Q: I changed my knee when hiking and it hurts on the inside and I’m limping now. Thoughts?
A: There are many possible causes and you should see your health care provider for evaluation. One possible cause is injury to the medial collateral ligament (MCL), and this will be the topic of today.
MCL injuries are very common. It is not known how common this is, as many never come to the attention of a doctor, but more than a third of knee injuries that are assessed in a health facility include an injury to the LCM, which which makes it the most common overall knee injury. It can affect anyone of any age group.
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The knee is an articulated joint, designed to be able to go from straight to fully bent where the calf rests against the thigh. It is not designed to fold laterally (unlike other joints such as the shoulder, wrist and hip which have many more degrees of movement possible). The MCL is a multilayer ligament inside the knee (the side facing the other leg) that helps stabilize the knee, in particular to bend outward (away from the other leg).
MCL injuries can occur as a result of direct contact injuries (most often when the patient is struck outside the knee), torsion / torque and even overuse.
Other knee structures, particularly in more serious MCL lesions, may be involved. For example, one quarter to three quarters of MCL injuries (depending on the severity of the MCL injury) also affect the anterior cruciate ligament (ACL), the meniscus involved in up to a quarter of cases and other structures, including including bone fractures, can also occur.
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An LCM lesion may be evident on physical examination when the knee is examined and excessive movement, usually with reproducing pain, is identified when the examiner gently tries to bend the knee outward. As other structures of the knee may be affected, X-rays – to look at the bones – and an MRI – to look at other structures – may be indicated.
There are different “grading” systems that assess the severity of an MCL injury on a scale of 1 to 3:
Grade 1 (the softest): few fibers torn, as shown by small amounts of excess movement / opening of the joint (0 to 5 mm) when the joint is tempted to bend outwards.
Grade 2: partial, but incomplete, tear, as evidenced by an average amount of excessive movement / joint opening (5 to 10 mm).
Grade 3: complete tear as evidenced by a large pathological laxity (sagging) allowing a large joint opening (more than 10 mm).
The goal of treating MCL injury is to help the patient regain range of motion (ROM), strength, and functionality while minimizing pain. Most MCL lesions disappear without surgery, although the more severe the injury, the longer the healing time.
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The initial treatment is RICE (rest, ice, compression and elevation) to minimize swelling. Your clinician may advise you to carry a limited weight using crutches, a knee brace (often a hinged brace) or other immobilization techniques. The duration necessary for these initial treatments can be a few days for a minor injury with return to sport in a few weeks and full resolution in a few months, for a longer rest and no return to sport for a few months and full resolution in several months at one year. Some selected patients with severe MCL lesions or injuries involving other knee structures may require surgery.
The duration of treatment required, including not resuming sports activities, depends on the time it takes for strength, range of motion and all functionality to return. The good news is that, overall, MCL lesions have a good prognosis and most patients recover fully.
Jeff Hersh, Ph.D., MD, can be contacted at [email protected]
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