What is an MCL Injury?
The most common knee injury is to the medial aspect of the knee.
The medial collateral ligament, or MCL, extends from the end of the femur (thigh bone) to the top of the tibia (shin bone) and is on the inside of the knee joint. There are three main anatomic structures in the medial side of the knee, with the superficial medial collateral ligament being the largest and strongest. The other main structures are the posterior oblique and deep medial collateral ligaments. It is important to note that an MCL injury means that the entire medial knee structures are affected.
A large number of isolated medial ligament injuries are due to sporting injuries. An MCL injury can occur through stress against the outside of the knee that stretches or tears the medial knee structures. This injury can be caused through either contact or non-contact.
MRI scan demonstrating a tear of the medial collateral ligament off the femur. Tears off the femur, especially those with a knee that does not gap open when the knee is tested in full extension, have a higher chance of healing compared to MCL tears off the tibia.
CLICK IMAGE TO ENLARGE
What are MCL Tear Symptoms?
- Pain directly over the ligament
- Swelling and inflammation over the inside (medial) part of the knee
- Severe cases patients will feel their knee “give out”, or buckle
Dr. LaPrade will examine the patient and use x-rays, stress x-rays, and in some cases, an MRI to evaluate the MCL area to determine the exact injury. An MRI shows the ligaments and muscles in addition to the bones, and it is very useful when determining if the injury is a partial or complete MCL tear and for which part of the medial knee structures are torn.
In order to verify if the MCL is in fact still partially intact or completely torn, Dr. LaPrade will perform a valgus stress test with the knee out straight and with the knee flexed to 30°. This test will check to see if the medial knee gaps open to side-to-side stressing. If increased gapping occurs, the MCL is most likely torn. To properly diagnose MCL injuries, doctors usually perform this test in combination or in addition to other physical exams.
MCL Injury Grading
The grade of the medial ligament injury is based upon the amount of tearing present.
- Grade I Injury: occurs when there is just slight tearing and no significant gapping
- Grade II Injury: occurs if there is gapping present but an end point to valgus stressing at 30° of knee flexion.
- Grade III Injury: occurs when there is a complete ligament tear of the medial side of the knee and stressing causes the lack of an endpoint. In chronic injury cases, a medial knee reconstruction will need to follow.
In general, most acute Grade I and II injuries will heal with a well supervised rehabilitation program. While the majority of isolated grade III medial knee injuries will heal, there are still some which do not heal and a grade III injury must be followed closely to be certain the patient does not have any problems with residual instability. In addition, it is well recognized having any “looseness” of the medial knee structures can cause an ACL graft to fail. Thus, when there is a combined medial knee injury and ACL injury, it is important to verify that the MCL injury heals completely prior to the ACL reconstruction or it should be concurrently repaired or reconstructed.
In the case of very severe combined knee ligament injuries, especially with a concurrent PCL tear, a concurrent medial knee injury should undergo a repair, augmentation repair, or a complete medial knee reconstruction.
Have you sustained an MCL injury?
There are two ways to initiate a consultation with Dr. LaPrade:
You can provide current X-rays and/or MRIs for a clinical case review with Dr. LaPrade.
You can schedule an office consultation with Dr. LaPrade.
(Please keep reading below for more information on this condition.)
How to Read an MRI of an MCL Tear
When is MCL Surgery Needed?
Historically, the surgical treatment of medial knee injuries resulted in a significant number of patients developing postoperative stiffness, which often resulted in more surgeries for the patient. Thus, we have developed newer techniques in our research lab which allow us to have patients move their knee sooner to try and decrease the risk of stiffness and the necessity of secondary surgeries to treat their stiffness.
Dr. LaPrade has performed extensive anatomic, biomechanical, diagnostic and related studies to better understand the medial knee structures. Through this work, he has been able to develop an anatomic medial knee reconstruction procedure, which has been performed in patients and is currently undergoing clinical outcome studies.
What is MCL Surgery Recovery Time?
In the acute medial knee ligament tear situation, patients are placed into a brace and are enrolled in an early rehabilitation program to emphasize quadriceps reactivation, edema control and knee range of motion. The main rehabilitation exercise for MCL tears is the frequent use of a stationary bike.
For isolated acute MCL injuries, most athletes can return to sports by multiplying the grade of the injury by two (in weeks) as a general time frame. Thus, a grade I acute MCL injury usually needs 1-2 weeks to heal, while a grade II injury takes 3-4 weeks to heal and a grade III isolated complete MCL injury typically takes 5-6 weeks of properly guided rehabilitation to have the injury heal completely.
The use of a hinged MCL protective knee brace is also commonly recommended in the acute situation when the knee is significantly unstable. Thus, we recommend the patient be fitted by one of our brace specialists. They will properly fit the MCL brace, which is durable enough for desired activity levels.
Related Studies
- Anatomy of the Medial Part of the Knee
- Medial Knee Part I – Static Function of the Main Medial Knee Structures
- Correlation of Valgus Stress Radiographs
- Management of Injuries to the Medial Side of the Knee
- Structural Properties of Primary Medial Knee Ligament
- sMCL – Anatomic Augmented Repair vs Anatomic Reconstuction
- Analysis of Anatomical Medial Knee Reconstructions
- Development of an Anatomic Medial Knee Reconstruction
MCL Injury FAQ
Dr. LaPrade and colleagues have published one of the first comprehensive books on treating the medial collateral ligament (MCL) and injuries to it. Following are some answers to very common questions that have been posted regarding the MCL.
1. Will an MCL injury heal itself?
Many MCL injuries do have the ability to heal. This is especially true if the MCL is the only ligament torn around the knee. Partial MCL tears almost always heal, while complete MCL tears mostly heal. The MCL tears that are most concerning about whether they heal or not are those that occur with other ligament injuries in the knee, especially with the PCL, when the chance of healing for a complete MCL tear is low. In addition, MCL tears that completely tear off the femur and the knee gaps open on the inside with the knee out straight (in full extension) or when the MCL tears off its distal attachment on the tibia, are the main types of MCL tears which do not heal.
MRI scan demonstrating a tear of the medial collateral ligament off the femur. Tears off the femur, especially those with a knee that does not gap open when the knee is tested in full extension, have a higher chance of healing compared to MCL tears off the tibia.
CLICK IMAGE TO ENLARGE
2. Does an MCL tear hurt?
As with all injuries around the knee, there are wide varieties of types of MCL tears. A lot of the pain associated with a ligament tear is because of bleeding and swelling from the injury. Therefore, some minor MCL sprains may not hurt very much, unless one is shuffling side-to-side, whereas most complete tears will hurt, especially if one pushes down on the MCL in the area where it has been injured. People who have had a previous MCL tear may have had it heal a little bit loose and a new injury may be concerning for an MCL tear, when in fact it is an old injury that just healed a little bit loose. In these instances, we would expect that one would not have much pain in the region of the MCL.
3. Which is the worst injury: MCL or ACL?
Almost all the time, an ACL tear is a worse injury than an MCL tear. This is because an ACL tear occurs inside the joint, where there is a very poor healing environment, whereas the MCL tear has a good blood supply around it and has an excellent chance of healing most of the time. In addition, if one does have surgery, because of the same blood supply issue, MCL reconstructions have a better chance of healing than ACL reconstructions in most instances.
4. What causes an MCL injury?
An MCL injury is due to extra stress on the inside of the knee causing the fibers within the MCL to stretch out. This could include a clipping injury, falling down towards the inside of one’s knee, or having a more the amount of gapping to serious injury while playing sports.
5. How does one test for an MCL injury?
Testing for an MCL injury involves both palpation and stressing to see if the ligament is torn. Palpation over the inside of the knee where the MCL courses may reveal pain, swelling, or thickness in the region of an MCL tear. Stressing the knee involves holding the thigh straight while pushing the leg towards the outside, which we call valgus stress. Ideally, one would put the examiner’s fingers directly over the joint line to assess if there is any gapping at the joint line to determine the grade of the MCL tear. Grade 1 partial MCL tears generally just have some mild tearing within the MCL and it does not gap at the joint line. Grade 2 partial tears do have some gapping, but there is an endpoint, whereas a complete grade 3 tear has no feeling of an endpoint at the joint line and is unstable. In all circumstances, one should always compare the amount of gapping to the normal contralateral knee when examining for an MCL tear to determine the “side-to-side” differences of gapping at the medial joint line.
6. How does one heal an MCL injury and how does one heal an MCL injury fast?
In general, most MCL tears do heal, especially when they occur in isolation without another ligament injury. One of the first steps is to try to decrease the swelling and bleeding in the region of the MCL tear so that one can work on knee motion and have a normal gait pattern. As long as there is some pain over the MCL, applying ice or a wrap to minimize swelling is beneficial. For MCL tears that do have gapping, we like to use a hinged knee brace to ensure that the knee does not continue to gap side-to-side and cause the MCL to heal in a stretched-out position. In addition, we have found that early knee motion, most commonly using a stationary bike, is very beneficial to help the healing MCL collagen fibers line up correctly and thicker so that they heal well. We have found that the more that one uses a stationary bike with an MCL tear, as long as it does not cause any significant pain or swelling at the knee, the faster the MCL tear tends to heal. In general, grade 1 MCL tears taken 1-2 weeks to return back to activities, grade 2 MCL tears 3-4 weeks, and grade 3 complete MCL tears taken 5-7 weeks to heal. This rehabilitation program can be very effective in getting MCLs to heal and even the MCL tears which have a low likelihood of healing can benefit from having the knee quiet down and having a less chance of becoming stiff with a surgical reconstruction or repair with this program.
7. Can an MCL injury occur from running?
An MCL tear usually occurs with a blow to the outside of the knee or a fall where one collapses down towards the inside of their knee. Therefore, a running injury where one slips and stresses the inside of their knee could potentially cause an MCL tear.
8. Does an MCL tear occur with skiing?
Skiing is one of the more common ways that an MCL tear happens. In fact, it is by far the most common knee ligament injury that occurs with skiing. This is because when one collapses down to the inside of their knee either with a fall or while slipping on an icier portion of the terrain, it puts extra stress on the inside of their knee. MCL tears often occur with ACL tears in skiers also.
9. What happens with an MCL tear where one is unable to straighten their leg?
When one tears their MCL and is unable to straighten their leg, one has to be concerned that possibly there are some other injuries inside the knee that are contributing to the lack of extension. These can include a torn ACL stump or a bucket handle tear of the meniscus. When the other structures in the knee are still intact and one cannot straighten their knee, commonly this is due to pain and swelling causing the hamstrings to go into spasm or pain with knee extension, which limits the ability to straighten one’s leg with an MCL tear. In this circumstance, after a physical exam or MRI scan demonstrates there is no pathology within the joint, a program of rehabilitation to cut down on the swelling and improve knee motion would be indicated.
10. What about MCL injuries in soccer or football?
MCL injuries in soccer or football have a common mechanism. Usually this is because the knee is hit on the outside and it puts extra stress on the inside and stresses the MCL. In those circumstances where there are no other injuries to the ACL or menisci, a standard rehabilitation program should consist of icing, bracing, and graduation to a stationary bike to improve one’s range of motion and quadriceps strength. Return to activity depends upon the grade of the injury.
11. Does an MCL injury occur with yoga?
If a yoga pose or position puts significant stress on the inside of the knee which is more than the MCL can take, it is possible that there could be an MCL tear with these positions. Because these are “low velocity” injuries, they are most commonly partial MCL tears rather than complete MCL tears. Partial MCL tears should go through a program of icing, crutches as needed, and use of a stationary bike to encourage healing prior to returning back to a stretching program. MCL tears can hurt for several months while the healing and repeated stretching could cause some localized irritation of the healing tissues.
12. What is the difference between an MCL injury or arthritis?
In patients who have arthritis, it may be difficult to determine if they have a partial MCL tear or just an exacerbation of their underlying arthritis because of some of the toggle that can occur at the joint line with a loss of cartilage. This is called “pseudolaxity.” In these cases, the knee can toggle side to side and it can be very difficult for the examiner to determine with one’s fingers if the gapping is due to an MCL tear or an exacerbation of the underlying arthritis when one does have an injury. In these circumstances, obtaining x-rays to see if there is any significant joint line narrowing or if there are concerns about a concurrent MCL tear, obtaining bilateral valgus stress x-rays to see if there is a side-to-side difference in medial compartment gapping may be indicated. In any circumstance, it can be difficult for physicians to determine the difference between the two conditions and x-rays may be indicated to help arrive at a diagnosis.
13. Why does an MCL injury hurt years later?
One of the most common reasons that MCL tears can hurt years later is because with a significant MCL injury, bone may actually form in the region of the tear rather than healing collagen fibers. This heterotopic ossification is called Pelligrini-Stieda disease. It may often show up years later on x-rays for somebody that had an MCL tear in the past. For those people who do have a lot of bone present, it can interfere with the collagen fibers from sliding from front to back as the knee bends, and this may cause some occasional irritation of this tissue. In addition, some people may have their MCL tear heal very thick and the increased thickness and scarring can be irritated if one does overdue it with long hikes or long runs even if one had an MCL tear, happen years previously. Surgery to treat this type of pathology is very rare and may only be indicated in people who have a lot of heterotopic ossification present that is causing their pain.
14. What does one do if an MCL tear is not getting better?
While the majority of MCL tears do heal, the rest of them that do not heal may not be in the “at risk” tear types. In these circumstances, if one has gone through a well-designed rehabilitation program, there is still a small chance that the MCL tear will not heal. In these circumstances, it can be difficult to shuffle or plant side-to-side because the knee will gap open on the inside. If this is a minor nuisance, one can brace their knee for these types of activities to see if that helps them increase their overall function. If it does not let one participate in activities as one desires, one should see a physician to have a physical exam and objectively determine the amount of gapping present with bilateral valgus stress x-rays. This can be an objective means to determine if the MCL is truly completely torn and is healed in a stretched-out position that will never tighten up.
15. When does an MCL tear need surgery?
Most MCL tears that occur with multiple ligament injuries need surgery. In addition, those MCL tears which completely tear off the femur and the knee gaps open with the knee out straight, or where the MCL tears off the tibia and retracts towards the joint line, have a high requirement for needing surgery. Other types of MCL tears generally heal, but they do not all heal so they should be followed closely and it should be determined if one has any significant functional limitations to decide if one does need a surgical procedure.
16. How does one prevent MCL tears?
There is some literature to show that the use of some hinged knee braces, especially in sports such as football, can be beneficial to prevent MCL tears. This is because the brace does provide support to the knee when one is hit from the outside of the knee and this can put less stress on the inside of the knee, which could tear the MCL.
17. What does it mean when one feels a pop with an MCL injury?
MCL tears in general do not cause a pop by themselves when they do tear. When one does feel a pop, one has to be concerned that it is a compression of the outside of the knee due to the opening on the inside causing a bone bruise in the lateral compartment. Bone bruises have been reported to be present about 50% of the time with a complete MCL tear. Bone bruises by themselves may or may not be a problem, depending upon whether the lateral meniscus is injured and the cartilage over the bone bruise has been damaged. An MRI may be indicated in these circumstances where one has swelling within the knee with an MCL tear.
18. What are the general time tables of returning back from an MCL tear?
Grade 1 or partial MCL tears usually require 1-2 weeks to return back to full activities. Grade 2 MCL tears, or a partial tear, but with an endpoint on physical exam usually take 3-4 weeks to return back to activities. Full MCL tears, which include the ones that have a high potential for healing, usually take 5-7 weeks to return back to full activities. In all these circumstances, a well-guided physical therapy regimen should help one to return back to activities sooner than if one did not undergo a rehabilitation program.
19. How can I treat an MCL at home?
First, it is important to make sure that you truly only have an MCL injury as part of the diagnosis. If one does have other things going on with the knee, especially an ACL tear or a meniscus tear, these have to be assessed as far of the determination as to the best rehabilitation program. When one does have a diagnosis of an isolated MCL tear, one should work on icing the area to try to minimize swelling, use crutches as needed until one can walk without a limp, and avoid any side-to-side activities which could cause the MCL to heal in an elongated position. Ideally, one should have a hinged knee brace if one does have a grade 2 or grade 3 MCL tear to treat this. As mentioned earlier, the use of a stationary bike is very effective at helping the collagen fibers with a torn MCL to line up correctly and based on our experience with athletes, it appears it also heals quicker. Therefore, once one’s knee can tolerate it without any pain or swelling, the use of a stationary bike can be effective to help an MCL tear to heal.
20. When can an MCL tear be repaired?
There are many factors which need to be reviewed to decide when an MCL should be repaired versus reconstructed. If there is any significant stretch injury to the MCL, then a repair has a lower likelihood of healing. MCL tears off the tibia with little retraction may be the best indication for repair, especially if they are performed concurrent with an ACL reconstruction. In general, the results in the literature are more successful for reconstructions over repairs, so looking at having a repair done has to be carefully assessed to make sure that there is the best chance for healing.
21. How does one determine between an MCL tear or a medial meniscus tear?
Determining between a medial meniscus tear and an MCL tear requires a careful assessment. First, the mechanism of injury can often determine if one has an MCL tear. If there is no significant blow or one’s leg did not fall inwards, then there is a lesser likelihood that there was an MCL tear that is causing the problem. Palpation of the joint line can also help determine the difference between an MCL tear and a meniscus tear. The MCL will usually hurt directly over the ligament itself, whereas pain in the front or behind the MCL it often can be a meniscus tear. In addition, if one gaps open, one commonly has an MCL tear. The occurrence of medial meniscus tears with an MCL tear, when there are no other ligament tears in the knee, is relatively uncommon and potentially the only way to determine that is to obtain an MRI scan to be sure if one is concerned about this concurrent pathology.
22. Should one use ice or heat to treat an MCL injury?
When one does originally injure their MCL, there are torn fibers present and torn blood vessels which will cause swelling and pain. In this circumstance, applying heat would cause more swelling and pain, so the usual treatment for the first few days after an MCL tear is to ice it down. Once one prolongs into a rehabilitation program and the MCL may feel somewhat stiff prior to getting on a stationary bike, warming it up with a hot pad may be indicated in those circumstances.
23. How does one assess an MCL tear on MRI?
An MRI tear on MRI is best assessed on the coronal view. In these circumstances, we like to assess the 2 main portions of the MCL, which are the meniscofemoral and meniscotibial portions. The meniscofemoral portion goes from the meniscus up to the femur, whereas the meniscotibial portion goes from the meniscus down to the tibia. Most MCL tears are meniscofemoral-based and these have a fairly good blood supply and more underlying stem cells to allow it to heal. As long as it is not completely torn off the femur with the posterior oblique ligament and deep MCL, there is a good chance that these MCL tears will heal. Meniscotibial-based MCL tears can also heal. However, when they are torn off their distal attachment and retracted proximally, they can become entrapped in the hamstring tendons and have a low likelihood of healing back. In these circumstances, there is a much lower chance of these healing, but trying a rehabilitation program to allow the knee to have less chance of getting stiff after surgery may be indicated and there are some instances where these could potentially heal.
24. What pain medication should one take for an MCL tear?
An MCL tear involves disruption of collagen fibers and healing of these fibers is important to return one back to activity. Therefore, with a complete MCL tear, the use of anti-inflammatory medications like ibuprofen or Naprosyn may potentially slow down the healing. Therefore, we generally recommend that one use acetaminophen as the initial medication for an MCL tear. In addition, the use of the anti-inflammatory medications right after injury may make the bleeding worse, which could prolong one’s ability to return back to activities. If one does have severe pain from an MCL tear, icing it down and applying some compression may help to decrease this pain. If one needs a higher level of pain medications, then one should see a physician for assessment as to whether there are other concurrent injuries or if one does need different medications to treat their injury.
25. How does one treat an MCL tear in a hockey goalie?
Treatment of an MCL tear in a hockey goalie can be complicated because butterfly goalies are extremely MCL dependent. Therefore, allowing the MCL to heal prior to returning back to competition can be very important because if one returns back too soon before the MCL is healed adequately, the MCL could heal in a stretched-out position, which could affect one’s function. Therefore, wearing a brace, working on a stationary bike as often as possible, and focusing on straight-ahead activities until it completely heals before one does side-to-side or butterfly goalie drills would be indicated. In some instances, the scar tissue from an MCL tear can be limiting with one going down into a butterfly position, even when the MCL tears heal completely. In these circumstances, assessment by a physician to determine if a one-time intraarticular steroid injection may be indicated is a possibility. Also, once the MCL tear has completely healed, the use of anti-inflammatory medications as a trial for determining if pain relief may also be indicated.
26. What diet should one be on for an MCL tear?
A well-balanced diet would be indicated for treating an MCL tear. In general, there is no specific food substance which helps to make an MCL heal sooner. However, the avoidance of nicotine or tobacco products would be indicated because these have been demonstrated to slow orthopaedic injury healing.
27. When should one use a brace during an MCL tear?
In general, we recommend brace wear for those who have grade 2 or grade 3 MCL tears. If one can be totally careful and avoid any side-to-side activities or stress to their knee, it is possible they could get away without wearing a brace, but there is a risk without a brace that one could cause the MCL to heal in an elongated position. When these do heal in an elongated position, one can notice difficulty with side-to-side activities or planting on the affected knee and twisting towards the inside, so the use of a hinged knee brace would be indicated in those who have a higher grade MCL tear and who wish to return back to sporting activities.
28. What does one do with a chronic MCL tear?
Patients who have a chronic MCL tear and who have instability need a complete workup to verify that the MCL tear is causing the problem and also to look at other associated body habitus issues which can affect the healing of the MCL tear. In general, chronic MCL tears in people who are knock-kneed have a much higher risk of causing symptoms and also having the surgery not work because of the extra stress placed on the inside of the knee when one is knock-kneed (valgus alignment). Therefore, long leg x-rays to look at one’s lower extremity alignment would be indicated in chronic MCL tears to determine if a surgery to take you out of the valgus alignment (a distal femoral osteotomy) would be indicated concurrent with an MCL reconstruction. In addition, determining objectively the amount of gapping that one has to confirm that there is a complete MCL tear, with the use of bilateral valgus stress x-rays, is important to confirm the diagnosis. Physician’s fingers are notorious for either underestimating or downplaying the amount of gapping that may occur, so confirming the amount of gapping objectively with the stress x-rays is one way to determine if the patient is having their symptoms from a complete MCL tear which has healed in an elongated position.
29. What does one do with an MCL tear after a total knee replacement?
MCL tears after total knee replacements are notorious for being difficult to heal. These can occur from releases during surgery, which are required to be able to insert the prosthesis, or they can occur because of an injury after the knee replacement. Surgery to treat these complete MCL tears can be difficult because they require reconstruction and the blood supply is not as good in these patients who have had knee replacements and these patients are generally older. Therefore, in many patients, the use of an MCL brace for activities may be indicated rather than a big surgical reconstruction. In those patients who do require surgery, a careful assessment to their overall health, which includes whether they use tobacco products, if they have diabetes, and other medical issues, is necessary to determine the ability of a reconstruction to heal for them.
30. When can I drive after an MCL tear?
The ability to drive after an MCL tear depends on the grade of the tear (grade 1, 2, or 3) and how one’s knee has responded to the physical therapy regimen. It is very important to have a normal brake/reaction time prior to returning back to driving. If it is one’s right knee, it could take 4-6 weeks for a complete MCL tear to heal sufficiently to be able to drive safely. With the left knee, as long as one does not have a clutch, once one can safely bend their knee in the car, they are not on any narcotic medications, and their right knee can function safely, it would probably be safe to drive with minimal risk.
31. When can one swim after an MCL tear?
Once one has control of the pain and swelling at the knee, one could get into a pool and use a pool buoy between their knees to work on upper extremity swimming. With grade 1 MCL tears, swimming should be possible within 2-3 weeks after injury for most people. For a grade 2 MCL tear, one would want to make the sure the MCL has healed sufficiently before starting any significant kicking and avoiding the breast stroke or flip-turns at the end of the pool to ensure that the MCL does not stretch out. For those with a grade 3 MCL tear, one should certainly make sure that the MCL has healed completely before they start any significant kicking in the pool, especially with the breast stroke, and avoid any flip turns at the end of the pool where they could stress their MCL. This could take anywhere from 5-8 weeks and should be assessed concurrent with your athletic trainer or physician to ensure that the MCL has healed sufficiently before starting this activity.
