rashadjennings

The Medial Collateral Ligament (AKA Tibial Collateral Ligament)

Starring Rashad Jennings

            Strangely, the one experience that made me feel like a professional athlete was when I injured my medial collateral ligament (MCL, AKA tibial collateral ligament). Playing in my JV year of Amador Valley High School football, the weekly Wednesday night practices were a team favorite because playing on turf and under the lights added to the feeling of primetime. But on that particular Wednesday night, after catching a pass on a drag route, I planted, turned and embarrassingly collapsed onto the turf. My MCL was torn; out of service for 6 weeks. Sometime after, I saw Dallas Clark, Tight End of the Indianapolis Colts, catch a pass from Peyton Manning, turn, and collapse the same way I did! His tight end position, drag route, lights, and collapse onto the turf in a non-contact injury were all similarities I held with the underrated Dallas Clark. A 6-year, $41 million contract extension was the only thing that separated our lives! Well…maybe just one of a few differences…

            The MCL is an 8-10 cm long, hour glass shaped, ligament on the outside of the knee that connects your femur (thigh bone) to your tibia (shin bone). Along with the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), the MCL is one of many ligaments that support the medial knee. Its location, along with other medial structures, resists valgus forces (knock knees) and external tibial rotations. Changes in direction and lateral movements are very demanding on the MCL.

            Risk factors for MCL injuries include prior history of MCL injury, level of play, involvement in contact sports, access to equipment, and the shoe-surface interface. 40% of all knee injuries involve ligament damage (Bolten, 2000) with the MCL being the most common casualty (Wilk et al., 1996). Traumas to other ligaments are observed in 20-78% of all MCL injuries (Indelicato et al., 2003). These multi-ligament injuries occur frequently because the MCL and posterior oblique ligaments attach to the medial meniscus, a fibrocartilaginous tissue in the knee joint that disperses the friction generated between the femur and tibia.

            When the knee “buckles” and collapses, an MCL injury could occur. Receiving a direct blow to the knee, getting “rolled up” under a pile or catching onto the playing surface with your foot are events that could involve an external tibial rotation. Amador Valley High School “Wall of Fame” Center and fellow victim of a Grade II MCL sprain, Mike “Slim” Lady, recounts one such event, “As I ran upfield [to block a linebacker at the next level], I felt someone trip over my planted right foot from behind and fell on my leg. I felt a couple of pops as I went down…” These pops are often the result of a ligament or tendon that has been stretched over a bony lump around the joint and then snapping back into place. More than one pop could also occur when the knee is hyperextended, which could be more of a cause for concern, as it usually includes multiple ligaments and the peroneal nerve, a branch of the sciatic nerve that supplies movement and sensation to the lower leg, foot, and toes (Takagi et al., 2002).

            As usual, a Grade I-III scale is used to measure the severity of the MCL sprain:

  • Grade I – Few fibers are torn but the MCL is largely intact. Less than 5mm of joint opening.
  • Grade II – An incomplete MCL tear with some remaining ligamentous integrity. 5-9mm joint opening.
  • Grade III – A complete tear and laxity of the knee joint (more than 10mm joint opening) may suggest that other knee ligaments are involved.

Depending on the degree of sprain, scar tissue will form, causing a decrease in range of motion. Initial symptoms of injury may also differ between cases. For example, I had to be carried off the field and couldn’t bear any weight after my Grade II sprain. In contrast, Slim was able to jog back to the huddle after the same sprain grade and attempt another play before deciding that he shouldn’t be playing on a Slideboard. Could this be simply a question of toughness? Haha, no comment. However, all MCL sprains heal in four classic stages of hemorrhage, inflammation, repair, and remodeling.

            Fantasy owners can breathe a sigh of relief, as MCL sprains do not require surgery for repair. As mentioned earlier, this may be because of its well-vascularized and innervated anatomy, which allows the area of injury to be supplied with the nutrients they need to recover quickly. MCL injuries demonstrate better healing and faster recovery compared to proximal or distal ligaments (Creighton et al., 2005). Halinen et al. (2009) could not identify any significant differences in stability, motion, strength, or speed of return between nonoperative and surgically repaired Grade III MCL sprain patients. In addition, Sandberg et al. (1987) found no difference in outcome among 200 randomly selected patients who received nonoperative or operative treatment for their MCL injuries.

            Diagnosis of the MCL involves feeling how loose or far the knee deviates away from the joint. Upon examining Slim’s knee, his physician observed that his leg “really opened up”. RICE-ing (rest, ice, compress, and elevate) and gradually returning to exercise is vital for recovery but may seem like a slow progress (especially if you were competing for a starting position like Slim was!). Players usually return sporting a custom-fitted knee brace to protect and limit the chance of reinjury although most NFL players will complain that its bulk slows them down (some NCAA teams make it mandatory for all their linemen to wear knee braces, but upon arriving to the NFL, most shed the brace in favor of the split second of quickness they previously sacrificed) (Creighton et al., 2005). On average, a return time of 3-6 weeks is expected, but this depends from athlete to athlete.

Relevant Players:

  • Rashad Jennings, RB, New York Giants: Early reports indicate that Jennings will need more time to recover from his MCL injury in Week 5. In addition to the last three weeks, Jennings will have a few extra days to be evaluated because of the Monday night kickoff time. This is already a longer recovery time than a similar injury he suffered during Week 1 of the 2012 season in which he missed only 2 games. I am a little surprised that the Giants were quick to determine him unavailable for this week’s contest because of the extra time he had to recover. This has me suspicious of a more serious injury than the previous consensus and I would be worried of his ability to perform in Week 10. But past next week, I have no doubt that Jennings will be a fantasy stud. Since Tom Coughlin took the helm, the Giants have deployed more running plays in the red zone than any team in the league. In the fantasy playoffs (usually Week 14-17), the Giants will have enticing matchups against the Titans, Redskins, Rams, and Eagles.
  • Darren Sproles, RB, Philadelphia Eagles: I am still nervous after hearing Sproles’ injury was diagnosed as only a “mild” sprain. A dynamic, speedy, don’t-blink-because-he-might-reverse-it-for-a-TD player, Sproles demands the most out of his MCL because of how much he changes direction in his running style. The bye two weeks ago helped him miss only one game, but the requirements of his playing style and the emergence of LeSean McCoy have me hesitating. 
  • Ryan Mathews, RB, San Diego Chargers: Mathews may have the most serious MCL injury out of all of the players discussed in this column. He has already missed 6 weeks and the high level play from Branden Oliver has put a damper on his fantasy stock. Mathews was spotted running agility drills and sprints in the Thursday, Week 8 matchup against the Denver Broncos and could possibly play Week 9. Many fantasy analysts are forecasting a 50-50, Mathews-Oliver split when Mathews returns so if you only need 3-5 points, go for it.
  • Nick Fairley, DT, Detroit Lions: One of the league’s premier pass rushers, Nick Fairley has helped the Detroit Lions rank #1 in total defense and #2 in rush defense (#5 in Pass Defense just in case you were wondering). Needless to say, spraining his MCL and PCL is a big blow to the Lions D. Fantasy owners shouldn’t rush to drop them, but I would keep a close eye on their fantasy production going forward.
  • Jadeveon Clowney, DE/LB, Houston Texans: In contrast, the Houston Texans have someone coming back from injury to bolster their defense. After missing 7 weeks with a MCL sprain, Clowney returned to a Texans defense that ranked 23rd in total defense. He only made 1 tackle and is probably, understandably rusty. However, don’t forget that Clowney is only a rookie and was injured midway into his first game of the season, which means that last week’s performance was his first full game of his career. The Texans D could be a sneaky pick-up for the fantasy playoffs (Jaguars, Colts, Ravens, Jaguars) and once Clowney gets more acclimated to game speed.

 

On Deck: Jimmy Graham’s Shoulder Sprain

In the Hole: Donnie Avery’s Hernia

And special thanks to my teammate, neighbor, and longest friend, Mike “Slim” Lady, for contributing to this piece!

Reference:

  1. Wilk, KE, Andrews, JR, Clancy, WG. Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee. Op Tech Sports Med 1996; 4:192.
  2. Indelicato, P, Linton, R. In: DeLee and Drez Orthopaedic Sports Medicine, DeLee, J, Drez, D, Miller, M (Eds), Saunders, Philadelphia 2003. p.1937.
  3. Takagi T, Nakao Y, Takayama S, Toyama Y. Traction injury of common peroneal nerve associated with multiple ligamentous rupture of the knee: a case report. Microsurgery 2002; 22:339.
  4. Creighton, RA, Spang, JT, Dahners, LE. Basic Science of Ligament Healing: Medial Collateral Ligament Healing With and Without Treatment. Sports Med Arthrosc 2005; 13:145.
  5. Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am 2009; 91:1305.
  6. Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am 1987; 69:1120.