Question for Physiotherapists

Literature review: The lack of consistency in classification makes it difficult to compare the results of treatment strategies for grade II and grade III injuries. This is probably why there are no decent meta-analyses or systematic reviews of treatment strategies for MCL injuries.

Clinical Management: Traditional treatment of MCL tears was based on the thought that the ligament would heal in a lengthened position if the knee was allowed to achieve full extension. This has not been borne out by any of the recent biomechanical studies or clinical trials. While it is important to protect the MCL from valgus stress there is no need to limit the patients ROM.

To allow adequate healing of the MCL the knee should be immobilized for 1 to several days (depending on symptoms and injury grade). This should be followed immediately by controlled knee flexion and extension exercises. A hinged knee brace is frequently used to stabilize the knee and provide pain relief while allowing early range of motion and muscle strengthening. Weight bearing helps the healing process but should only be done while in the brace and with adequate arm supports.

Grade I and II Injury:  The rehabilitation protocols for grade I and II injuries are similar (except for the length of time for the patient to progress through the various stages). Generally speaking, return to competition is allowed once the patient is: pain-free with full range of motion, has no instability; and has muscle strength comparable with the uninjured side.

Patients with isolated grade I injuries return to play as early as 10 days and those with grade II injuries about 4 weeks. An incomplete MCL complex injury usually does not result in functional problems for the knee. The results after nonoperative management of a complete MCL injury are not entirely uniform. There are certain circumstances in which surgical treatment is necessary, such as if the superficial MCL is torn from its tibial insertion and becomes displaced outside the pes anserinus tendons. This means that the ligament is unable to reattach to its insertion on the tibia and will not heal properly.

It is not clear whether the long term outcome for knees with grade III MCL injuries is improved with surgery.

Routine hinged bracing after isolated MCL injury is supported primarily by biomechanical reasoning and expert consensus rather than high-quality clinical evidence. A 2024 Level I systematic review found substantial heterogeneity in brace prescription, duration and rehabilitation protocols, with very low-certainty evidence regarding the effectiveness of bracing. The strongest evidence currently available supports early controlled loading and structured rehabilitation. Bracing remains a reasonable adjunct in Grade II–III injuries for pain control and patient confidence, but clinicians should recognise that its routine use is not underpinned by robust comparative trials.

Summary

• MCL injuries are common.
• Most can be treated with a brief period of rest followed by mobilisation in a hinged brace with weight bearing as pain allows.
• Occasionally surgical repair of an MCL injury is needed.

Clinical Implications for Physiotherapists:  Based on the current literature, we can be confident that:

• Early weight-bearing is appropriate for most isolated Grade I–II injuries.
• Restoration of full extension and progressive quadriceps strengthening should begin early.
• A brace should be considered an adjunct rather than the primary treatment.
• Rehabilitation progression should be guided by pain, swelling, range of motion, strength and valgus stability rather than simply the duration of brace wear.
• Patients should be informed that the decision to use a brace is based more on clinical judgement than on definitive scientific evidence.