Medial Collateral Ligament (MCL) Injury

The medial collateral ligament (MCL) is on the inner side of the knee connecting the femur (thighbone) to the tibia (shinbone). This ligament plays a crucial role in stabilizing and supporting the knee, particularly during side-to-side movements. Its primary role is to resist forces that push the knee inward (valgus forces) preventing the knee joint from buckling inward during activities. This ligament works in concert with other knee structures, such as the anterior cruciate ligament (ACL) and the menisci, to facilitate proper knee mechanics during various activities, including walking, running, and jumping. When the MCL is injured, it can cause significant disruption to knee stability and function. The severity of the injury can range from a mild sprain to a complete tear.

Cuban orthopaedic surgeons are highly skilled in accurately assessing the severity of MCL injuries and devising the most effective treatment plans. Treatment in Cuba can vary based on the injury’s severity, ranging from rest, ice, and physical therapy for minor injuries to surgical intervention for complete tears.

When MCL is left untreated several complications may develop, including:

• Persistent pain and swelling
• Chronic instability in the knee may remain unstable
• Increased risk of further injury to the MCL and surrounding structures,
• Altered gait patterns,
• Increased risk of secondary injuries or conditions such as arthritis
• Deterioration in the overall function of the knee

Types of MCL Injuries

The medial collateral ligament (MCL) can sustain various types of injuries, each differing in severity. MCL injuries are referred to as sprains and are classified by grades, ranging from one (the least severe) to three (the most severe).

• Grade 1 sprain: This is a mild tear in which the ligament is overstretched but not torn.
• Grade 2 sprain: This tear involves a partial or moderate tear of the ligament. This type of injury is more severe than a Grade 1 tear and affects knee stability more significantly.
• Grade 3 sprain: This is the most severe tear involving a complete tear of the ligament. This injury significantly compromises knee stability.

Causes of MCL Injuries

The causes of a medial collateral ligament (MCL) tear typically involve activities that place excessive stress on the knee, particularly from side-to-side movements or direct impact.

MCL tears are commonly caused by:

• A blow to the outer side of the knee.
• Quick pivots or sudden changes in direction.
• Squatting or lifting heavy objects.
• Landing awkwardly on the knee after a jump.
• Repeated stress and overuse can weaken the MCL over time, making it more susceptible to injury.

Symptoms of MCL Injuries

Symptoms of an MCL tear can vary based on the severity of the tear.

• Pain and tenderness along the inner side of the knee.
• Swelling and stiffness around the knee joint.
• Instability in the knee joint.
• Limited range of motion.
• Difficulty walking.

Diagnosis of MCL Injuries

Diagnosing an MCL injury starts with a medical history review and a physical examination. This process involves evaluating symptoms, understanding the history of the injury, examining the knee for structural integrity, and comparing the injured knee to the non-injured knee. Other tests include:

• X-Ray: X-ray images do not detect injuries to the MCL directly; however, they can reveal presence of broken bones or other injuries in the knee.
• Magnetic Resonance Imaging (MRI): This is the most effective imaging test for diagnosing an MCL tear, providing detailed images of soft tissues.
• Ultrasound: These images can assess how severe the MCL tear is and if there are other injuries in the knee.

Treatment Options for MCL Injury

Treatment for an MCL injury depends on the severity of the injury and the patient’s activity level. For grade 1 and 2 injuries, nonsurgical options such as bracing or physical therapy are typically most appropriate, allowing for a gradual return to regular activities. In more severe cases, surgical treatment may be recommended.

Non-Surgical Options

• Bracing: Bracing is crucial for MCL injury recovery as it stabilizes the knee, prevents further damage by absorbing external forces, and reduces pain by limiting unnecessary movements, thereby aiding in a safer and more comfortable healing process.
• Physical Therapy: Physical therapy is essential for recovering from an MCL injury as it focuses on restoring knee strength, stability, and range of motion. Through targeted exercises, physiotherapy helps strengthen the muscles surrounding the knee, providing better support and reducing the risk of further injury. It also aids in improving flexibility and mobility, ensuring that the knee can move efficiently and without pain. Included are:
  • Range of motion (ROM) exercises
  • Quadriceps activation
  • Strengthening exercises
  • Weight-bearing activities
  • Proprioception training exercises
• Balance exercises
  • Patellar mobility exercises
  • Dynamic stability exercises
• Side-to-side exercises
  • Neuromuscular Training
  • Agility Training
• Manual therapy
• Functional Electrical Stimulation (FES)

Surgical Option

Most MCL injuries can heal with non-surgical treatments, surgery however may be necessary for complete tears or when conservative treatments fail.

Indications for Surgery

• Grade III Tears: Complete tears of the MCL that cause significant instability in the knee.
• Combined Injuries: MCL injuries that occur along with other ligament injuries, particularly the ACL.
• Failure of Non-Surgical Treatments: Persistent instability or pain despite adequate non-surgical management.
• Displaced Avulsion Fractures: When a piece of bone attached to the ligament is pulled away from the main bone.

The specific surgical method is dependent on the nature and location of the tear:

• Direct Repair: This procedure is typically indicated for acute, complete tears or when the ligament has been pulled away from the bone at its attachment points and involves surgically suturing the torn ends of the ligament back together to restore stability and function to the knee. During the surgery, an incision is made over the inner side of the knee to access the damaged MCL. The torn ligament is carefully identified, and any damaged tissue is trimmed. Strong, non-absorbable sutures are used to reattach the ligament ends, often securing them to the bone using small anchors if necessary. Following the procedure, the knee is typically immobilized in a brace to protect the repair and allow for initial healing.
• Ligament Reconstruction: This procedure is performed when the ligament is severely damaged, or in cases of chronic instability where direct repair is not feasible. It involves replacing the damaged MCL with a graft harvested from the patient’s own hamstring tendons or from a donor. During the procedure an incision on the inner side of the knee is made to expose the damaged MCL. The remnants of any of the torn ligaments are removed and the site for the graft is prepared. Tunnels are then drilled into the femur (thighbone) and tibia (shinbone) at the original attachment points of the MCL through which the graft is threaded. The graft is then secured with screws or other fixation devices to ensure stability and proper alignment. This creates a new ligament that mimics the natural anatomy and function of the MCL. The knee is then closed and bandaged, and the patient is placed in a brace to immobilize the knee.

Postoperative physical therapy following MCL surgery is essential for a successful recovery and involves a structured, progressive rehabilitation program aimed at restoring knee function, strength, and stability.