You’ve had an accident and hurt your knee. You know you’ve damaged something inside the joint. Now you’ve had some scans and the results are in: a torn ligament. To be more specific, you’ve torn your MCL (the medial collateral ligament).
So… what next? And will it inevitably mean some kind of surgery? Let’s have a look at the possible answers.
The short answer: probably not
The good news about the MCL is that it’s a resilient piece of soft tissue. Unlike some other structures in the knee, the collateral ligaments are good at self-healing after damage. Even if you’ve torn the soft tissue of that MCL, the tissue fibres can often knit themselves together again, given time. So most MCL tears can be treated conservatively. MCL surgery usually only happens in very specific or severe cases.
What exactly is an MCL tear (and how bad is mine)?
We mentioned that the MCL is positioned on the inner edge of the knee. Its job there is to keep your knee stable and control sideways movement. But that position also makes it vulnerable to certain types of impact. Typical injuries include:
- A direct blow – usually to the outside of the leg, pushing your knee inwards and overstretching the ligament
- A twist or pivot – stopping suddenly, or rapidly changing direction, often made worse if your foot is firmly planted on the ground
- A fall or repeat stress – falling directly onto your knee, or simply overworking it with a repetitive activity that gradually damages the tissue fibres
So, with MCL injuries, the key question is: how severe is the tear? Orthopaedic surgeons tend to categorise the damage in three stages:
Grade 1 (mild sprain) – When you damage or stretch a few fibres, but your MCL is intact and there’s little to no instability when you move
Grade 2 (moderate sprain) – Where you’ve frayed or partially torn the ligament. You might feel some weakness or looseness when you walk or try to run. You may struggle to get the full range of motion from your knee
Grade 3 (severe tear) – When you completely rupture the ligament. Your knee is likely to feel very unstable; it will be difficult to bear weight on it, and it may give way completely if you try.
Understanding the grade of MCL tear you’ve suffered goes a long way to understanding what you’ll need to do next. On which note…
The good news: how an MCL tear heals on its own
If you’re like most people with MCL damage, non-surgical treatment is the usual route back to health. What does that look like in practice?
Soon after the injury
If you’ve only recently injured your knee, use the RICE protocol to begin with. That’s Resting completely, regularly Icing your knee, using a bandage to Compress the joint if necessary, and Elevating your leg to reduce pain and swelling
Over the coming weeks
Depending on your doctor’s advice, you may need to support the joint and prevent sideways movement (for instance with a brace) as the healing process gets underway. Physiotherapy is often crucial for MCL injuries because the ligament can get quite stiff during healing. Effective physio is all about helping you to support your MCL by strengthening the surrounding muscles, while gently encouraging flexibility in the joint.
(For more detail about conservative treatment for a torn ligament, see this blog: Will an MCL tear heal by itself?)
So when is MCL surgery actually necessary?
If you’ve already had a scan, or been diagnosed with a bad MCL tear, you may now be wondering if surgery is necessary. As a general rule, we only contemplate the surgical option in quite specific circumstances; for example, if you’ve sustained:
Multiple ligament damage
The injury has damaged other ligaments in your knee at the same time, such as the ACL or PCL (this is what happened to Robb, a patient who badly twisted his knee in a football match; you can read about his story in this case study).
Severe damage to the MCL
The ligament is completely ruptured or has pulled away from the tibia (the shinbone, just below your knee). Bear in mind, though, that bad MCL tears can potentially heal by themselves; even a Grade 3 tear isn’t an automatic case for surgery.
Persistent instability
You’ve been through rehab and physiotherapy but your knee is still unstable and keeps giving way.
What does MCL surgery involve?
So what happens if you do end up needing surgery on your MCL? What does it look like in practice? There are essentially two approaches here. The first is what we call a direct ligament repair. The other, more complicated approach, is a ligament reconstruction. Both types of surgery often begin with an arthroscopy (keyhole surgery). This allows us to examine the damage using a tiny camera probe, before we then open up the knee to access the ligament.
Direct repair
With a direct repair, the surgeon aims to restore your natural ligament using stitches or medical “anchors”. Often, this means reattaching the MCL where it has torn away from the bone. For example, if your MCL has pulled away from the tibia (a distal avulsion), we can use staples or tiny surgical anchors to re-fix it to the bone so that it can gradually heal and strengthen with time and rehab. A more complicated case is a mid-substance tear, which means the tissue has torn somewhere in the middle. The two portions of ligament can sometimes be stitched together again using specialised sutures, often with some reinforcement.
Ligament reconstruction
In a reconstruction operation, the surgeon is aiming to replace your natural MCL with a graft. This happens when the original MCL is too badly damaged to salvage, or if you have chronic laxity in your ligament. The operation works by removing your old ligament, then taking a stretch of similar tendon from your leg (often the hamstring), or a synthetic graft. The graft is then stitched into your knee to act, effectively, as a new MCL. It’s worth adding that MCL reconstruction is a rare operation; the vast majority of MCL tears can be resolved in other ways.
Recovery from MCL surgery: when can I return to normal?
How long will it take you to get back to full after your operation? This will vary depending on what type of operation you had, how it went, and other key factors like your age, fitness and how your physio programme fares. But as a rule of thumb, you should be looking at around 6 to 9 months for a full recovery from MCL surgery. For the first few weeks, up to about week 6, you may need to wear a hinged knee brace. This basically restricts how far your knee can bend and provides protection as the ligament tissues heal. After that, your knee should become progressively stronger – especially if you stick with your rehab programme and keep doing the exercises that help to strengthen your leg and maintain flexibility.
