MCL Tear (Medial Collateral Ligament)

(Also known as a MCL Tear, Torn MCL, MCL Sprain, Sprained MCL, MCL Injury, Ruptured MCL)

What is a MCL tear?

A MCL tear is a relatively common sporting injury affecting the knee and is characterized by tearing of the Medial Collateral Ligament of the knee (MCL).

A ligament is a strong band of connective tissue which attaches bone to bone. The MCL is situated at the inner aspect of the knee joint and is responsible for joining the inner aspect of the femur (thigh bone) to the inner aspect of the tibia (shin bone) (figure 1).

The MCL is one of the most important ligaments of the knee, giving it stability. The MCL achieves this role by preventing excessive twisting, and side to side movements of the knee (valgus forces – figure 2). When these movements are excessive and beyond what the MCL can withstand, tearing to the MCL occurs. This condition is known as a MCL tear.

A MCL tear may range from a small partial MCL tear resulting in minimal pain, to a complete rupture of the MCL resulting in significant pain and disability. A MCL tear can be graded as follows:

• Grade 1 MCL tear: a small number of fibres are torn resulting in some pain but allowing full function
• Grade 2 MCL tear: a significant number of fibres are torn with moderate loss of function.
• Grade 3 MCL tear: all fibres are ruptured resulting in knee instability and major loss of function. Other structures may also be injured such as the menisci or cruciate ligaments.

Causes of a MCL tear

MCL tears typically occur during activities placing excessive strain on the MCL. This generally occurs suddenly due to a specific incident, however, occasionally may occur due to repetitive strain. There are two main movements that place stress on the MCL, these include:

• twisting of the knee
• valgus forces on the knee (figure 2)

When these movements (or combination of these movements) are excessive and beyond what the MCL can withstand, a MCL tear may occur.

MCL tears are frequently seen in contact sports or sports requiring rapid changes in direction. These may include: football, netball, basketball and downhill skiing. The usual mechanism of injury for a MCL tear is a twisting movement when weight-bearing (especially when landing from a jump) or due to a collision to the outer knee, forcing the knee to bend in the wrong direction (such as another player falling across the outside of the knee). Occasionally a MCL tear may occur gradually due to repetitive activities such as breaststroke kicking when swimming.

Signs and Symptoms of a MCL tear

Patients with a MCL tear may notice an audible snap or tearing sound at the time of injury. In minor cases of a MCL tear, patients may be able to continue activity only to experience an increase in pain, swelling and stiffness in the knee after activity with rest (particularly first thing in the morning). Often the pain associated with a MCL tear is localized to the inner aspect of the knee.

In cases of a complete rupture of the MCL, pain is usually severe at the time of injury, however, may sometimes quickly subside. Patients may also experience a feeling of the knee going out and then going back in as well as a rapid onset of swelling (within the first few hours following injury). Patients with a complete MCL tear generally can not continue activity due to pain or the knee feeling unstable. Occasionally, the patient may be unable to weight bear at the time of injury due to pain and may develop bruising and knee stiffness over the coming days.

Diagnosis of a MCL tear

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a MCL tear. Investigations such as an X-ray, MRI scan or CT scan may be required to confirm diagnosis of a MCL tear and determine the extent of damage or involvement of other structures within the knee.

Treatment for a MCL tear

Most patients with a MCL tear heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. A vital aspect of treatment is that the patient rests sufficiently from any activity that increases their pain (a MCL brace or crutches may be required). Activities placing large amounts of stress on the MCL should also be minimized, particularly twisting and valgus forces to the knee. Resting from aggravating activities ensures the body can begin the healing process in the absence of further damage to the MCL tear. Once the patient can perform these activities pain free a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the MCL tear becoming chronic. Immediate, appropriate treatment in patients with a MCL tear is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times, an increased likelihood of future MCL tear recurrence and chronic knee instability.

Patients with a MCL tear should follow the R.I.C.E. Regimein the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following a MCL tear or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities (this may include a brace or the use of crutches), regular icing, the use of a compression bandage and keeping the leg elevated. Anti-inflammatory medication may also significantly hasten the healing process in patients with a MCL tear by reducing the pain and swelling associated with inflammation.

Patients with a MCL tear should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. One of the key components of MCL rehabilitation is pain-free strengthening of the quadriceps, hamstring, adductor and gluteal muscles to improve the control of the knee joint with weight-bearing activities. The treating physiotherapist can advise which exercises are most appropriate for the patient.

Prognosis of a MCL tear

With appropriate management, most patients with a minor to moderate MCL tear (grades 1 and 2) can return to sport or normal activity within 2 – 8 weeks. Patients with a complete rupture of the MCL will require a longer period of rehabilitation to gain optimum function. Patients with a MCL tear who also have damage to other structures of the knee such as the meniscus or collateral ligaments are likely to have an extended rehabilitation period.

Physiotherapy for a MCL tear

Physiotherapy for patients with a MCL tear is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of future recurrence. Treatment may comprise:

• soft tissue massage
• joint mobilization
• taping
• bracing
• ice or heat treatment
• electrotherapy (e.g. ultrasound)
• anti-inflammatory advice
• exercises to improve flexibility, strength and balance
• hydrotherapy
• education
• activity modification advice
• crutches prescription
• biomechanical correction
• a gradual return to activity program

Other intervention for a MCL tear

Despite appropriate physiotherapy management, a small percentage of patients with a MCL tear do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, CT scan or MRI, or a review by a specialist who can advise on any procedures that may be appropriate to improve the MCL tear. Surgical reconstruction of the MCL may be required in rare cases of a complete MCL tear when conservative measures fail.

Exercises for a MCL tear

The following exercises are commonly prescribed to patients with a MCL tear. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Knee Bend to Straighten for a MCL Tear

Begin this exercise for a MCL tear by lying on your back as demonstrated (figure 3). Bend and straighten your knee as far as possible without increasing your pain. Repeat 20 times.

Figure 3 – Knee Bend to Straighten for a MCL tear (left leg)

Static Quadriceps Contraction for a MCL Tear

Begin this exercise for a MCL tear in the position demonstrated (figure 4). Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel. Put your fingers on your inner quadriceps to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible without increasing your symptoms.

Figure 4 – Static Quadriceps Contraction for a MCL Tear (left leg)

Find a Physio for a MCL tear

To find a physiotherapist in your local area to treat a MCL tear click here.

Other Exercises

For more knee strengthening exercises click here.

For more knee flexibility exercises click here.

Physiotherapy products for a MCL tear

To purchase physiotherapy products for a MCL tear such as knee braces, sports tape, ice packs or crutches visit the PhysioAdvisor Shop.

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