The medial collateral ligament (MCL) is a crucial stabilising structure on the knee’s inner side. It connects the femur (thigh bone) to the tibia (shin bone). MCL tears are a common knee injury, especially among athletes involved in contact sports or activities that put stress on the knee, and it’s one of the most common skiing injuries I see in the clinic.

What is an MCL Tear?

An MCL tear occurs when the ligament is overstretched or torn due to sudden twisting, direct impact, or a change in direction while the foot is planted. Some people may even hear or feel a popping sound. The severity of an MCL tear can vary from a mild sprain (Grade 1) to a complete tear (Grade 3).

Symptoms of an MCL tear include:

  • Grade 1 MCL tears may cause pain, swelling and tenderness along the inner side of the knee, but they don’t tend to cause knee instability.

  • Grade 2 MCL tears may lead to some sensation of knee instability when walking or trying to run. The knee may feel stiff and lack the complete range of movement.
  • Grade 3 MCL tears often make the knee feel very unstable, and it may be difficult to bear weight on the affected leg.

Instability or a feeling that your knee may give way.

MCL tears can occur in isolation, but they are frequently involved in combination with injury to other structures, such as ACL and meniscal tears.

Does my MCL tear need surgery?

Thankfully, most isolated MCL tears can be treated without surgery, particularly if they occur at the proximal (femoral) end of the ligament. Physiotherapy to reduce pain and swelling, improve the range of movement, and strengthen the knee joint enables most people to return to being fully active. Some people experience persistent feelings of instability in the knee despite excellent rehab, and surgery may be needed.

Early MCL repair

Sometimes, I meet a patient with significant laxity in their knee when the knee is in an extended position. This usually means they have a distal tear (i.e. the tear is at the tibial end), and the tendon is completely pulled off the tibia. The blood supply of the ligament in this area is poorer, and the surrounding tendons (pes anserine) stop it from healing properly. In these situations, it is best to surgically repair the tendon as soon as possible, ideally within the first three weeks from the time of the injury. If the MCL tear has happened along with an ACL (Anterior Cruciate Ligament) tear, and if the ACL has torn very close to the femoral (upper end) attachment, it may be possible to repair both the ACL and the MCL very soon after injury. However, at the time of the surgery, if the tissue quality of the ACL is poor, I may need to reconstruct rather than repair the ACL.

MCL surgery

Most surgically treated MCL tears can be repaired if treated early. This is performed by putting a suture anchor into the bone and tying the ligament to the anchor. This is usually reinforced with a suture tape that acts like a brace inside the knee to protect the repair (internal brace).

Occasionally, if the tissue quality does not allow adequate repair, then a reconstruction will be required. I will typically use an allograft (donated tissue) or synthetic (artificial) ligament to reconstruct the MCL. Chronic MCL injuries also require reconstruction as repair is no longer possible.

Combined MCL injuries

If a person has sustained an anterior cruciate ligament (ACL) tear, along with a partial MCL tear, I recommend a six-week period of prehabilitation before the ACL reconstruction, and at that stage, we assess how lax the MCL is. Much like degrees of tearing, we have degrees of laxity:

Grade 1 laxity means that when we apply stress across the inside of the knee to separate apart the femur and tibia, there is little to no opening up of that side of the joint (although there may be pain).

Grade 2 laxity means that some gapping is possible in the joint, but the ligament still has a ‘firm end point’ – in other words, the ligament feels stretched.

Grade 3 laxity means that it’s possible to gap the joint fully and that there’s no restraint offered at all by the ligament.

If after the prehab period has ended, there’s still a Grade 1 laxity of the MCL, I would recommend carrying out an ACL reconstruction using a quads tendon graft. This is in preference to using a hamstring graft because the hamstrings give medial stability to the knee, and we want to preserve them to protect the MCL.

If a person has significant, persistent laxity of their partial MCL tear, when combined with an ACL tear, I will likely recommend repairing or reconstructing the MCL ligament (along with the quads tendon ACL reconstruction).

Post MCL surgery

It is really important that you engage fully with a physiotherapist and commit to your range of motion exercises after any knee surgery, particularly after MCL surgery. MCL surgery often makes the knee feel stiff in the early recovery phase, and I will ensure you have adequate painkillers to allow you to do your exercises (particularly getting your knee fully straight).

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