A medial collateral ligament injury or MCL sprain is an injury to the ligament on the inside of the knee, and occurs when the force on the ligament is too great to resist. Usually as a result of direct impact or twisting of the knee. This force is known as a valgus force, which means the knee “knocks in”. These incidents usually occur at high speed.

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What is the MCL made up of?

The MCL is there to resist the valgus force, therefore it is the ligament on the inner (medial) side of your knee. A valgus force means the tibia (lower leg bone) or foot is forced outwards in relation to the knee joint.

The MCL runs from the medial femoral condyle (the bony part on the inside and top of your knee), to the medial tibial condyle (the bony part on the inside and bottom of your knee). It is one of four ligaments in the knee that keeps the knee stable. It is a very fibrous, tough band of connective tissue that is made up of collagen molecules.

The Medial Collateral ligament specifically prevents the knee  from buckling outwards. So while standing on your knee and your knee moves inwards, the MCL takes up the tension to prevent excessive movement of your knee inwards.  Protective function.

There are sliding movements of the femur on the tibia, which is called ‘joint translation’. These movements are controlled by the MCL to avoid the knee from deviating off its normal path. Therefore the MCL is crucial in the stability of the knee from sliding inwards or outwards.

Medial Collateral Ligament injury, MCL injury, MCL Sprain, Knee ligament sprain Medial Collateral Ligament

How does an MCL injury happen?

A ligament sprain is a form of overstretching the ligament. There are several classifications in which ligament sprains can be divided, depending on the severity. The fibrous band is like a pulley, which prevents load from forcing the joint into extreme ranges. But when the force is too big for the ligament to resist, a sprain can occur. Over stretching leads to a tear and it is very important to know and understand the difference & implications thereof. In the case of a tear, you may hear a snap or tearing sound.

For example when a rugby player is tackled on his knee from the outside when his foot is firmly planted, the weight of the tackler will be greater to what the MCL can resist. The force directed on the player’s knee is pushing his knee inwards. The MCL is at full stretch while a uncontrollable load is being forced on it, therefore this will thrust the ligament past its boundaries and cause the ligament to tear or completely rupture.

The collagen fibers tear like a rope. On a cellular level, injury will cause inflammation along the sheath of the ligament (a membrane that gives the ligament its nutrients – normal sustenance is disrupted). In turn, the inflammation causes swelling, pain and loss of function of the ligament. The swelling along the sheath causes loss of space and limiting normal slide of the ligament.

Ligament tears are indicated by Mucoid degeneration and fibrinoid necrosis (a type of cell death).

Causes of an MCL injury

An MCL sprain occurs mostly during sporting activities. For example, a tackle during rugby, where the opponent tackles your from the outside, and your knee gives way inwards. This puts the MCL at a strain and if the force exceeds the tension of the ligament, it could cause a  sprain.

Another example could be during netball or ballet, where your foot stays planted in the ground, but your upper body and knees turn either in or out, leaving the MCL to twist in such a fashion, that it could be sprained if the force is bigger than the tension in the ligament.

When these mechanisms of injuries occur, they usually happen at speed, and if the knee stability muscles are not firing properly, the ligament will have to take up the slack, therefore it will increase your risk of a MCL sprain. If the ligament doesn’t get properly treated and rehabilitated, it could cause repetitive sprains.

A single, sudden, overload on the ligament will be classified as acute trauma, but repetitive straining of the ligament in excess of its abilities, will develop a persistent laxity of the ligament over and over again. The end result is a Chronic MCL sprain. The ligament will end up in a cycle of constant damage leading from fatigue, strain and eventually tear or full rupture.

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Sprained your Medial Collateral Ligament?

There are different classifications based on the degree of the stretching or tearing in the ligament:

Grade 1 MCL sprain (mild)

Small amount of fibers torn, some discomfort and pain. The ligament only has a slight stretch. No swelling or much pain, but you may run into trouble if this starts happening over and over again. Recurrence of micro tears in the ligament could lead to more severe tears. You will have no loss of function or range of movement of your knee, but it may be painful at some point during the movement. You will be able to continue playing.

Symptoms of a 1st degree MCL tear

  • Mild pain,
  • No dysfunction,
  • Not swollen or discoloured.
  • Tender to the touch on the inside of the knee.
  • Pain only at the end of range
  • Feeling hesitant to move the knee in the same direction as when the injury occurred.
  • When there is an outward force applied to the knee when bent at 30 degrees, there is discomfort felt over the ligament, but no joint laxity as a grade I means fewer than 10% of the fibers were being torn.

Medical treatment
You will need to consult with a Physio to establish the extent of damage and accurate diagnosis. Physio treatment of a Gr 1 MCL sprain is very successful.

Recovery Time
Grade 1 – 2 to 4 weeks (We try to get you pain free within 2 weeks)

Grade 2 MCL tear (moderate)

Partial tear with some swelling and bruising. Pain level increases quite a bit from a grade I, and moving the knee will not occur without pain. It may feel uncomfortable to bend or straighten the knee and your knee may feel unstable and like it wants to “give way”. 20% to 80% of the fibers torn. You will not be able to put weight through the leg. Even if you try to continue playing, you will have a considerable amount of pain and limping. The pain will not allow you to straighten your knee or lift your leg forward (knee to chest).

Symptoms of a 2nd degree MCL tear

  • Sharp sting and pulling feeling over the inside of the knee
  • Very painful,
  • Swollen,
  • Discolored (bruised, blue colour)
  • Can’t straighten or bend the knee without pain.
  • Pain through the range
  • Unable to climb down stairs
  • Feeling of instability and trouble putting full weight on the affected leg.
  • Unable to continue play (sport), have to stop moving (running, jumping)
  • When the same valgus stress is applied, there is some joint laxity, but there is a definite endpoint (the knee won’t give way completely).

Medical treatment
Contact us A.S.A.P. The faster we have a look at it before the swelling and bleeding sets in, the better. You have to consult with a Physio to establish the extent of damage and determine the most appropriate course of action. We can successfully restore your ligament without any surgical intervention.

  • Use of a weight-bearing brace or supportive strapping will be used during this phase. This aids in avoiding overuse of the ligament and puts some pressure on the ligament to ease the pain.
  • Physiotherapy management during this grade will be the same as with a grade I, progression will be expected to be slower.
  • Comprehensive rehabilitation program addressing all the stages of recovery

Recovery Time
Grade 2 – 6 to 8 weeks (With early treatment, we try to get you jogging at 6 weeks)

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Grade 3 MCL tear (severe)

Complete tear. Swelling and discolouration (bleeding under the skin) is visible. The knee feels like it wants to give way completely. Bearing full weight is almost impossible. Bleeding and swelling will definitely be present.

The main concern with a Gr 3 tear, is the ligament’s ability to stabilize the knee joint,  if the ligament tears into two separate flaps, there is no way the ligament can ‘heal’ or re-attach without surgery. A Sonar or Diagnostic Ultrasound will show the full extent of the damage. Surgery is the best option to re-connect the separated segments of the torn muscle.

Often there will be no pain, but the disfigurement is quite obvious, since all the fibers are torn. It is important to know that there could be other structures involved with such an injury, but we will discuss this in more detail with our differential diagnosis later.

Symptoms of a 3rd degree MCL tear

  • Hearing a loud pop, snap when it happens.
  • Unable to continue playing, have to stop moving
  • Could have experienced initial pain, but it subsides if all the fibers are torn.
  • Pain through the range
  • Severe pain when stretched
  • Always swelling
  • Discolored, always considerable amount of bleeding under skin
  • Complete loss of stability, knee buckles inwards
  • Unable to stand on your knee with all your wieght
  • The valgus stress test will show significant joint laxity with no end point.

Medical treatment
Contact us immediately! The faster we have a look at it before the swelling and bleeding sets in, the better. You have to consult with a Physio to establish the extent of damage and determine the most appropriate course of action.

A hinged brace locked at full extension is usually worn during this time, and you will have to use crutches for 2 weeks as not to put full weight on the injured knee. As pain allows, the brace can be unlocked as tolerated. Return to sport in this instance can take up to 4 months, after a thorough rehabilitation program.

Recovery Time
Will depending on conservative or surgery treatment option. Conservative may be more than 8 weeks with intensive rehab. If you have completely ruptured your medial collateral ligament you will need surgery and may take 4 – 6 months to full recovery.

How we test

These are some of the test that we perform in the practice, if this position is painful going into it, the test is positive meaning you may have some degree of Medial Collateral ligament tear.

Single leg squat

  • Stand on one leg (the affected leg)
  • Bend the knee slowly
  • Your knee will either give way inwards
  • Or you will feel pain on  the inside of your knee
  • With a grade III onwards, you will almost immediately feel pain and instability, you may even feel too scared to try this test.

Step-down test

  • Stand on a step
  • Step down slowly with the unaffected leg (the affected leg stays on the step)
  • Try to keep your knee over your second toe
  • If the knee gives way inwards or if you feel pain on the inside of your knee, it could be an indication of an MCL sprain.

The side step

  • Stand with your leg on a stair, sideways, thus, your body faces away from the step
  • The gravitational force on your knee will already indicate a weakness on the inside of the knee
  • Pain and/or weakness could again be an indication of an MCL sprain.

Twisting

  • Stand on one leg (the affected leg)
  • Bend that knee slightly
  • Twist your body left to right and right to left
  • The twisting motion will bring forth a weakness or pain if the MCL (OR the medial meniscus) is involved, as these structures are very closely related anatomically.

Diagnosis

Our Physiotherapists diagnose a ligament sprain by stressing each individual ligament. Our physiotherapists are experts at detecting a MCL sprain because we develop a fine dexterity for this type of injury. Forgive us when we say, “we just have the feeling for it”. We will test the ligaments ability to stabilize the joint by putting the ligament at full tension.

X-ray

In this case, it is unnecessary to perform an x-ray, as the ligament will not show up on an x-ray and pathology will go undetected.

MRI

An MRI may be useful to rule out other injuries to the knee, for example, a meniscus injury, bursitis, ACL, Tendonitis’. But when a pure MCL injury is suspected, it is an unnecessary and expensive thing to do an MRI. the deep part of the ligament is more prone to get injured first, so this could also lead to a medial meniscus injury, in which case an MRI would be sufficient to diagnose.

Sonar (Diagnostic Ultrasound)

This is the most cost effective diagnostic tool to determine an MCL sprain. The width of the ligament can be compared to that of the opposite side, and the degree of the tear is determined through a diagnostic ultrasound.

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Why is my pain not going away?

Grade I ligament sprains usually heal within a few weeks, anything between 2-4 weeks. However, maximal ligament strength will only return after about 6 weeks, when the collagen fibers have rearranged and matured.

Before this, the ligament can be prone to re-occurring injury or progression of the injury from a grade I to II or III. For example, if you sustained a grade I injury this past weekend during rugby, you have rested and iced it well, and now, a few days later, you run onto the field. Your knee bends while you run and you have to suddenly change direction, your foot stays in  the ground and your knee bends inwards. The ligament is definitely not ready to handle this load at this stage. You may have made it worse progressing from a sprain to a tear. It is always better to allow the full time to its’s normal state, whilst strengthening, before getting back onto the sport field.

Grade II: Recovery can take up to 8 weeks

Grade III: Up to 4 months.

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Physiotherapist treatment

Grade I

Resting the knee from harmful activity, Icing and the use of an anti-inflammatory (AFTER 48 hours) is advised during this period. Physiotherapy management techniques will consist of:

  • Manual therapy – we use joint mobilizations if the ankle or knee joint movements are restricted.
  • Soft tissue massage – we use a technique called deep cross frictions restore normal muscle function and promote healing
  • Electrotherapy – Laser and Ultrasound to the tendon
  • Dry needling – to release tension in the calf muscles and promote blood flow to the tendon itself
  • Taping – taping is used to correct bio-mechanical problems. Anti-pronation taping must be considered before orthotics.
  • Stages will be described later

Grade II

  • Use of a weight-bearing brace or supportive strapping will be used during this phase. This aids in avoiding overuse of the ligament and puts some pressure on the ligament to ease the pain.
  • Physiotherapy management during this grade will be the same as with a grade I

Grade III

  • A hinged brace locked at full extension is usually worn during this time, and you will have to use crutches for 2 weeks as not to put full weight on the injured knee. As pain allows, the brace can be unlocked as tolerated. Returning to sport in this instance can take up to 4 months, after a thorough rehabilitation program.
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Is Surgery necessary?

Most MCL injuries do not require any surgery. However, if there are other structures involved (Like ACL or Meniscus), surgery might be considered, depending on the severity. But even with a grade III there is no more advantage to surgery than there is with bracing and proper rehabilitation. In fact, the healing after surgery will take longer than going through the rehabilitation process conservatively, and it will be less invasive and also less costly.

Why my Knee pain doesn’t go away

If you are asking yourself ‘why is it taking so long for the pain to go away’ then you might want to consider the following. When the ligament tears the body attempts to repair the injured fibers by sending cells to reattach the torn ends of the fibers.

It reacts similar to repairing an open wound. Like having a cut at the bottom of your foot. If you keep on walking on it, you will shear away the cells that are healing and closing the wound. The more you walk or run through the pain, the longer it will take to heal. If the pain returns every time you start running again, you have missed the most vital aspect of the cause your ligament tear. The ligament length and strength must return to normal before you return to participating.

If you take a few days off and the pain in the MCL is gone (usually 3 days) when you try running again, the pain just returns. If the ligament is not allowed to return to its normal state, you will rip the wound wide open and start from the beginning again, causing even more damage This is the most common reason why patients consult us.

If you are taking anti-inflammatory medication for your ligament tear, STOP taking them. Inflammation is the body’s natural way of healing the injured collagen fibers. The medication is preventing this process from taking place, not to mention, masking the effect of the trauma on the tissue if you return to running while still taking anti-inflammatory medications.

Anti-inflammatories Medications in MCL sprains: To take or not?

This is a bit of a “catch-22” situation. During healing, inflammation is necessary for the whole process to take place. But inflammation causes swelling, pain and discomfort in the joint. If your goal is to just have less pain, take the anti-inflammatories. If the goal is to heal the ligament quicker, leave the anti-inflammatories and go along the natural process of healing.

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Professional Advice & Experience

The pain will return, if the program is not followed until the last week. Patients generally “feel better” after the two weeks of pain management and thus continue on their own with their activities, only to come back after a few weeks with the same problem. The main aim here is not to merely get rid of the pain. This is important to know.

We need to get that ligament and knee muscles strong enough again, to condition the tendon for what is expected of it. This takes a very specific exercise program that needs to be followed, along with your physiotherapist’s guidance. When followed correctly, you will get cleared to continue with your sport/activity by your physiotherapist.

Physio treatment & Rehab Program

Grade 1 Medial Collateral Ligament sprain:

Phase 1 (Week 1)

Goals:

  • To reduce swelling
  • To get the knee to fully extend (straighten)
  • To get the knee flexed (bent) more than 90 degrees
  • Start pain free strengthening exercises

Rehabilitation:

  • Pain free Passive stretches of the quads and hamstring muscles
  • Static quad and hamstring strengthening exercises
  • Isometric quad, hamstring, glute and calf exercises. All but adductors, as to avoid additional strain on the MCL
  • Examples: calf raises, quads contractions on pillow, theraband resistance exercises- but come see us for a more specific exercise protocol and put us to the test! 🙂

Phase 2 (Week 1-2)

Goals:

  • Get rid of swelling completely
  • Restore full range of motion (ROM)
  • Start jogging

Rehabilitation:

  • Dynamic strengthening exercises introduced here
  • Examples: knee flexions, extensions, step ups, half squats, single leg calf raises, bridging exercises

Phase 3 (Week 2-4)

Goals:

  • Regain full strength
  • Maintain Full ROM
  • Introduce sport specific exercises/ exercises that allow you to get back to your daily activities completely like driving, climbing stairs and running

Rehabilitation:

  • Adding more load/weight to activities
  • Increasing the speed and agility of movements
  • Examples: weighted squats, leg presses, plyometrics, sideways running drills

Phase 4 (Week 3-6)

Goals:

  • Maintaining full ROM, strength, agility, speed
  • Adding endurance
  • Performance based when dealing with a sports person (full time training and competition based)

Rehabilitation:

  • Finally hopping, bouncing or jumping activities can be included here

Grade 2 or 3 Medial Collateral Ligament sprain sprain:

Phase 1 (Week 1 – 4)

Goals:

  • Control swelling
  • Maintain full extension of knee
  • Gain range to more than 90 degrees flexion
  • Introduce strengthening exercises
  • Maintain fitness (best suggestion would be a stationary bike).

Rehabilitation:

  • Non weight bearing week 1-2 (use crutches)
  • Partial weight bearing week 3-4
  • Full weight bearing week 4 onwards
  • Wear a brace that is set at 30 degrees
  • Stretching, strengthening and mobility exercises will be done in the brace (knee extension should not be more than 30 degrees)
  • Examples of exercises: static quads, hamstrings, calf raises, hip abductions

Phase 2 (Week 4 – 6)

Goals:

  • Completely eliminate swelling
  • Full weight bearing
  • Full ROM
  • Injured leg as strong as uninjured leg

Rehabilitation:

  • Week 5: Knee brace set to 60 degrees
  • Week 6: Remove knee brace (other knee support can be used at this time for compression, for example a knee guard, only to support knee during this transition phase for a week, no longer than that because we don’t want the knee to become dependent on external support)
  • Examples of exercises: Quads and hamstring stretches, along with static and isometric quad exercises: leg presses, hamstring curls, step ups, calf raises. Upper body strength and endurance should be maintained, and general fitness kept by swimming or stationary bike. No breastroke though!

Phase 3 (Week 6 – 10)

Goals:

  • Full ROM
  • Strength
  • Return to light jogging
  • Return to sport specific exercises at week 10
  • Return to full activities of daily living (walking, driving, getting in and out of bed without pain)

Rehabilitation:

  • Light jogging after week 6
  • Sideways running after week 8
  • Plyometrics, hopping, jumping, agility, speed by week 10.

What else could the pain be?

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