Medial collateral ligament injuries in football
Nonoperative management of gradeI and grade II sprains *
GARY L. DERSCHEID,† RPT, ATC,
From †Affiliated Physical Therapist Limited, Phoenix, Arizona,
ABSTRACT
During four academic years (1974-1978) at a major
university, 51 of 70 knee injuries sustained by football
players were GradeI or II sprains of the medial collat-
eral ligament of the knee. All were managed identically
with an active rehabilitation program involving partial
or no immobilization. Players with Grade I sprains
returned to full, unprotected participation after an
average of 10.6 days of time loss; those with Grade II
sprains returned after 19.5 days. Neither group
showed an appreciably increased likelihood of rein-
jury. The likelihood of sustaining any knee injury was
more than three times greater during spring as op-
posed to fall football.
INTRODUCTION
There are few injuries in sports that have received more
attention than those involving the knee. Likewise, there are
few sports more closely associated with knee injuries than
football. To the participant and the news media, the &dquo;foot-
ball knee&dquo; is a distinct entity. To the sports medicine com-
munity, knee injury (usually associated with football) is
viewed with such concern that it often provides the sub-
stance for entire meetings or conferences.
The rationale for surgical management of a complete
collateral ligament tear (Grade III sprain) has been docu-
mented by both Clayton et al.1 and O’Donoghue et al.2
Although one might argue that the method the investigators
used for dividing the ligament in animal models was not
similar to the clinical ligament tear, the fact remains that
the end results, i.e., complete loss of ligament continuity
with the resulting instability, were the same.
’ Presented at the Amencan College of Sports Medicine, May 1979,
Honolulu, Hi
§ Address correspondence to James G Garrick, MD, Center for Sports
Medicine, St Francis Memonal Hospital, 900 Hyde St , San Francisco, CA
94109
365
AND JAMES G. GARRICK,ठMD
and the ‡Center for Sports
Medicine, San Francisco, California
Unfortunately, less severe sprains (Grade I and Grade II)
are not only more common, but are also more difficult to
study. Creating identical Grade I or Grade II medial collat-
eral ligament sprains in an animal model would be a difficult,
if not impossible, task. Thus it would appear that the eval-
uation of treatment options for Grade I and Grade II sprains
currently rests in the clinical sphere.
Elsasser et al.3 reviewed the results of nonoperative, non-
immobilization treatment of 64 partial tears of the medial
collateral ligament. Bergfeld,4O’Connor,5 and Cox6 have also
presented management regimes for this type of injury. Al-
though the exact techniques of treatment differ among these
authors, the consensus appears to be that the vast majority
of football players sustaining this type of injury return to
full participation within six to eight weeks.
Evaluation of the effectiveness of any treatment regime
requires that a number of variables be held constant. The
extent of the injury must be the same. The components of
the treatment regime, as well as the interim goals at various
stages of treatment, should be the same. This is not to imply
that individualized treatment should not be employed. Such
individualization should, however, be based on how fast the
patient goes through the program (i.e., attains various goals)
rather than what program is used.
Determining the effectiveness of the treatment might be
viewed as a continuum of observations that includes the
athlete’s ability to attain specific rehabilitation goals, return
to full participation, and continue participating without an
increased risk of subsequent injury or reinjury.
This investigation prospectively studied a group of football
players who had sustained injuries which met specific and
unchanging diagnostic criteria. They were treated according
to a specific protocol and were observed for the presence of
injuries after they returned to participation.
METHODS
The investigation was carried out from the fall of 1974
through the spring of 1978. During this period the same
athletic training staff evaluated and rehabilitated all injuries.
366

TABLE 1 TABLE 2
Knee examination Knee rehabilitation program

In addition, all football players underwent preseason evalu-

ations in which the same functional criteria were used.
Knee injuries were catalogued according to the criteria
presented in Table 1. All injuries not fulfilling these criteria
were categorized as &dquo;other&dquo; and were not included in the
rehabilitation portion of the study. All grade I and II sprains
of the medial collateral ligament were placed on a standard
rehabilitation program (Table 2). Upon return to full partic-
ipation, none used any brace or taping procedures to enhance
stabilization of the knee.
None of the injured athletes judged to have sustained an
isolated Grade I or II sprain of the medial collateral ligament
were subjected to arthrography or arthroscopy. In view of
the fact that, by definition, none of these injured athletes
had any evidence of injury to the cruciate ligaments or
menisci (i.e., none developed large effusions or exhibited
anterior instability, as judged by Lachman and drawer tests),
it was believed that additional special examinations were not
warranted

RESULTS

Four hundred forty-two athletes participated in the four fall

seasons (average, 110 players per season) and 394 in the four
spring practices (average, 99 per spring). Participants aver-
aged 82 exposures (i.e., practices and games) each fall and 20
exposures each spring.
A total of 70 knee injuries, involving time loss from prac-
tices or games, occurred during the study. Fifty-one (73%)
were classified as Grade I (N 23) or Grade II (N 28)
= =
Table 4 also illustrates various means of expressing injury
sprains of the medial collateral ligament. The structures rates for fall and spring exposures. When rates were based
involved in the remaining 19 injuries are presented in Table the likelihood of occurrence of these
on player exposures,
3.
particular injuries was over three times greater in the spring
Table 4 shows when Grade I and II sprains occurred. than in the fall.
Sixty-three percent of all knee injuries and 59% of the grade Table 5 identifies the positions played by those who
I and II sprains occurred during the fall. sustained knee injuries. Overall, injuries were slightly more
likely to occur in defensive team members, with the middle
II
During the penod of the study, arthroscopy was routmely performed on guard position (9%) most frequently involved. Defensive
all individuals with any evidence of injury to either of the cruciate ligaments tackles were next most likely to sustain these injuries (7%

TABLE 3
Knee injuries other than isolated MCL&dquo; I-II
a
The abbreviations used are MCL, medial collateral ligament;
AC, acromioclavicular, MM, medial memscus; LM, lateral meniscus;
PC, posterior cruciate
TABLE 4
Grade I and II medial collateral liagment sprains
TABLE 5
Team position of injured
per tackle), followed by running backs (6.5% per back), tight
ends (6%), and linebackers (6% per linebacker).
A total of 789 practices and games were missed as a result
of the Grade I and II medial collateral ligament sprains, for
an average of 15.5 days per injury. The Grade I sprains
resulted in a mean of 10.6 activity days lost (range, 4 to 19
days), and Grade II sprains resulted in a mean of 19.5 days
lost (range, 12 to 28 days).
During the period of study, 14 players sustained two knee
injuries each. Ten of these 14 injuries involved the contra-
lateral knee (Table 6), eight of which occurred in players
who originally sustained Grade I or II injuries. Only 30% of
367
TABLE 6
Second injury-contralateral knee
_ _
a
F, fall.
b S, spring.
_
TABLE 7
Reinjuries
a
This reinjury required surgical treatment.
the subsequent injuries were Grade I, whereas 50% of the
original injuries were Grade I.
Four injuries were classified as reinjuries (Table 7). Only
one injury was more severe (higher grade) and involved
greater time loss than the original injury.
Even though two of the subsequent ipsilateral injuries
occurred more than a year after the original problem, they
must be considered &dquo;reinjuries&dquo; because the same structure
(medial collateral ligament) was involved in both episodes.
The likelihood of ipsilateral reinjury following a Grade I or
Grade II medial collateral ligament injury treated in the
manner described was 8.33 per hundred previously injured
participants. The likelihood of sustaining a Grade I or II
medial collateral ligament injury in a previously uninjured
(in this study) knee was 4.01%.
In three of the four reinjuries, the position played by the
injured athlete was associated with an apparently increased
risk of sustaining knee injury (linebacker, middle guard, and
defensive tackle). However, since there were only four cases,
it is impossible to establish a legitimate relationship between
reinjury and the presence of a prior injury, the position
played, or any other variable for that matter. One can only
say that reinjuries appeared to be exceptions rather than the
rule.
Subsequent preseason examinations of the 51 knees that
had sustained the Grade I and II medial collateral ligament
sprains failed to reveal any evidence of increased anterior
instability on Lachman and drawer tests. Thus, it would
appear that no significant cruciate injuries were missed. The
368
same (subsequent) examinations revealed no increased laxity
in those with Grade I sprains. The majority of the grade II
sprains resulted in a slight residual increase in medial insta-
bility.
DISCUSSION
The rate of occurrence for knee sprains resulting in time loss
from participation was 8.4 per hundred participants. The
rates for Grade I and II medial collateral ligament injuries
were 2.7 and 3.3, respectively. The rate for Grade III medial
collateral ligament sprains (alone or in combination with
other injuries) was 1.0. Nearly 20% of the knee injuries
sustained during the study required surgical intervention.
While the scope of this study is large enough to assume
statistical credence, any projection of these findings to other
institutions or levels of participation should be done with a
great deal of caution. The injury determinant criteria, albeit
rigidly viewed from the authors’ standpoint, must still be
considered subjective. It is not difficult to imagine that, in
other, perhaps less closely monitored situations, some of the
Grade I sprains would be ignored, and, while they might
result in some temporary loss of player effectiveness, would
not lead to removal from the active playing squad. On the
other end of the spectrum, some of the Grade II medial
collateral ligament sprains might have prompted surgical
intervention-with predictably good results. Regardless of
the decision model one uses, knee injuries are among the
most frequent of the more significant injuries resulting in
time loss in college level football.
The relationship of team offense or defense and position
played to knee injuries depends not only on the tasks re-
quired of these participants at various positions, but also on
less precise factors such as offensive and defensive strengths,
weaknesses, and strategies. To deemphasize or dilute the
role played by these latter, more nebulous, variables would
require a simultaneous study of many teams.
In spite of the presence of these subjective variables, there
does seem to be a higher risk (of knee injuries) for the
defensive team members, especially for those other than
defensive backs.
We believe that one of the most striking findings is the
higher rate of knee injuries during spring practice. When one
considers risk (number of players multiplied by number of
practices), the knee injury rate in the spring is more than
three times as great as that seen in the fall.
Although all Grade I and II sprains that occurred during
spring practice should be rehabilitated and ready to resume
play by the fall season, this was not the case with the more
severe injuries that required surgical intervention. Thus, the
consequences of spring injuries are, indeed, felt during the
succeeding fall season.
Finally, insofar as is possible, one must look critically at
the long-term consequence of sustaining a Grade I or Grade
II sprain of the medial collateral ligament. One would not
expect to see any appreciable evidence of such things as an
accelerated degenerative change in the short period of time
documented here, although such findings are surely part of
the observations used to help determine success of treat-
ment. Realistically, about the only measure of successful
treatment available for examination is the likelihood of
reinjury. In this investigation the likelihood of reinjury does
not appear to be substantially increased, especially when
one considers the influence of team membership and posi-
tion. However, to examine this thoroughly and to a statisti-
cally meaningful degree would require a study that follows
all injured players to at least culmination of their college
careers.
We have not used &dquo;return to participation&dquo; as a goal in
rehabilitation. The goals of rehabilitation were, insofar as we
could control, objective tests and measurements.
REFERENCES
1 Clayton ML, Miles JS, Abdulla M Experimental investigations of ligamen-
tous healing Clin Orthop 61 146-153, 1968
2 O Donoghue DH, Rockwood CA, Zancznyj B, et al The repair of knee
ligaments in dogs J Bone Joint Surg 43A 1167-1178. 1961
3 Ellsasser JC, Reynolds FC, Omohundro JR The nonoperative treatment
of collateral ligament injuries of the knee in professional football players
J Bone Joint Surg 56A 1185-1190, 1974
4 BergfeldJ Functional rehabilitation of isolated medial collateral ligament
sprains First-, second-, and third-degree sprains Am J Sports Med 7
207-209, 1979
5 O Connor GA Functional rehabilitation of isolated medial collateral liga-
ment sprains Collateral ligament injuries of the joint Am J Sports Med 7
209-210, 1979
6 Cox JS Functional rehabilitation of isolated medial collateral ligament
sprains Injury nomenclature Am J Sports Med 7 211-213, 1979