What is the treatment for medial tendon issues of the knee, such as Medial Collateral Ligament (MCL) injuries or pes anserine tendinitis?

Treatment for Medial Tendon Issues of the Knee

The treatment for medial tendon issues of the knee should focus on relative rest, functional support, and exercise therapy, with NSAIDs for pain relief and consideration of corticosteroid injections for refractory cases. 1

Types of Medial Tendon Issues

Medial Collateral Ligament (MCL) Injuries

MCL injuries typically occur from valgus stress to the knee and can be classified based on severity:

• Grade I: Mild stretching without instability
• Grade II: Partial tear with some laxity
• Grade III: Complete tear with instability

Pes Anserine Tendinitis/Bursitis

This involves inflammation of the conjoined tendon insertion of the sartorius, gracilis, and semitendinosus muscles on the medial proximal tibia, often with associated bursal inflammation.

Diagnostic Approach

1. Physical examination:

   • Localized tenderness along the medial aspect of the knee
   • Pain with valgus stress testing (for MCL injuries)
   • Tenderness at the inferomedial aspect of the knee (for pes anserine tendinitis)

2. Imaging:

   • Plain radiography: May show bony abnormalities but limited for soft tissue evaluation 1
   • Ultrasonography: Useful for detecting tendon thickening, decreased echogenicity, and inflammation 1, 2
   • MRI: Most sensitive for detecting ligament tears, degeneration, and chronic tendinopathy 1

Treatment Algorithm

1. Conservative Management (First-Line)

A. Relative Rest and Activity Modification

• Reduce activities that cause pain to prevent ongoing damage 1
• Avoid complete immobilization to prevent muscular atrophy 1
• Gradually return to activities as symptoms improve

B. RICE Protocol

• Limited evidence supports RICE (Rest, Ice, Compression, Elevation) for acute management 1
• Ice application through a wet towel for 10-minute periods may help with acute pain relief 1

C. Medications

• NSAIDs are effective for short-term pain relief and reducing inflammation 1
• Topical NSAIDs may provide pain relief with fewer systemic side effects 1

D. Exercise Therapy

• Begin as soon as possible to restore joint function 1
• Focus on:
  • Eccentric strengthening exercises (particularly effective for tendinopathies) 1
  • Quadriceps strengthening 1
  • Proprioception training
  • Range-of-motion and flexibility exercises

E. Functional Support

• For MCL injuries:
  • Bracing is preferred over immobilization 1
  • Prophylactic knee braces may help protect the MCL during valgus stress 1
  • Choice between tape or brace should be based on patient preference 1

2. Advanced Interventions (For Refractory Cases)

A. Corticosteroid Injections

• May provide more effective acute pain relief than oral NSAIDs 1
• Particularly effective for pes anserine tendinitis/bursitis 3
• Consider for cases that fail to respond to conservative measures 4

B. Physical Therapy Modalities

• Manual mobilization in combination with other treatment modalities 1
• Deep transverse friction massage may help reduce pain 1
• Therapeutic ultrasonography and iontophoresis have uncertain benefits 1

C. Surgical Intervention

• Rarely needed for medial tendon issues
• Consider only for:
  • Patients requiring quick recovery (e.g., professional athletes) 1
  • Cases not responding to conservative treatment after 3-6 months 1
  • Specific cases like Stener-like lesions of the MCL where the ligament is blocked by the pes anserine tendons 5

Special Considerations

For MCL Injuries

• Most MCL injuries heal well with conservative treatment 1
• Functional bracing allows for earlier return to activities while protecting the healing ligament 1
• Surgery is rarely indicated except in complex injuries or Stener-like lesions 5

For Pes Anserine Tendinitis

• Often associated with overuse, obesity, osteoarthritis, or diabetes 3
• Response to treatment is variable, with recovery times ranging from 10 days to 36 months 3
• Corticosteroid injection into the pes anserine bursa can provide significant relief 2, 3

Recovery and Return to Activities

• Work resumption: Implement a return-to-work schedule to minimize absenteeism 1
• Sports resumption: Supervised exercises focusing on proprioception, strength, coordination, and function 1
• For recurrent issues, incorporate preventive exercises into regular training activities 1

Common Pitfalls to Avoid

1. Prolonged immobilization: This can lead to muscle atrophy and joint stiffness 1

2. Premature return to full activity: May lead to re-injury or chronic issues

3. Misdiagnosis: Medial knee pain can have multiple causes (meniscal tears, osteoarthritis, etc.) that require different treatments

4. Overreliance on passive treatments: Active rehabilitation with appropriate exercises is essential for long-term recovery 1

5. Unnecessary surgery: Most medial tendon issues respond well to conservative management 1

By following this structured approach to treatment, most patients with medial tendon issues of the knee can expect significant improvement in pain and function within 3-6 months 1.