Treatment of Grade 2 MCL Injury
Grade 2 MCL injuries should be treated non-surgically with early functional rehabilitation, which consistently produces good outcomes without the need for surgery. 1, 2
Initial Management
Immediately implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) to control pain and swelling 1, 3. This forms the foundation of acute management and should be started as soon as possible after injury.
- Obtain radiographs to exclude fractures or bony avulsions if clinical examination suggests these possibilities 1
- Consider aspiration of any painful, tense knee effusion for symptomatic relief 1, 3
- Use NSAIDs at the lowest effective dose to improve healing, speed recovery, and manage pain during the acute phase 3
Functional Rehabilitation Protocol
Begin early functional rehabilitation rather than prolonged immobilization, as motion restoration and strengthening exercises produce superior outcomes 1, 3. The key is controlled loading of damaged tissues while avoiding complete rest.
- Limit any immobilization to a maximum of 10 days if needed for pain control, then commence functional treatment 4
- Start range of motion exercises immediately once pain allows, progressing to proprioception training and gradual strengthening 4
- Manual joint mobilization combined with exercise therapy provides better outcomes than exercise alone 3
Bracing Considerations
Functional braces may be used for support during rehabilitation of moderate MCL instability 1. However, prophylactic knee braces are not recommended for injury prevention as evidence of effectiveness is limited and they may actually increase forces on the medial knee 1.
Critical Diagnostic Consideration
Carefully exclude associated injuries, particularly ACL tears, meniscal injuries, or deep MCL involvement, as these significantly influence prognosis and may require different management 2, 5. The presence of concurrent ligament injuries, especially ACL compromise, substantially affects recovery and may necessitate surgical intervention for those structures while the MCL heals conservatively 5.
Management of Persistent Symptoms
If pain persists beyond expected healing timeframes (typically 8-12 weeks), consider deep MCL injury as a specific cause 6, 7. This problematic subgroup presents with:
- Persistent tenderness at the proximal deep MCL attachment that can be precipitated by rapid external rotation 7
- MRI confirmation showing thickening, scarring, and tearing of both superficial and deep MCL layers 6
- Ultrasound-guided corticosteroid injection into the deep MCL provides excellent outcomes, with 96% of patients achieving immediate and sustained return to sporting activity 6
Return to Activity
Base return to sport decisions on functional evaluation rather than time-based protocols alone 1, 3. Premature return can lead to chronic problems including decreased range of motion, pain, and joint instability 1, 3.
Common Pitfalls
Avoid prolonged immobilization, which leads to joint stiffness, muscle atrophy, and delayed recovery 4. Do not overlook associated injuries, particularly ACL tears, as 80% of grade III MCL injuries have concomitant ligament damage, and this principle applies to careful evaluation of grade II injuries as well 5.