Treatment of Old MCL Avulsion Injury at Proximal Insertion
For an old (chronic) avulsion injury at the proximal insertion of the medial collateral ligament identified incidentally on radiographs without acute symptoms, conservative management with activity modification, relative rest, and physical therapy focusing on eccentric strengthening is the appropriate treatment approach.
Initial Assessment and Imaging Considerations
The radiographic finding of a "linear avulsion off of the proximal insertion of the medial collateral ligament within the medial femoral epicondyles" represents a healed or chronic injury, as evidenced by maintained joint spacing and absence of joint effusion 1.
If the patient has persistent pain or functional limitations despite the "old" appearance of the injury, MRI without IV contrast is the most appropriate next imaging study to assess the current integrity of the MCL and evaluate for associated injuries 1.
MRI can distinguish between complete and partial MCL tears, assess chronicity, and identify any associated meniscal or cruciate ligament pathology that may have occurred at the time of the original injury 2, 3.
Conservative Management Protocol (First-Line Treatment)
For chronic/old MCL avulsion injuries without acute instability, conservative treatment should be implemented as follows:
Relative rest is essential to prevent ongoing damage while avoiding complete immobilization that could lead to muscular atrophy 4.
Activity modification: Continue activities that don't worsen pain while temporarily stopping those that aggravate symptoms 4.
Cryotherapy (ice application) for 10-minute periods through a wet towel provides effective short-term pain relief if there is residual discomfort 4.
NSAIDs (oral or topical) effectively relieve tendon and ligament pain, with topical NSAIDs reducing pain while avoiding gastrointestinal risks 4.
Counterforce bracing/orthotics help reinforce, unload, and protect the ligament during activity 4.
Rehabilitation Phase (Critical for Old Injuries)
Eccentric strengthening exercises are beneficial for promoting tissue healing and increasing strength around the knee joint 4.
Stretching exercises for the knee are widely accepted and helpful for maintaining range of motion 4.
Tensile loading of the ligament stimulates collagen production and guides normal alignment of newly formed collagen fibers 4.
Continue bracing as needed during activities, particularly those involving valgus stress 4.
When to Consider Surgical Intervention
Surgical evaluation is warranted only if:
The patient develops acute instability with valgus stress testing despite conservative management 2.
Pain persists despite 6-12 months of well-managed conservative treatment 4.
There is evidence of associated multiligament injury (ACL, PCL) requiring reconstruction, in which case the MCL avulsion should be addressed simultaneously 3.
MRI reveals a complete MCL avulsion with significant displacement or associated meniscal subluxation 5, 6.
Important Clinical Pitfalls and Caveats
Avoid overreliance on corticosteroid injections for chronic MCL injuries, as they may lead to ligament weakening and potential rupture 4.
Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 4.
Be vigilant for heterotopic ossification in patients who underwent previous surgical repair of MCL avulsions, which can develop as early as 2 weeks post-operatively and typically stabilizes by 3 months 3.
Assess for associated injuries: MCL avulsion fractures, particularly those involving the femoral attachment, are often associated with ACL or PCL injuries and should prompt evaluation for multiligament knee injury 3, 6.
In the setting of severe varus deformity, knee subluxation, or "cup and saucer" morphology, there is increased risk of MCL avulsion injury during any future knee procedures 7.
Prognosis for Old Injuries
Chronic MCL avulsion injuries that have healed in anatomic position (as suggested by maintained joint spacing on radiographs) typically have excellent functional outcomes with conservative management 3.
Even surgically repaired acute MCL avulsions demonstrate full knee function, stability, and pain-free range of motion at one-year follow-up 3.
The presence of a small ossific fragment at the femoral attachment site does not necessarily indicate the need for surgical intervention if the knee is stable and functional 6.