Medial Collateral Ligament Bursitis

By: Gregory Rubin, DO

Rubinsportsmed.com

Medial joint line pain can be a challenging clinical entity to sports medicine providers. Among the differential for medial joint line pain include medial meniscus tear, articular cartilage damage, MCL sprain or tear, pes anserine bursitis, and MCL bursitis (Jean Jose, 2011). The difficulty in differentiating these different entities on physical exam can lead to unnecessary MRIs or arthroscopies (Glousman, 1988). The medial collateral ligament is also known as the tibial collateral ligament. There are multiple bursas located along the medial portion of the knee. These include the MCL bursa, pes anserine bursa, and the semimembranosus and gastrocnemius bursa (Jean Jose, 2011). For the purpose of this review, we will focus on the MCL bursa also known as Voshell’s bursa. Risk factors for developing MCL bursitis are pes planus, trauma, osteophytes, genu valgus, and other rheumatologic conditions (Hakan Nur, 2018).

The first article describing the entity of MCL bursitis was in 1943 by doctors Brantigan and Voshell (Glousman, 1988). However, it took until 1988 for clinical criteria for MCL bursitis to be published in the American Journal of Sports Medicine. They defined MCL bursitis as tenderness of the medial collateral ligament at the level of the medial joint line (Glousman, 1988). Patients also should not have a history of knee buckling or locking (Hakan Nur, 2018). In their study, Dr. Glousman identified patients with the above outlined criteria for MCL bursitis and then enrolled them in a rehab protocol and provided a corticosteroid injection in to Voshell’s bursa (Glousman, 1988). They treated 91 patients with an injection and of those, 62% reported resolution of symptoms (Glousman, 1988). Among those patients who did not improve, 23% required arthroscopic exam and were found to have a medial meniscus tear and chondromalacia of the medial compartment (Glousman, 1988).

In 2011, an article published in the Journal of Ultrasound Medicine looked at how to perform an ultrasound guided MCL bursa injection. With the knee in slight flexion and the probe at the level of the medial knee, an injection is performed in the coronal plane into the MCL bursa (Jean Jose, 2011). There are three layers of the medial knee. These include the superficial structures, which include the medial patellar retinaculum, the vastus medialis, and the sartorius (Jean Jose, 2011). The second level consists of the superficial and posterior oblique portion of the MCL (Jean Jose, 2011). The third level includes the joint capsule and deep medial collateral ligament fibers (Jean Jose, 2011). The MCL bursa is found between the second and third levels (Jean Jose, 2011). In a recent article in 2019 in the Journal of Ultrasound Medicine, it was recommended to perform the MCL bursa injection under ultrasound guidance in order to target the bursitis and resolve the adhesions between the superficial and deep fibers of the MCL (Vincenzo Ricci, 2019).

A study published in Radiology and Oncology in 2017 looked at the relationship of periarticular bursitis in patients with Osteoarthritis. They evaluated MRIs in patients with OA and found that of 100 patients, 13 had fluid within the MCL bursa and 26 had fluid within the pes anserine bursa (Mustafa Resorlu, 2017). They hypothesized that mechanical changes in the knee with osteoarthritis can cause the increase in bursitis around the knee (Mustafa Resorlu, 2017).

Overall, MCL bursitis should be considered in patients with medial sided knee pain. A quick ultrasound guided injection into the MCL bursa, which is located between the superficial and deep portion of the MCL, can decrease inflammation and help resolve adhesions. Ultimately, if the injection is unsuccessful, physicians can proceed to an MRI to evaluate for meniscus or articular cartilage damage.

References

Glousman, R. K. (1988). Tibial Collateral Ligament Bursitis. The American Journal of Sports Medicine, 344-346.

Hakan Nur, A. A. (2018). Medial collateral ligament bursitis in a patient with knee osteoarthritis. Journal of Back and Musculoskeletal Rehabilitation, 589-591.

Jean Jose, E. S. (2011). Sonographically Guided Therapeutic Injection for Primary Medial (Tibial) Collateral Bursitis. The Journal of Clinical Ultrasound, 257-261.

Michel De Maeseneer, F. V. (2000). Three Layers of the Medial Capsular and Supporting Structures of the Knee: MR Imaging—Anatomic Correlation. RadioGraphics.

Mustafa Resorlu, D. D. (2017). The Relationship between Chondromalacia Patella, Medial Meniscal Tear and Medial Periarticular Bursitis in Patients with Osteoarthritis. Radiology and Oncology, 401-406.

Vincenzo Ricci, L. O. (2019). Ultrasound‐Guided Treatment of Extrusive Medial Meniscopathy: A 3‐Step Protocol. Journal of Ultrasound in Medicine.