Management of Old MCL Bony Avulsion with Heterotopic Ossification
For this patient with an old, asymptomatic bony avulsion at the proximal MCL insertion and heterotopic ossification, conservative management with activity modification and NSAIDs is the appropriate initial approach, reserving MRI and surgical intervention only if pain persists or worsens despite conservative treatment. 1, 2, 3
Initial Conservative Management
Start with oral NSAIDs for pain control, as they demonstrate superior efficacy (effect size 0.32-0.49) compared to acetaminophen for knee pain, though acetaminophen remains an option for patients with NSAID contraindications 3
Topical NSAIDs (diclofenac) provide an effective alternative with an effect size of 0.91 versus placebo for patients unable to tolerate oral NSAIDs 3
Activity modification and rehabilitation are essential components, as most grade I-II MCL injuries respond to nonoperative treatment 4
Diagnostic Considerations Before Advanced Imaging
The radiographic findings show an old injury pattern (narrow 6.5mm heterotopic ossification at the medial femoral epicondyle suggesting prior MCL avulsion), which requires specific evaluation before proceeding:
Verify the current radiographs included AP, lateral, and tangential patellar views before considering MRI, as approximately 20% of patients inappropriately receive MRI without adequate plain films 1, 2
Assess for referred pain from the hip by examining for groin pain, range of motion limitations, or positive impingement signs, as hip pathology commonly presents as knee pain with normal knee radiographs 1, 2, 3
Evaluate for lumbar radiculopathy patterns or neurogenic claudication that could refer pain to the knee 1, 2, 3
Obtain hip and/or lumbar spine radiographs if clinical examination suggests referred pain before proceeding to knee MRI 1, 2
When to Proceed with MRI
MRI without contrast is indicated only if pain persists despite 6-8 weeks of conservative management or if the clinical examination suggests additional internal derangement 1, 2, 3. MRI would evaluate for:
Meniscal tears, though note these occur with equal frequency in painful and asymptomatic knees in the 45-55 age group, making correlation with symptoms critical 1, 3
Bone marrow lesions, which are strongly associated with knee pain and fluctuate with pain intensity 1, 2, 3
Articular cartilage damage not visible on plain radiographs 1
Chronic MCL injury patterns, including complete tears or associated meniscal subluxation that may require surgical treatment 5, 4
Surgical Considerations
Surgical intervention is reserved for specific scenarios and should not be the initial approach for this old injury:
Chronic grade III MCL tears with persistent instability after failed conservative treatment may require reconstruction 4
Symptomatic heterotopic ossification causing mechanical symptoms or severe pain unresponsive to conservative measures can be treated with surgical excision plus adjunctive celecoxib 200mg for 8 weeks postoperatively to prevent recurrence 6
Novel ultrasonic percutaneous debridement has shown promise for calcified or ossified MCL lesions causing chronic pain refractory to conservative treatment 7
Critical Caveats
The presence of heterotopic ossification does not automatically establish it as the pain source, as this represents an old injury that may be incidental to current symptoms 1, 8
Heterotopic ossification following trauma has unpredictable onset and recurrence patterns, with poorly understood physiopathology 8
Avoid premature surgical intervention, as chronic MCL injuries without associated cruciate ligament tears or meniscal pathology typically respond to nonoperative management with bracing and rehabilitation 4
If considering intra-articular corticosteroid injection for acute pain exacerbation, ultrasound or fluoroscopy guidance can facilitate technically difficult aspirations, providing both diagnostic and therapeutic benefit 3