What is the treatment for a medial collateral ligament (MCL) tear?

Treatment of Medial Collateral Ligament (MCL) Tears

Most MCL tears should be treated conservatively with non-surgical management, including bracing, rehabilitation, and progressive return to activity. 1, 2

Classification and Initial Assessment

MCL tears are typically classified by severity:

• Grade I: Ligament sprain without laxity
• Grade II: Partial rupture with limited laxity
• Grade III: Complete rupture with significant laxity 1

Treatment Algorithm

Non-Surgical Management (First-Line Treatment)

1. Acute Phase (0-2 weeks)

   • RICE protocol (Rest, Ice, Compression, Elevation) 1
   • Pain management with NSAIDs as needed 1
   • Knee bracing:
     • Use the longest brace that fits the patient's leg for better MCL protection 3
     • Indicated for Grade II and III injuries 1
   • Aspiration of painful, tense knee effusions may provide symptomatic relief 1

2. Rehabilitation Phase (2-6 weeks)

   • Progressive exercises including:
     • Isometric strengthening
     • Concentric strengthening
     • Proprioceptive exercises 1
   • Continue bracing during this phase
   • Monitor for pain and instability

3. Return to Activity Phase

   • Gradual return to sports based on injury grade:
     • Grade I: 2-3 weeks
     • Grade II: 4-6 weeks
     • Grade III: 6-12 weeks 1, 2

Surgical Management (Limited Indications)

Surgery is rarely needed for isolated MCL tears but may be considered in specific situations:

• Indications for surgical repair/reconstruction:

  • Grade III tears with severe valgus alignment
  • MCL entrapment over pes anserinus
  • Intra-articular or bony avulsion
  • Failed conservative treatment with persistent instability 2

• Timing considerations:

  • Primary repair is usually performed within 7-10 days after injury 2
  • Reconstruction may be needed for chronic instability that fails to heal 2

Special Considerations

Combined Injuries

• When MCL tears occur with ACL tears, the MCL component can often still be treated non-surgically while the ACL may require reconstruction 1, 4
• For chronic medial knee injuries with valgus misalignment, a two-stage approach may be needed:
  1. Distal femoral osteotomy
  2. Reconstruction of medial knee structures 2

Bracing Considerations

• Prophylactic knee braces may provide:
  • Protection after previous MCL injury
  • Enhanced knee proprioception
  • Reduced tibial rotation and knee translation 3
• However, braces have limitations:
  • May limit speed and athleticism
  • Can create a false sense of security
  • Protective effects diminish at physiologic levels of activity 3

Common Pitfalls to Avoid

1. Overlooking associated injuries: Always evaluate for concomitant ACL, PCL, or meniscal injuries that may require different treatment approaches
2. Rushing return to activity: Premature return to sports can lead to re-injury
3. Unnecessary surgery: Most isolated MCL tears heal well with conservative management; surgery should be reserved for specific indications
4. Inadequate bracing: Using braces that are too short provides insufficient MCL protection 3

The high success rate of non-surgical treatment for MCL injuries is well-documented, with most patients able to return to their prior level of function without surgical intervention 2.