For the treatment of incomplete tears, we recommend minimal immobilization for 1 to 3 weeks followed by physical therapy focusing on quadriceps- and hamstring-strengthening exercises.
The senior author's management of grade III acute MCL injuries has evolved over the past 20 years. His initial recommendations were to immobilize all knees with MCL tears in a cast brace in 30 degrees of flexion for 2 weeks, which limited range of motion from 30 to 90 degrees of flexion as well as weight bearing for 6 weeks.18
Now, for complete proximal isolated tears of the MCL, the senior author prefers to place the knee in a commercially available splint in full extension for 2 weeks. A concern with these lesions is the possibility of excessive stiffness developing in the knee early in the healing process; therefore, immobilization should be minimized in any degree of flexion. For distal-based tears of the MCL, we immobilize the knee (splint versus cylinder cast) for 2 weeks in 30 degrees of flexion. Irrespective of the location of the tear, after 2 weeks of immobilization has passed, we begin to mobilize the knee throughout a comfortable range of motion without any set limitations. Weight bearing as tolerated is encouraged. We focus on quadriceps- and hamstring-strengthening exercises similar to those used in an incomplete MCL tear rehabilitation program.
Once isokinetic studies show that the extremity has recovered at least 80% of its strength, power, and endurance, then an on-the-field agility program is begun. For contact sports, we recommend a double upright knee orthosis for the first season. After that, the use of an orthosis is left to the patient's discretion. Since writing the original article in 1983, the senior author does not know of any patient who has developed functional laxity as a result of being treated in this fashion.
Indications for primary repair both for isolated and combined ligament injuries of the knee remain somewhat controversial. Most surgeons still choose not to operate on isolated complete tears, especially those that demonstrate no laxity to valgus stress in full extension. When asymmetrical laxity occurs in full extension, some surgeons may choose to perform primary repair of the MCL and posterior capsule. Wilson et al24 reported that in their series distal tears healed less reliably, leading to the need for late reconstructions. This led them to advocate acute surgical repair for distal tears in athletic populations.24
At our institution, we seldom perform acute MCL repair when there is a concomitant anterior and/or posterior cruciate ligament tear(s). In this clinical situation, we immobilize the knee for 3 to 4 weeks to allow early primary healing of the MCL. Following this, patients are started on a rehabilitation program in order to recover most of their motion. This may take up to 6 to 8 weeks, especially if the lesion is proximal. Once most motion and quadriceps control of the leg has been recovered, an ACL reconstruction is performed. Intraoperatively, following the ACL reconstruction, the knee is reexamined for medial laxity, both in 30 degrees of flexion and in full extension. Using this approach, the senior author seldom has needed to perform an MCL repair and/or reconstruction. If the knee remains grossly unstable, particularly in full extension, a small postero-medial incision is made and the POL is tightened by advancing it as advocated by Hughston.5,6 Care is taken to avoid significant anterior advancement or reefing of this ligament because of the risk of developing a flexion contracture, as discussed earlier.
If an acute MCL repair is deemed necessary, it is performed using a straight medial incision extending from the medial epi-condyle to 5 cm distal to the medial joint line. The sartorius fascia is divided and the sartorius retracted distally. Flexing the knee further retracts the sartorius and the pes anserinus components, giving visualization of the superficial MCL. If the MCL is torn distally, it is important to reflect it proximally, exposing the deep meniscocapsular ligaments. If these are torn, and they frequently are, they are repaired with simple interrupted suture. The sequence of repair thus proceeds from deep to superficial. If the posterior capsule is torn mid-substance, it is approximated with interrupted sutures. If the posterior capsule is torn from the femoral or tibial attachment, it is advanced and reattached to either the femur or the tibia, respectively, with suture anchors. Once this is accomplished, repair of the superficial MCL is addressed. Reapproximation of mid-substance tears is performed using Bunnell-Kessler suture configuration. Proximal or distal tears are advanced and reattached with anchors or over a post depending on tissue quality. If tissues are deemed inadequate, we commonly will augment this repair with Achilles tendon allograft secured via interference screws. Irrespective of open or closed treatment of a complete MCL tear, normal medial tightness is almost never completely achieved. Despite this fact, the senior author rarely has seen this result in a functionally unstable knee unless there was coexisting laxity in other structures (Figs. 54-6 through 54-10).
Rehabilitation for Primary Repair
Following surgery, the knee is immobilized in full extension for the first 3 weeks. The focus of the early rehabilitation program
is quadriceps-strengthening exercises in order to minimize muscle atrophy. It is critical to avoid any loss of full extension, particularly if the MCL lesion is more proximal. Hip and ankle exercises also should be included throughout the entire program.
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