Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

isolated grade I injury

1st line – rest, ice, compression, elevation (RICE) + physiotherapy

Back
ACUTE
|
isolated grade I injury
1st line – 

rest, ice, compression, elevation (RICE) + physiotherapy

After an MCL injury, the damaged ligament will bleed internally and become inflamed. RICE is started immediately after injury to reduce pain, minimise swelling, and protect the injured tissue; all of which help to speed the healing process. RICE should be employed for 24 to 48 hours.

The RICE protocol involves resting the injured leg, applying ice, compressing the knee with an elastic bandage, and elevating the leg above the level of the heart.

Initially, the goal of physiotherapy is to decrease pain and restore range of motion (ROM). Once sufficient progress is made, the focus switches to rebuilding strength and regaining function. Therapy for 2 to 3 weeks is recommended.

Exercises are frequently sport- or activity-specific and usually involve hydrotherapy, weight training, and agility training.

Only after demonstrating pain-free ROM, 80% to 90% strength, and no swelling/effusion in the lower extremity can the athlete return to sports.[18][40]

Primary options

rest: rest the injured leg for 24-48 hours

More

and

ice: apply ice or a cold pack for 20 minutes at a time, 4-8 times a day

More

and

compression: compress the knee with an elastic bandage or comparable device

and

elevation: elevate the knee above the level of the heart; pillows are often helpful

and

physiotherapy

Consider – protective ambulation

Back
ACUTE
|
isolated grade I injury
Consider – 

protective ambulation

Additional treatment recommended for SOME patients in selected patient group

Protective ambulation may not be needed with an isolated grade I injury; however, if the knee appears unstable or the injury is particularly painful, then it is recommended. A hinged knee brace that allows full flexion but minimises full extension is recommended for minimising strain on the MCL and protecting against further injury.

It is critical that the brace has enough rigidity to stabilise medial and lateral movement. The brace should be worn for 4 to 6 weeks.

Crutches may be used for further comfort.

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
isolated grade I injury
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups. They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

isolated grade II injury

1st line – rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

Back
ACUTE
|
isolated grade II injury
1st line – 

rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

After an MCL injury, the damaged ligament will bleed internally and become inflamed. RICE is started immediately after injury to reduce pain, minimise swelling, and protect the injured tissue; all of which help to speed the healing process. RICE should be employed for 24 to 48 hours.

The RICE protocol involves resting the injured leg, applying ice, compressing the knee with an elastic bandage, and elevating the leg above the level of the heart.

Initially, the goal of physiotherapy is to decrease pain and restore range of motion (ROM). Once sufficient progress is made, the focus switches to rebuilding strength and regaining function.

Therapy for 3 to 4 weeks is recommended.

Exercises are frequently sport- or activity-specific and usually involve hydrotherapy, weight training, and agility training.

Only after demonstrating pain-free ROM, 80% to 90% strength, and no swelling/effusion in the lower extremity can the athlete return to sports.[18][40]

A hinged brace that allows full flexion but minimises full extension is recommended for minimising strain on the MCL and protecting against further injury.

It is critical that the brace has enough rigidity to stabilise medial and lateral movement. The brace should be worn for 4 to 6 weeks.

Crutches may be used for further comfort.

Primary options

rest: rest the injured leg for 24-48 hours

More

and

ice: apply ice or a cold pack for 20 minutes at a time, 4-8 times a day

More

and

compression: compress the knee with an elastic bandage or comparable device

and

elevation: elevate the knee above the level of the heart; pillows are often helpful

and

physiotherapy

and

protective ambulation

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
isolated grade II injury
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups. They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

isolated grade III injury

1st line – rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

Back
ACUTE
|
isolated grade III injury
1st line – 

rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

After an MCL injury, the damaged ligament will bleed internally and become inflamed. RICE is started immediately after injury to reduce pain, minimise swelling, and protect the injured tissue, all of which help to speed the healing process. RICE should be employed for 24 to 48 hours.

The RICE protocol involves resting the injured leg, applying ice, compressing the knee with an elastic bandage, and elevating the leg above the level of the heart.

Initially, the goal of physiotherapy is to decrease pain and restore range of motion (ROM). Once sufficient progress is made, the focus switches to rebuilding strength and regaining function.

Physiotherapy for 8 to 12 weeks is recommended.

Exercises are frequently sport- or acitivty-specific and usually involve hydrotherapy, weight training, and agility training.

Only after demonstrating pain-free ROM, 80% to 90% strength, and no swelling/effusion in the lower extremity can the athlete return to sports.[18][40]

A hinged brace that allows full flexion but minimises full extension is recommended for minimising strain on the MCL and protecting against further injury. Grade III MCL injuries should be immobilised using a hinged knee brace with the knee at 30 degrees flexion to minimise the distance between the two ends of the torn ligament.

It is critical that the hinged knee brace has enough rigidity to stabilise medial and lateral movement. Patient can gradually progress to full weight-bearing over 4 weeks. The brace should be worn for 4 to 6 weeks.

Crutches may be used for further comfort.

Primary options

rest: rest the injured leg for 24-48 hours

More

and

ice: apply ice or a cold pack for 20 minutes at a time, 4-8 times a day

More

and

compression: compress the knee with an elastic bandage or comparable device

and

elevation: elevate the knee above the level of the heart; pillows are often helpful

and

physiotherapy

and

protective ambulation

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
isolated grade III injury
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups. They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

2nd line – MCL reconstruction or repair

Back
ACUTE
|
isolated grade III injury
2nd line – 

MCL reconstruction or repair

Surgical intervention for acute grade III MCL injuries is still controversial. Isolated grade III MCL injuries may warrant operative intervention if there is also a large bony avulsion, tibial plateau fracture, intra-articular entrapment of the end of a ligament, or anteromedial instability (positive anterior drawer test). [Figure caption and citation for the preceding image starts]: The anterior drawer testFrom the collection of Sanjeev Bhatia, MD; used with permission [Citation ends].com.bmj.content.model.Caption@536666fb

MCL repair is usually performed 7 to 10 days after injury.[17][18][31]

In many cases some mild degree of persistent instability remains even after successful reconstruction. Specific complications are unusual, but include decreased range of motion (if the MCL graft is placed in a non-anatomical position) and saphenous nerve injury.

MCL + anterior cruciate ligament (ACL) combined injury

1st line – rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

Back
ACUTE
|
MCL + anterior cruciate ligament (ACL) combined injury
1st line – 

rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

After an MCL/anterior cruciate ligament (ACL) injury, the damaged ligaments will bleed internally and become inflamed. RICE is started immediately after injury to reduce pain, minimise swelling, and protect the injured tissue, all of which help to speed the healing process. RICE should be employed for 24 to 48 hours.

The RICE protocol involves resting the injured leg, applying ice, compressing the knee with an elastic bandage, and elevating the leg above the level of the heart.

Prior to surgery, MCL/ACL injury rehabilitation should focus on regaining range of motion (ROM), rebuilding strength, and resolving knee effusion. This typically takes 4 to 6 weeks.

Postoperative rehabilitation generally requires a rigorous physiotherapy regimen.

A brace locked in full extension should be used during weight-bearing to minimise strain on the MCL and protect against additional injury.

The brace should be opened for ROM exercises. It should be worn for 4 to 6 weeks.

Crutches may be used for further comfort.

Primary options

rest: rest the injured leg for 24-48 hours

More

and

ice: apply ice or a cold pack for 20 minutes at a time, 4-8 times a day

More

and

compression: compress the knee with an elastic bandage or comparable device

and

elevation: elevate the knee above the level of the heart; pillows are often helpful

and

physiotherapy

and

protective ambulation

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
MCL + anterior cruciate ligament (ACL) combined injury
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups.

They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

Plus – ACL reconstruction or repair

Back
ACUTE
|
MCL + anterior cruciate ligament (ACL) combined injury
Plus – 

ACL reconstruction or repair

Treatment recommended for ALL patients in selected patient group

Anterior cruciate ligament (ACL) reconstruction is generally recommended after a period of rehabilitation to allow the MCL to heal. Surgery is performed after achieving full range of motion and adequate strength, and resolution of knee effusion.[7][18][35] At approximately 4 to 6 weeks after injury, the ACL can be reconstructed with a patellar tendon graft or hamstring tendon graft. An autograft or allograft tendon can be used with excellent results.

Consider – MCL reconstruction or repair

Back
ACUTE
|
MCL + anterior cruciate ligament (ACL) combined injury
Consider – 

MCL reconstruction or repair

Additional treatment recommended for SOME patients in selected patient group

If valgus instability persists after anterior cruciate ligament reconstruction, the patient should undergo surgical MCL reconstruction. MCL reconstruction may also be warranted if there is a large bony avulsion, tibial plateau fracture, intra-articular entrapment of the end of a ligament, or anteromedial instability (positive anterior drawer test). [Figure caption and citation for the preceding image starts]: The anterior drawer testFrom the collection of Sanjeev Bhatia, MD; used with permission [Citation ends].com.bmj.content.model.Caption@351e758e

In many cases some mild degree of persistent instability remains even after successful reconstruction. Specific complications are unusual, but include decreased range of motion (if the MCL graft is placed in a non-anatomical position) and saphenous nerve injury.

MCL + non-anterior cruciate ligament (ACL) combined injury

1st line – rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

Back
ACUTE
|
MCL + non-anterior cruciate ligament (ACL) combined injury
1st line – 

rest, ice, compression, elevation (RICE) + physiotherapy + protective ambulation

After a multi-ligament injury, the damaged ligaments will bleed internally and become inflamed. RICE is started immediately after injury to reduce pain, minimise swelling, and protect the injured tissue, all of which help to speed the healing process. RICE should be employed for 24 to 48 hours.

The RICE protocol involves resting the injured leg, applying ice, compressing the knee with an elastic bandage, and elevating the leg above the level of the heart.

Prior to surgery, multi-ligament injury rehabilitation should focus on regaining range of motion (ROM) and resolving knee effusion. This typically takes 2 to 3 weeks. Postoperative rehabilitation generally requires a rigorous physiotherapy regimen.

A brace locked in full extension should be used during weight-bearing to minimise strain on the MCL and protect against additional injury. The brace should be opened for ROM exercises. It should be worn for 4 to 6 weeks.

Crutches may be used for further comfort.

Primary options

rest: rest the injured leg for 24-48 hours

More

and

ice: apply ice or a cold pack for 20 minutes at a time, 4-8 times a day

More

and

compression: compress the knee with an elastic bandage or comparable device

and

elevation: elevate the knee above the level of the heart; pillows are often helpful

and

physiotherapy

and

protective ambulation

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
MCL + non-anterior cruciate ligament (ACL) combined injury
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups.

They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

Plus – surgical repair of MCL + non-ACL ligament

Back
ACUTE
|
MCL + non-anterior cruciate ligament (ACL) combined injury
Plus – 

surgical repair of MCL + non-ACL ligament

Treatment recommended for ALL patients in selected patient group

MCL reconstruction is usually warranted because its healing capacity may be compromised in multi-ligament injuries.[33] Surgery is especially warranted if there is a large bony avulsion, tibial plateau fracture, intra-articular entrapment of the end of a ligament, or anteromedial instability (positive anterior drawer test). [Figure caption and citation for the preceding image starts]: The anterior drawer testFrom the collection of Sanjeev Bhatia, MD; used with permission [Citation ends].com.bmj.content.model.Caption@1468b633

MCL repair is usually performed 7 to 10 days after injury.

In many cases some mild degree of persistent instability remains even after successful reconstruction. Specific complications are unusual, but include decreased range of motion (if the MCL graft is placed in a non-anatomical position) and saphenous nerve injury.

Surgical reconstruction or repair of the other injured ligament (posterior cruciate ligament, meniscus, lateral collateral ligament) is usually warranted shortly (<3 weeks) after injury. Compared with non-surgical management or a delay in surgery, early operative treatment of the multi-ligament-injured knee yields improved functional and clinical outcomes.[38][39] Reconstruction of the posterolateral corner is preferred over repair as it results in decreased revision rates.[38]

ONGOING

persistent high-grade valgus laxity after ≥3 months

1st line – ligament reconstruction or repair

Back
ONGOING
|
persistent high-grade valgus laxity after ≥3 months
1st line – 

ligament reconstruction or repair

Chronic valgus instability, defined as persistent high-grade valgus laxity after 3 or more months, usually requires surgical reconstruction of the superficial MCL.[18][30][31] Quadriceps tendon autograft, hamstring autograft, hamstring allograft, and Achilles allograft are frequently used.

Plus – physiotherapy

Back
ONGOING
|
persistent high-grade valgus laxity after ≥3 months
Plus – 

physiotherapy

Treatment recommended for ALL patients in selected patient group

Since chronic MCL injuries are generally treated surgically, physiotherapy will be a necessary and crucial step for postoperative rehabilitation. The exact regimen depends on the type of reconstructive surgery.

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

Back
ONGOING
|
persistent high-grade valgus laxity after ≥3 months
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

NSAIDs inhibit cyclo-oxygenase activity and curb prostaglandin synthesis. Their analgesic and anti-inflammatory properties may improve pain and reduce swelling.

Caution should be used when prescribing NSAIDs because they may have adverse effects or cause drug interactions in certain groups.

They are contraindicated in patients with peptic ulcer disease, recent gastrointestinal bleeding/perforation, or renal disease.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally every 12 hours when required, maximum 1250 mg/day

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer