Treatment of Complete Medial Collateral Ligament (MCL) Tear
Conservative management is the first-line treatment for complete MCL tears, with surgical intervention reserved only for specific cases with associated injuries or persistent instability.
Initial Management
- For isolated complete MCL tears:
- Rest, ice, compression, and elevation (RICE) protocol
- Early protected range of motion exercises
- Progressive weight-bearing as tolerated with knee brace
- Pain control with oral or topical NSAIDs
Conservative Treatment Protocol
Acute Phase (0-2 weeks):
- Hinged knee brace locked at 30° flexion
- Partial weight-bearing with crutches
- Gentle range of motion exercises within pain limits
- Quadriceps isometric exercises
Subacute Phase (2-6 weeks):
- Progressive weight-bearing as tolerated
- Gradually increase range of motion
- Advance to hinged brace allowing 0-90° motion
- Begin closed-chain strengthening exercises
Rehabilitation Phase (6-12 weeks):
- Full weight-bearing without brace (typically by 6 weeks)
- Progressive strengthening program
- Proprioceptive and balance training
- Sport-specific exercises if applicable
Indications for Surgical Management
Surgery is only indicated in specific circumstances:
- Avulsion of the MCL from its femoral or tibial attachment
- Grade III MCL tear with associated multi-ligament injuries (especially ACL or PCL tears)
- Persistent instability after 6-8 weeks of appropriate conservative management
- Presence of a displaced tibial "Pellegrini-Stieda" lesion causing mechanical symptoms
Functional Evaluation for Return to Activity
- Consider functional hop tests to determine readiness to return to sports 1
- Full range of motion should be achieved
- No pain with activity
- No instability with valgus stress testing
- Adequate quadriceps and hamstring strength (>90% compared to uninjured side)
Special Considerations
- For combined ACL and MCL tears, the MCL is typically treated conservatively first, with delayed ACL reconstruction if needed 2
- Some patients with combined ACL/MCL tears may experience spontaneous healing of both ligaments with proper conservative management 2
- Chronic MCL injuries that fail conservative management may require surgical reconstruction 3
Pitfalls to Avoid
- Rushing to surgery for isolated MCL tears, as most heal well with conservative management
- Neglecting associated injuries (meniscal tears, other ligament injuries)
- Returning to sports too early before adequate healing and rehabilitation
- Failing to address persistent instability after appropriate conservative management
Follow-up Recommendations
- Clinical evaluation at 2,6, and 12 weeks post-injury
- Valgus stress testing at 30° of knee flexion to assess healing
- Consider MRI only if symptoms worsen or fail to improve with appropriate management
Conservative management of complete MCL tears has shown excellent outcomes with appropriate rehabilitation protocols, with most patients returning to pre-injury activity levels without surgery.