Medial Collateral Knee Ligament Injury Treatment & Management

Rehabilitation Program

Physical Therapy

The initial treatment of all sprains is similar and follows the RICE protocol with rest, ice, compression, and elevation. Protective weightbearing is instituted with crutches. This is continued until a normal gait is obtained. The severity of the injury dictates further treatment.

Grade 1 and 2 sprains are routinely treated nonoperatively. They may be braced with a knee sleeve or a double-upright hinged knee orthosis, individualized to the patient's discomfort. Crutches are only necessary for a few days. These injuries represent incomplete tears and allow for a rapid return to activities.

Historically, grade 3 tears were treated operatively but currently are routinely treated nonoperatively. In the past, nonoperative treatment meant a long leg cast. Currently, bracing with a hinged knee orthosis is common. Some authors recommend immediate braced increase in range of motion (ROM), while others prefer waiting up to 6 weeks with the knee at 30° of flexion. Crutches are usually necessary for 1-2 weeks.

The goals of therapy are to decrease pain, restore ROM, and regain strength. Crutches are used until weightbearing is comfortable. ROM exercises are performed in a cold whirlpool. Quadriceps strengthening is started with quad sets and progressed to closed-chain exercises as tolerated. Running is allowed when weightbearing is comfortable and is progressed to more narrow S-shaped patterns, until pivoting is comfortable. At this point, sport-specific exercises and drills are added and advanced until the athlete is ready to return to the sport. Return to play is allowed when sport-specific agility testing is performed comfortably. People with grade 1 and 2 injuries usually return to play within 2-3 weeks. People with grade 3 injuries frequently require 6 or more weeks before a return to play.

After sufficient healing of the ligament has occurred, the initial focus of rehabilitation is to restore full ROM. After acceptable knee ROM is restored, the therapist is to concentrate on controlled strengthening. Often in the knee, the functional strength of the quadriceps muscle, especially the medial VMO muscle, is weak and atrophied. After restoration of sufficient strength, the athlete needs to go through sport-specific or function-based training. Upon achieving full strength and pain-free ROM in the lower extremity, the athlete can be cleared to return to their sport, most often without any brace or external support.

Medical Issues/Complications

Persistent instability and laxity may require surgical treatment.

Surgical Intervention

The consensus is that isolated MCL tears rarely require operative repair, while treatment of severe combined ruptures of the MCL and ACL or PCL would require reconstruction. ^[9] A study found that nonoperative and operative treatments of medial collateral ligament injuries lead to equally good results. Another indication for surgical intervention would be persistent instability, with surgery consisting of tissue repair and imbrication. Often, reinforcement with an allograft is necessary.

Lind et al investigated the effectiveness of treating chronic valgus instability of the knee with a surgical reconstruction technique involving the MCL and the posteromedial corner of the knee. ^[10] Patients in the study underwent either isolated MCL reconstruction, combined MCL and ACL reconstruction, or multiple ligament reconstruction, with surgery in each case including the use of ipsilateral semitendinosus autografts for MCL and posteromedial reconstruction. In the 50 patients who received a follow-up examination more than 2 years postsurgery, substantial improvements were seen in the International Knee Documentation Committee (IKDC) scores.

A retrospective study by Pandey et al compared outcomes in 35 patients who were divided into two groups, a group who had primary MCL- posteromedial corner repair without subsequent ACL reconstruction and group who a primary MCL- posteromedial corner repaired with a delayed ACL reconstruction. The study reported that the Lysholm (94.6 vs. 91.06) and IKDC (86.3 vs. 77.6) scores of the group that included the delayed ACL reconstruction were higher and 60% of the patients in the group that did not undergo ACL reconstruction complained of instability vs 0% in the ACL reconstructed group. ^[11]

Rehabilitation Program

Physical Therapy

Long-term outcome studies have shown that almost all patients with grade 1 and 2 injuries have returned to full preinjury activities by 3 months. Isolated grade 3 injuries still allow excellent return to preactivity levels by 6-9 months.

Return to Play

Return to play is allowed when sport-specific agility testing is completed comfortably. Usually this requires 90% return of strength compared to the contralateral knee.

Grade 1 and 2 sprains often allow return to play within 1-2 weeks. Grade 3 injuries usually require at least 6 weeks for return to play, although some authors have reported 3-4 weeks.

Prevention

Prophylactic bracing is controversial, although many athletes wear braces. Some studies recommend bracing after showing a decrease in injury rate. Older studies did not show a decrease in injuries, and some actually demonstrated a slightly increased rate of injuries.