What are the treatment options for medial knee pain and difficulty straightening the knee after a skiing injury?

Medial Knee Pain After Skiing Injury with Difficulty Straightening

You most likely have a medial collateral ligament (MCL) injury, which is the most common knee ligament injury in skiing, and should be treated conservatively with immediate bracing, early range-of-motion exercises, and progressive rehabilitation—surgery is rarely needed.

Initial Assessment and Diagnosis

The combination of medial knee pain and difficulty straightening the knee after a skiing injury strongly suggests an MCL tear, which accounts for 15-20% of all skiing injuries and 60% of knee injuries in skiers 1. The MCL is the most commonly injured ligamentous structure of the knee, reported in 7.9% of all knee injuries 2.

Key Physical Examination Findings

• Apply a valgus stress test at full knee extension and at 20-30 degrees of knee flexion to assess MCL integrity 3
• Check for swelling, tenderness along the medial joint line, and pain with palpation over the MCL 3
• The mechanism in skiing typically involves external rotation and valgus forces 4

Imaging Considerations

• Plain radiographs are usually satisfactory for initial assessment 5
• MRI is the gold standard for definitive diagnosis of MCL tears 2
• Weight-bearing views can help assess joint alignment 5

First-Line Treatment: Conservative Management

Isolated MCL injuries should be treated nonoperatively, as this approach has favorable outcomes and is the consensus first step even for complete (grade III) tears 3.

Immediate Phase (First 2 Weeks)

• Apply a patellofemoral or knee brace immediately to provide stability and resist abnormal motion 5
• Most patients report significant subjective improvements in pain and disability with brace wear 5
• Off-the-shelf braces can be successfully fitted without customization for most patients 5
• Apply cold therapy for 20-30 minutes, 3-4 times daily to reduce pain and swelling 6
• Avoid activities that increase pain 6

Early Rehabilitation Phase (Weeks 2-6)

• Begin early range-of-motion exercises as soon as tolerable 1
• Start isometric quadriceps strengthening exercises immediately 1
• Progressive quadriceps strengthening is effective and should be included, as recommended by the American Academy of Orthopaedic Surgeons 5
• Continue brace wear during this phase for stability 5

Progressive Strengthening Phase (After Full ROM Achieved)

• Institute progressive resistance exercises once full range of motion is achieved 1
• Add isokinetic and closed chain exercises 1
• Include functional rehabilitation activities 1
• Continue using functional support (braces) to prevent recurrence 6

Adjunctive Treatments

• Consider patellar taping for short-term pain relief (Grade B recommendation from the American Academy of Orthopaedic Surgeons) 5
• Medial taping shows statistically significant effects on pain reduction immediately and within days of application 5
• Shoe orthoses may be considered if patellofemoral pain persists despite bracing 5
• Do NOT use lateral heel wedges—they have limited effectiveness and may worsen symptoms 5

Expected Recovery Timeline

• Grade I MCL sprains: Return to light activities in 2-3 weeks 6
• Grade II-III MCL sprains: Return to activities in 3-6 weeks with restrictions 6
• Full recovery and return to skiing: Most cases achieve good results with nonoperative treatment 1
• Recovery may take several months, as recommended by the American Academy of Orthopaedic Surgeons 5

Critical Pitfalls to Avoid

• Do not immobilize for prolonged periods (>10 days)—this leads to worse outcomes than functional treatment 6
• Rule out associated injuries: MCL tears can occur with ACL tears, meniscal injuries, or posterior oblique ligament damage 3, 1
• If the knee remains unstable or pain persists despite 6-8 weeks of conservative treatment, reassess for associated ligamentous injuries 3
• Returning to skiing too soon increases reinjury risk 6

When to Consider Surgery

Surgery is rarely needed for isolated MCL injuries 3. Consider surgical consultation if:

• Associated ACL tear is present (though even combined injuries are often treated conservatively first) 3
• Multiple ligament injuries are identified 3
• Persistent instability after 3 months of appropriate conservative treatment 3

Monitoring During Recovery

• Periodically inspect brace for migration, strap loosening, or material fatigue 5
• Re-examine at 3-5 days post-injury to better distinguish partial from complete tears 6
• Progress rehabilitation based on pain-free achievement of milestones, not arbitrary timelines 1