What is the initial treatment for a patient with a medial collateral ligament (MCL) sprain, a horizontal tear of the medial meniscus of the posterior horn, and a bone contusion?

Initial Treatment of MCL Sprain with Horizontal Tear of Medial Meniscus Posterior Horn and Bone Contusion

Begin with conservative non-operative management consisting of protected weight-bearing, structured physical therapy with strengthening exercises, and activity modification for 6-12 weeks, as the MCL will heal without surgery and the horizontal meniscal tear does not require arthroscopic intervention. 1, 2, 3

Immediate Management Approach

First 2-4 Weeks: Protection Phase

• Initiate protected weight-bearing with crutches if needed for comfort, progressing to full weight-bearing as pain allows. 2
• Apply ice and compression to manage effusion and bone contusion symptoms. 1
• Consider aspiration only if the effusion is tense and causing significant pain. 1
• Avoid valgus stress and pivoting activities that stress the MCL during the acute healing phase. 2

Weeks 2-12: Rehabilitation Phase

• Begin structured strengthening exercises focusing on quadriceps and hamstring development, as this approach produces equivalent outcomes to meniscectomy for degenerative horizontal tears. 3
• Progress range of motion exercises as tolerated, avoiding forced terminal flexion initially. 2
• The bone contusion will resolve spontaneously over 6-12 weeks without specific intervention beyond activity modification. 1, 4

Critical Decision Points

MCL Management

• Grade I and II MCL sprains heal reliably with non-operative treatment even when combined with meniscal pathology. 2
• Grade III complete MCL tears also respond well to conservative management after excluding associated injuries requiring surgery (ACL/PCL tears, meniscal root tears, or posterolateral corner injuries). 1, 2
• The American Academy of Orthopaedic Surgeons confirms that non-surgical MCL treatment results in good outcomes when combined with ACL tears, making isolated MCL surgery rarely necessary. 1

Horizontal Meniscal Tear Management

• Do not perform arthroscopic meniscectomy for degenerative horizontal tears, as randomized controlled trials demonstrate no functional advantage over strengthening exercises at 2-year follow-up. 3
• Both meniscectomy and non-operative groups achieved equivalent VAS pain scores (1.8 vs 1.7), Lysholm scores (83.2 vs 84.3), and satisfaction levels. 3
• The American Academy of Orthopaedic Surgeons recommends against routine arthroscopic partial meniscectomy for degenerative tears in patients with knee osteoarthritis. 5

Bone Contusion Significance

• Bone contusions are present in 84% of significant knee injuries and indicate higher-energy trauma, but they resolve without specific treatment. 4
• The presence of bone contusions predicts development of focal osteoarthritis at 1 year, requiring long-term monitoring but not altering acute management. 1
• Bone contusions involving both medial and lateral compartments correlate with increased prevalence of meniscal (p=0.010-0.011) and MCL injuries (p=0.066), confirming this is a significant injury pattern. 4

Essential Diagnostic Confirmation

MRI Findings to Verify

• Confirm the meniscal tear is truly horizontal and degenerative rather than a posterior root tear, as root tears have 87% failure rates with non-operative treatment and require surgical repair. 6
• Exclude ACL or PCL tears, as these change management entirely—MRI within 6 weeks of injury detects anterolateral ligament injuries that become less visible with chronicity. 1, 7
• Verify no posterolateral corner injury is present, as these occur in 19.7% of significant knee injuries and lead to considerable morbidity if missed. 1, 7

Common Pitfalls to Avoid

• Do not attribute knee instability to the meniscal tear—the MCL injury is the source of any medial instability, and if true rotatory instability exists, an ACL tear is present. 5
• Do not rush to arthroscopy for horizontal meniscal tears based on mechanical symptoms alone, as 93.5% of acute knee injuries are soft-tissue injuries that improve with conservative management. 1, 3
• Do not ignore the bone contusion pattern—medial compartment involvement suggests higher-energy injury and warrants careful exclusion of ACL/PCL tears. 4
• Do not assume the MCL requires surgery—even Grade III tears heal non-operatively unless there is intra-articular entrapment (extremely rare) or associated cruciate ligament reconstruction is planned. 1, 2

Surgical Indications (Rare in This Scenario)

Surgery is indicated only if:

• The meniscal tear is a posterior root tear rather than horizontal tear (87% failure rate non-operatively). 6
• Concurrent ACL reconstruction is planned, in which case MCL repair may be performed simultaneously. 1, 2
• The MCL is incarcerated intra-articularly (exceptionally rare). 8
• Conservative management fails after 12 weeks with persistent instability or mechanical symptoms. 2

Expected Outcomes

• Most patients achieve relief of knee pain, improved function, and high satisfaction with non-operative treatment by 12 weeks. 3
• The MCL heals predictably with conservative management regardless of grade. 1, 2
• Horizontal meniscal tears treated non-operatively have equivalent 2-year outcomes to meniscectomy. 3
• Monitor for progression to osteoarthritis given the bone contusion pattern, but this does not alter acute management. 1