What is the recommended treatment for a grade 2 MCL (Medial Collateral Ligament) injury with cartilage abnormalities?

MRI Summary: Right Knee Injury

Key Findings

The MRI reveals a Grade 2 proximal MCL injury with intact menisci but multiple cartilage abnormalities including a lateral patellar facet flap, medial patellar facet fissuring, and medial femoral condyle cartilage damage.

Ligamentous Injury

• Grade 2 MCL tear at the proximal attachment with periligamentous edema 1
• ACL and PCL are intact 1
• Lateral collateral structures are intact 1

Cartilage Damage

• Superficial cartilage flap on lateral patellar facet 2
• Superficial fissuring of medial patellar facet 2
• Fissuring in the weightbearing portion of medial femoral condyle 2
• Intact trochlear and lateral compartment cartilage 2

Meniscal Status

• Both medial and lateral menisci are intact 1

Other Findings

• Mild patellar tendinopathy 1
• Remote Sinding Larsen Johansson injury 1
• No joint effusion or loose bodies 1

---

Treatment Recommendations for Grade 2 MCL Injury with Cartilage Abnormalities

Primary Treatment Approach

Conservative (non-surgical) management is the definitive treatment for isolated Grade 2 MCL injuries, as most respond well without surgery and the cartilage findings do not alter this approach. 1, 3

Initial Phase (Weeks 0-2)

• Immediate weight-bearing as tolerated with crutches if needed, provided there is correct gait pattern and no pain or effusion 1
• Avoid knee bracing - functional knee braces show no clinical benefit for isolated ligamentous injuries and may prolong recovery 1, 4
• Cryotherapy in the first week to reduce pain 1
• Activity modification to avoid pivoting and cutting movements that stress the MCL 1

Rehabilitation Protocol (Weeks 2-12)

Supervised physical therapy focusing on quadriceps strengthening and neuromuscular control is essential and superior to self-directed programs. 1

Strength Training

• Begin isometric quadriceps exercises when pain-free 1
• Progress to concentric closed kinetic chain exercises from week 2 1
• Add eccentric exercises once quadriceps is reactivated without effusion 1
• Target >80% limb symmetry index for quadriceps strength before advancing activities 1

Neuromuscular Training

• Balance and proprioception exercises are mandatory and should be combined with strength training 1
• Motor control training to address altered biomechanics that increase reinjury risk 1
• Progress from explicit to implicit motor learning strategies 1

Return to Activity Criteria (Typically 6-8 Weeks)

Do not base return to activity solely on time elapsed; use objective functional criteria. 1

• No pain or swelling 1
• Full knee range of motion 1
• >90% limb symmetry on hop testing 1
• >80% quadriceps strength symmetry 1
• Normal gait pattern without compensation 1

Addressing Cartilage Concerns

The cartilage abnormalities identified do not require surgical intervention but necessitate long-term joint protection strategies. 2

• Weight control to reduce stress on damaged cartilage 5
• Quadriceps strengthening as a modifiable risk factor for osteoarthritis progression 2
• Avoid high-impact activities that load the patellofemoral and medial compartments excessively 5
• Regular monitoring for progression of symptoms 5

Surgical Considerations

Surgery is NOT indicated for this injury pattern. 1, 3

• Grade 2 MCL injuries heal reliably with conservative treatment 3, 6
• Isolated MCL injuries without ACL involvement do not require surgical repair 1, 6
• The cartilage findings represent superficial damage that does not warrant arthroscopic intervention 2
• Surgery should only be considered if significant functional instability persists after 3 months of adequate rehabilitation 3

Common Pitfalls to Avoid

• Do not use functional knee bracing - evidence shows no benefit and may prolong recovery time (41.5 vs 31.5 days in grade 2 injuries) 4
• Do not delay supervised rehabilitation - self-directed programs alone are insufficient for optimal recovery 1, 5
• Do not return to sport based on time alone - require objective functional testing to prevent reinjury 1
• Do not ignore the cartilage damage - implement joint protection strategies to minimize osteoarthritis risk 5, 2
• Do not immobilize the knee - early mobilization and weight-bearing are safe and beneficial 1

Prognosis

• Grade 2 MCL injuries typically heal in 6-8 weeks with appropriate rehabilitation 3, 4
• The presence of cartilage damage increases long-term osteoarthritis risk, but this does not affect acute treatment decisions 2
• Excellent functional outcomes are expected with adherence to structured rehabilitation 3, 6