Medial Collateral Ligament Injury

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Medial Collateral Ligament Injury

Medial Collateral Ligament Injury
John H. Wilckens MD
Marc Urquhart MD
  • An MCL injury is a sprain of the MCL, which is the primary restraint to valgus stress on the knee.
  • It occurs mainly in athletic teenagers and young adults, and equally among males and females.
  • Classification (Fig. 1) (1):
    • Grade I (mild): Microscopic sprain with intact fibers
    • Grade II (moderate): Partial tear
    • Grade III (severe): Complete tear
General Prevention
Prevention is best accomplished through conditioning before sport activities.
Risk Factors
  • Contact sports
  • Falls
  • Direct blow to the lateral knee
  • Valgus load to the knee
Associated Conditions
ACL injuries via a noncontact mechanism
Fig. 1. MCL injuries may be graded as follows: I, microscopic strain; II, partial tear; or III, complete tear.
Signs and Symptoms
  • Pain along the medial aspect of the knee, typically extending proximally and distally along the course of the MCL
  • Possible knee effusion
  • Can be associated with an ACL tear and/or a meniscus tear
  • Increased pain with valgus loading
  • Occasionally, recollection by patient of a “pop” or “snap” at the time of the injury
  • Occurs most commonly with a direct blow to the lateral knee, causing the knee to gap open
  • If MCL injury occurs with a noncontact mechanism, a high association with ACL injury exists.
Physical Exam
  • MCL ruptures can be associated with other injuries; physical examination and diagnostic workup should reflect a high suspicion.
  • Test the stability of the MCL:
    • Flex the patient’s knee 30° and apply a valgus force
    • Estimate degree of opening and character of the end point (soft, solid).
    • Valgus laxity of the knee in 0° of flexion suggests an MCL injury in addition to a cruciate ligament injury.
  • Perform a complete neurovascular examination distal to the knee.
  • Perform the Lachman and posterior drawer tests to rule out associated ACL or PCL injury.
  • Compare with the contralateral knee.
  • AP and lateral plain radiographs should be obtained initially to rule out fractures.
  • MRI is an appropriate study because of its sensitivity to other ligamentous or meniscal disease.
Differential Diagnosis
  • ACL rupture
  • Medial meniscal tears
  • OSD rupture
  • Tibial plateau fractures
  • Tibial spine avulsions
  • Patella dislocation


General Measures
  • Initially, a patient with an MCL injury
    is treated with ice, elevation, analgesics, a hinged knee brace, and
    protected weightbearing as tolerated.
  • The patient should be referred to physical therapy.
  • If the patient has a suspicion for an
    associated cruciate ligament injury, early referral to an orthopaedic
    surgeon is indicated.
Special Therapy
Physical Therapy
  • Gentle ROM exercises
  • Muscle-strengthening program with emphasis on medial hamstrings (MCL agonists) and core muscles
  • Progressive weightbearing in hinged knee brace as tolerated
  • Ice, electrical stimulation (2)
  • Once pain free, progressive agility and proprioception training
Chronic MCL tears unresponsive to nonoperative treatment may require surgical repair.
  • Most patients with MCL injuries respond to nonoperative treatment (bracing and early ROM).
  • Bracing should be considered for patients returning to contact sports.
Patient Monitoring (3,4)
  • Patients are followed at 2–6 weeks to check ROM, muscle strength, and joint laxity.
  • MRI if examination suggests associated cruciate ligament and/or meniscal injuries.
1. O’Donoghue DH. Treatment of acute ligamentous injuries of the knee. Orthop Clin North Am 1973;4:617–645.
2. Wilk KE, Andrews Jr, Clancy WG. Nonoperative and postoperative rehabilitation of the collateral ligaments of the knee. Oper Tech Sports Med 1996;4:192–201.
3. Bergfeld
J. Symposium: functional rehabilitation of isolated medial collateral
ligament sprains. First-, second-, and third-degree sprains. Am J Sports Med 1979;7:207–209.
4. Inoue
M, McGurk-Burleson E, Hollis JM, et al. Treatment of the medial
collateral ligament injury. I: The importance of anterior cruciate
ligament on the varus-valgus knee laxity. Am J Sports Med 1987;15:15–21.
Additional Reading
PA, Hermansdorfer J, Huegel M. Nonoperative management of complete
tears of the MCL of the knee in intercollegiate football players. Clin Orthop Relat Res 1990;256:174–177.
Shelbourne KD, Nitz PA. The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and MCL tears. Am J Sports Med 1991;19:474–477.
844.1 Medial collateral ligament
Patient Teaching
  • Most MCL injuries heal without surgery.
  • Patients are instructed in ROM and muscle-strengthening exercises.
Q: How can you tell if someone has had an associated injury with the MCL sprain?
An MCL injury sustained via a noncontact incident, with a large
effusion, or with valgus laxity in full extension suggests that another
structure (commonly the ACL) has been injured.

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