that a completely torn ligament will heal with proper care and does not require surgery.
With grade 1, the athlete may feel a twinge when the sprain occurs. Sometimes the player will continue playing until the practice or game is over only to experience pain later. With grade 2 sprains, there is usually still a twinge and some degree of instability felt. The athlete may or may not continue in the practice or game. With grade 3 sprains, there is usually a pop and the athlete is unable to participate in the sport any longer. Remember, the more severe of a sprain to the MCL, the more likely there is to be another injury.
MCL sprains can occur with other associated injuries, such as ACL or PCL tears and injuries to the meniscus. Other structures within the knee may be injured in association with the MCL. The ACL is injured in approximately 20% of grade 1 injuries and up to 75% of grade 3 injuries. The medial meniscus may also be injured and the incidence and severity increase in direct proportion to the extent of the MCL injury. Lastly, in some cases, one of the quadriceps muscles (the one on the inner part of the quads) is also injured. I will cover some of these injuries another time.
MCL injuries are treated with RICE – rest, ice, compression, and elevation. If anyone has seen the first episode of HBO’s 24/7, Capitals defenseman Mike Green was held out of action due to an MCL sprain. In one scene, he is sitting on a training table using a Game Ready ice machine. That particular machine performs intermittent compression as well as ice therapy. Other treatments utilized for this type of sprain include: electric stimulation, ultrasound and heat. Even non-conventional remedies and treatments, such as prolotherapy and acupuncture have found use here. The most important aspect of treating this injury is rehabilitation that focuses on decreasing swelling, maintaining range of motion, and strengthening the muscles around the knee.
After the initial injury, weight-bearing is often supported with crutches until a normal gait is obtained and the athlete no longer limps. Most grade 1 and 2 sprains will only require crutches for a few days. Sometimes, athletes will use a hinged brace or knee sleeve as their activity level increases. Utilizing a hinged brace is much more common in grade 3 sprains. Crutches are usually necessary for a couple of weeks.
After the RICE phase of treatment plans, the goal is to restore full range of motion (ROM) and incorporate some mild strengthening. Once ROM and strength are sufficiently restored, the athlete will progress to sports specific training, including plyometrics and agility drills. Upon achieving full strength and pain-free ROM in the lower extremity, the athlete can be cleared to return to their sport.
Mild, Grade 1 MCL sprains may keep a player out of action for 10-14 days at most, but usually the time missed is far less than that. Grade 2 sprains require more time and rehab and will keep a player sidelined for around 3 weeks as we saw with Flyers left wing, Daniel Carcillo, in the latter part of November and early December. People with grade 3 injuries frequently require 6 or more weeks before a return to play. Oilers center Shawn Horcoff is estimated to miss 8 weeks with his right MCL injury, which points to a more severe, grade 3 sprain.
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