Management of Prolonged Pain with Grade 2 MCL Tear
For a grade 2 MCL tear with prolonged pain that has not responded to initial conservative management, targeted corticosteroid injection into the deep MCL under ultrasound guidance should be performed, as this provides immediate and sustained pain relief in 96% of patients with chronic symptoms. 1
Initial Conservative Management
Most grade 2 MCL injuries heal well with non-operative treatment and should be managed conservatively first. 2, 3 The standard approach includes:
- PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for initial pain and swelling control 4
- NSAIDs to improve healing and speed recovery 4
- Functional rehabilitation with motion restoration and strengthening exercises, which is superior to immobilization 4
- Manual joint mobilization combined with exercise therapy provides better outcomes than exercise alone 5, 4
When Pain Persists Beyond Expected Timeline
If symptoms persist beyond 10-12 weeks despite appropriate conservative treatment, this represents a problematic subgroup requiring further investigation. 6, 1
Key Clinical Features of Chronic Grade 2 MCL Pain:
- Persistent tenderness at the proximal femoral attachment of the deep MCL 6
- Pain precipitated by rapid external rotation of the knee during clinical testing or sport 6
- Thickening and scarring of the MCL on examination 1
- Mean presentation time of 23.6 weeks from injury in refractory cases 6
Diagnostic Workup for Prolonged Symptoms
MRI is essential to confirm the diagnosis and localize the lesion within the deep MCL. 1 MRI findings typically show:
- Injury to both superficial and deep MCL components 1
- Thickening, scarring, and incomplete healing of the deep MCL 1
- Failure of healing at the femoral origin of the deep MCL 6
Critical pitfall to avoid: The deep MCL component is often the source of persistent pain in grade 2 injuries, and this must be specifically evaluated. 1
Treatment Algorithm for Prolonged Pain
First-Line for Chronic Symptoms (>10-12 weeks):
Ultrasound-guided corticosteroid injection into the deep MCL 1
- Provides immediate and sustained resolution of medial knee pain in all patients 1
- 96% achieve immediate and sustained return to sporting activity 1
- 81% report no change in level of sporting function at mean 20-month follow-up 1
- Allows immediate return to sport after injection 1
Alternative Emerging Treatment:
Percutaneous ultrasonic debridement may be considered for chronic grade 2 MCL sprains refractory to conservative management, though evidence is limited to case reports. 7
Surgical Intervention:
Surgery should be reserved for cases that fail injection therapy. 6 Surgical repair of the deep MCL at its femoral origin is indicated when:
- Conservative treatment and injection therapy have failed 6
- High-level athletes with persistent symptoms preventing sport participation 6
- Surgical findings show failure of healing at the femoral origin requiring direct repair 6
Surgical outcomes: All patients in one series returned to sport and remained asymptomatic at mean 48 weeks post-operatively after repair of the proximal deep MCL. 6
Important Considerations
Rule out concomitant injuries: While isolated grade 2 MCL tears typically heal well, you must exclude associated ACL, PCL, or meniscal injuries that would change management. 5, 4, 3 The American Academy of Orthopaedic Surgeons guidelines note that combined ACL/MCL tears can be treated non-operatively for the MCL component with good outcomes. 5
Timeline matters: The prognosis is significantly influenced by duration of symptoms and presence of concurrent ligament compromise. 3 Early recognition of the refractory subgroup (typically presenting at 10-24 weeks) allows for timely intervention. 6, 1
Avoid prolonged ineffective conservative care: Patients with persistent symptoms beyond 10-12 weeks despite appropriate rehabilitation should not continue with the same conservative approach indefinitely, as this delays definitive treatment and prolongs disability. 6, 1