What is the appropriate treatment plan for a patient with knee pain and swelling and MRI showing a medial collateral ligament avulsion at its femoral attachment and a grade 2 medial patellofemoral ligament sprain?

Treatment Plan for MCL Femoral Avulsion and Grade 2 MPFL Sprain

For a patient with an MCL avulsion from the femoral attachment combined with a grade 2 MPFL sprain, surgical repair of the MCL avulsion is indicated, while the MPFL sprain should be managed conservatively with functional rehabilitation. This combined injury pattern requires addressing the complete MCL disruption surgically while allowing the partial MPFL injury to heal with appropriate support.

Immediate Management

MCL Femoral Avulsion - Surgical Indication

• Acute surgical repair is indicated for MCL femoral avulsions because these represent complete disruptions (grade III injuries) with bony or proximal attachment failure that will not heal appropriately with conservative treatment 1, 2
• Surgery should be performed within 7-10 days of injury to allow primary repair while tissue quality remains optimal 2
• The surgical technique involves reattachment of the avulsed MCL to its femoral origin using bone anchors or transosseous sutures 1
• Femoral avulsions, unlike midsubstance tears, require surgical fixation because the ligament cannot reattach to bone without intervention 1, 2

Grade 2 MPFL Sprain - Conservative Management

• Grade 2 (partial thickness) MPFL tears without complete disruption should be treated non-operatively with functional bracing and rehabilitation 3, 2
• The MPFL will heal with conservative treatment when the injury is incomplete and the patella remains stable in extension 4
• Surgical intervention for the MPFL is reserved only for complete tears (grade 3) with documented patellar instability or recurrent dislocation 4

Surgical Approach for MCL Avulsion

Operative Technique

• Perform medial femoral incision to expose the avulsed MCL attachment site 1
• Reinsert the avulsed bone fragment or ligament tissue to the anatomic femoral origin using bone anchors with or without spike washers 1
• Ensure repair is performed with the knee in 30 degrees of flexion to restore appropriate ligament tension 2
• Assess for any MCL entrapment over the pes anserinus, which would further support surgical indication 2

Concomitant Assessment During Surgery

• Examine the knee under anesthesia to assess valgus stability and confirm the grade 2 MPFL does not require repair 4
• Verify no associated meniscal entrapment or avulsion requiring concurrent treatment 3

Post-Operative Rehabilitation Protocol

Weeks 0-2: Protection Phase

• Hinged knee brace locked in extension for ambulation with weight-bearing as tolerated 5
• Begin gentle range of motion exercises from 0-90 degrees by week 2 5
• Quadriceps isometric exercises and straight leg raises initiated immediately 6
• Ice, compression, and elevation to control swelling 5

Weeks 3-6: Early Mobilization

• Progress range of motion to full flexion as tolerated 6
• Advance to closed-chain strengthening exercises (mini-squats, leg press) 6
• Continue hinged brace for protection during ambulation 5
• Proprioception and balance training initiated 6

Weeks 7-12: Strengthening Phase

• Progressive resistance training for quadriceps, hamstrings, and hip musculature 6
• Functional exercises emphasizing knee stability 6
• Gradual weaning from brace as stability improves 5
• Avoid pivoting and cutting activities during this phase 6

Months 4-6: Return to Activity

• Sport-specific training if applicable, with gradual progression 6
• Continued emphasis on neuromuscular control and proprioception 5
• Consider functional knee brace for high-demand activities 6

Critical Management Considerations

Why Surgery for MCL but Not MPFL?

• MCL femoral avulsions represent complete ligament disruptions that cannot heal to bone without surgical reattachment, whereas grade 2 MPFL sprains are partial tears that retain sufficient structural integrity to heal with conservative treatment 1, 2
• The MCL is the primary restraint to valgus stress, and femoral avulsions create severe instability requiring surgical stabilization 2
• Grade 2 MPFL injuries maintain some intact fibers that provide baseline patellar stability, allowing successful non-operative healing 3, 4

Common Pitfalls to Avoid

• Delaying MCL avulsion repair beyond 10-14 days results in tissue retraction and poor quality for primary repair, necessitating reconstruction rather than repair 2
• Treating MCL femoral avulsions conservatively leads to chronic medial instability, secondary ACL dysfunction, and accelerated osteoarthritis 2
• Over-treating the grade 2 MPFL sprain with surgery exposes the patient to unnecessary surgical risks when conservative treatment has excellent outcomes 3, 2
• Inadequate rehabilitation of the MPFL during MCL healing can result in persistent patellar maltracking 5

Follow-Up Monitoring

• Clinical examination at 2,6, and 12 weeks post-operatively to assess valgus stability and patellar tracking 6
• Valgus stress testing should demonstrate stable endpoint by 12 weeks 2
• Assess for patellar apprehension or instability suggesting MPFL healing failure 4
• MRI is not routinely needed unless clinical examination suggests inadequate healing or persistent instability 5

Long-Term Prognosis

• Surgical repair of MCL femoral avulsions combined with appropriate MPFL rehabilitation typically results in excellent outcomes with return to full activity by 6 months 1, 2
• Patients can expect 0-140 degrees range of motion and return to sports without pain when rehabilitation is optimized 1
• Risk of chronic instability or re-injury is minimal with appropriate surgical technique and rehabilitation compliance 2