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

Management of Medial Collateral Ligament (MCL) Tears

Non-surgical management is the recommended approach for most MCL injuries, including isolated grade I, II, and III tears, with appropriate bracing and rehabilitation. 1

Classification and Diagnosis

MCL injuries are classified into three grades:

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

Diagnostic imaging should include:

• Radiographs to exclude fractures
• MRI without contrast for suspected associated lesions
• Ultrasound to evaluate lateral ligament integrity 1

Treatment Algorithm

Acute Management (First 24-48 hours)

• RICE protocol (Rest, Ice, Compression, Elevation)
• Analgesia with NSAIDs as needed for pain control
• Partial weight-bearing as tolerated 1

Non-surgical Treatment (Primary approach)

1. Bracing:

   • Use the longest brace that fits the patient's leg for better protection
   • Recommended for grade II and III injuries 1
   • Functional bracing for 4-6 weeks 2

2. Rehabilitation Protocol:

   • Progressive exercises including isometric and concentric strengthening
   • Proprioceptive exercises
   • Gradual return to activities 1

3. Return to Activity Timeline:

   • Grade I: 2-3 weeks
   • Grade II: 4-6 weeks
   • Grade III: 6-12 weeks 1, 2

Surgical Indications (Limited cases)

Surgery is indicated only in specific circumstances:

• Grade III tears with severe valgus alignment
• MCL entrapment over pes anserinus
• Intra-articular or bony avulsion
• Combined ligament injuries requiring surgical repair/reconstruction 2

Timing of Surgery

• Primary repair should be performed within 7-10 days after injury 2
• For chronic instability, reconstruction rather than repair is recommended 2

Special Considerations

Combined Ligament Injuries

• Non-surgical treatment of MCL can still give good results even with associated ACL injury requiring reconstruction 1
• For multi-ligament injuries involving three or more ligaments, surgical management may be necessary, though evidence is limited 3

Chronic MCL Injuries

• Options include non-operative treatment (bracing, activity modification) or surgical reconstruction
• For chronic injuries with valgus misalignment, a two-stage approach is recommended:
  1. Distal femoral osteotomy
  2. Reconstruction of medial knee structures 2

Common Pitfalls to Avoid

• Using braces that are too short, providing insufficient MCL protection
• Overlooking associated ligament injuries, particularly ACL tears
• Unnecessary surgical intervention for isolated MCL tears that would heal with conservative treatment
• Delayed rehabilitation, which may lead to stiffness and prolonged recovery 1

The high success rate of non-surgical management for isolated MCL tears is well-documented, making it the treatment of choice in most cases 4, 5. Even complete (grade III) MCL tears typically respond well to conservative management, provided there are no associated injuries requiring surgical intervention 6.