An isolated injury to the LCL or MCL rarely requires surgical repair or reconstruction. Partial tears to the LCL, such as Grade 1 or Grade II injury, are usually treated by reduced activity and allow the ligament healed with or without a brace for several weeks. Most doctors opt not to immobilize the knee in a cast when the MCL is torn. Some doctors prefer to issue their patients a knee brace after the injury if there is significant pain and instability.
Initial treatments for a collateral ligament injury focus on decreasing pain and swelling in the knee. Rest and anti-inflammatory medications, such as aspirin, can help decrease these symptoms. You may need to use crutches until you can walk without a limp.
Most patients receive physical therapy treatments for collateral ligament injuries. Therapists may treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.
Exercises are used to help you regain normal knee movement. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full knee movement. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the joint by the therapist.
Exercises are also used to improve the strength of the quadriceps muscle on the front of the thigh. As your symptoms ease and strength improves, you will be guided through advancing stages of exercise.
When you get full knee movement, your strength is improving, and your knee isn’t giving way, you’ll be able to gradually get back to your work and sport activities. Some doctors prescribe the use of afunctional brace for athletes who intend to return quickly to their sport. These braces support the knee and protect the collateral ligaments.
Patients who continue having periods of swelling or instability in the knee may need surgery to correct their problem.
If other structures in the knee are injured, surgery may be required. Some surgeons feel that a combination of an ACL tear and an MCL tear should be treated surgically. Others disagree and feel that the MCL tear should be treated nonsurgically at first and the ACL reconstructed later. Time will tell if one approach is better than the other.
Repair of a recently torn collateral ligament usually requires an incision through the skin over the area where the tear in the ligament has occurred. If the ligament has been pulled from its attachment on the bone, the ligament is reattached to the bone with either large sutures (strong stitches) or special staples called suture anchors. Tears of the middle areas of the ligament are usually repaired by sewing the ends together.
Chronic swelling or instability caused by a collateral ligament injury may require a surgical reconstruction. Reconstruction differs from repair of the ligaments, described earlier. A reconstruction operation usually works by either tightening up the loose ligament or replacing the loose ligament with a tendon graft.
In the tightening procedure, your surgeon will use the remaining ligament tissue and take up the slack (similar to taking in the waist on a pair of pants). This is usually done by detaching one end of the ligament from its place on the bone and moving it so that it becomes tighter. The ligament is then reattached to the bone in the new place and held with sutures or metal staples.
If a tendon graft is needed to replace the loose ligament, it is usually taken from somewhere else in the same knee. Taking tissue from your own body is called an autograft. A common autograft that is used is one of the hamstring tendons called the semitendinosus tendon. Studies have shown that this tendon can be removed without affecting the strength of the leg. This is because other bigger and stronger hamstring muscles can take over the function of the tendon that is removed. In this operation, your surgeon will use the tendon graft to replace the damaged collateral ligament. The ends of the tendon graft are attached to the bone using large sutures or metal staples.
Another way to replace a badly torn collateral ligament is with an allograft. For this procedure, the surgeon gets graft tissue from a tissue bank. This tissue is usually removed from an organ donor at the time of death and sent to a tissue bank. There the tissue is checked for infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn collateral ligament.
What should I expect after treatment?
Minor sprains of either the MCL or LCL should get better within four to six weeks. Moderate tears should rehabilitate within two months. Severe MCL tears require up to three months. If patients are still having problems after three months, they will likely need surgery. Severe tears or ruptures of the LCL are the trickiest, because they tend to leave the knee joint the most unstable, and patients with this condition typically don’t do well with nonsurgical care.
Rehabilitation proceeds cautiously after surgery of the collateral ligaments, and treatments will vary depending on the type of surgical procedure that was used. Some surgeons have their patients use acontinuous passive motion (CPM) machine after surgery to help the knee begin to move and to alleviate joint stiffness.
Most patients are prescribed a hinged knee brace to wear when they are up and about. Surgeons occasionally cast the leg after reconstruction surgery of the LCL.
Patients are strongly advised to follow the recommendations about how much weight to place on the leg while standing or walking. After a ligament repair, patients will be instructed to put little or no weight on their foot when standing or walking for up to six weeks. Weight bearing may be restricted for up to 12 weeks after a ligament reconstruction.
Patients usually take part in formal physical therapy after collateral ligament surgery. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. The goal is to help you regain full knee motion as soon as possible.
Physical therapists will also work with patients to make sure they are using crutches safely and only bearing the recommended amount of weight while standing or walking.
As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function.
Ideally, patients will be able to resume their previous lifestyle activities. Some patients may be encouraged to modify their activity choices, especially if an allograft procedure was used.
The physical therapist’s goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion. When you are well under way, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.