Anyone who witnessed Na Vorro Bowman’s injury live on TV was quivering for a while. Cameron Meredith also suffered the same fate more recently. This injury looked brutal on TV. My immediate diagnosis was that Bowman and Meredith had probably torn their ACL and their MCL. Injuries to either the ACL or the MCL can lead to predictable results. Multi-ligament injuries involve much more surgery, a longer recovery time, and a worse prognosis. This post will cover how combined injuries to both the MCL and ACL are managed.
Injuries that involve more than one ligament are far more complex than injuries that involve only the anterior cruciate ligament or the medial collateral ligament in isolation. The treatment of these multi-ligament injuries is complex and has evolved over time.
The 49ers feared that linebacker NaVorro Bowman injured both his ACL and MCL against the Seahawks on Sunday and those fears have been realized.
Most people understand that an isolated ACL injury is usually followed by a brief course of therapy to resolve your stiffness and prepare your knee for surgical repair. Combined injuries to the ACL and MCL might need to be managed differently.
For patients with an isolated MCL or medial collateral ligament tear, the treatment will vary depending on the “grade” of the tear. MCL tears are graded as complete (Type 3) or partial Types 1, and 2). Partial tears of the MCL will almost always heal with time, bracing and physical therapy. Complete, but isolated grade 3 tears of the MCL generally require an open repair of the MCL followed by a period of bracing and then physical therapy.
ACL and MCL Combined Injuries
When both the ACL and the MCL are torn, the timing of treatment is critical. The MCL becomes the critical factor in early management of these combined injuries. If the MCL is a grade 3 complete tear then it needs to be repaired soon after the injury. Otherwise, the MCL ligament will scar and shorten making a repair difficult. This threatens the overall recovery and ability to return to sports.
Surgery for ACL and MCL combined injuries can take place in 2 separate procedures, or it can be accomplished at the same time with an MCL repair and an ACL reconstruction. If it is pursued in two separate surgeries then once the MCL ligament is repaired, and once the athlete has recovered, an additional surgery to reconstruct the ACL is necessary. This is not a common approach in professional or elite athletes. MCL injuries and MCL surgery can produce significant stiffness in the knee. ACL reconstructions can also produce significant stiffness. Having surgery on both the MCL and the ACL at the same time might not be the right approach for everyone. Having surgery on both the ACL and the MCL at the same time raises the risk of having permanent stiffness.
When dealing with an elite or professional athlete we usually approach this injury with a single surgery. The MCL can be repaired in a traditional sense. The torn ends of the MCL are sewn together or anchored to the bone if they tore off of the bone. As you know, the ACL can not be primarily repaired. The ACL needs to be reconstructed. When talking about professional football players, the most common graft choice for an ACL reconstruction is a bone-patella tendon-bone autograft. Other ACL graft choices are available and might be appropriate for athletes in other sports. In order to allow for immediate motion after a combined ACL/MCL surgery we may place an “internal brace” on the MCL repair to protect it so we can start immediate motion exercises to decrease the risk of stiffness.
Recovery from combined ACL and MCL injuries.
The recovery from a combined injury is often quite long. It takes the athlete more time to get their normal motion back when both ligaments are operated on. After the MCL heals in approximately 6 weeks, a more traditional ACL rehabilitation schedule can begin.
This is a long recovery process and many people do very well if a combined ACL/ MCL injury is managed in a timely manner. Whether or not Meredith can return to professional sports is an open ended question. Not all professionals can return after an isolated ACL tear. Return to play statistics predict that recovery and return to sports is likely. Sadly, the statistics also show that their careers are generally shorter than those of athletes that do not tear their ACL.
S says
I tore my ACL and MCL in a fall while skiing on Dec 7. The surgeon recommended that I wear a hinged knee brace 24/7 for 8 weeks to get the MCL to heal, and then get ACL surgery, with a hybrid graft of combined allograft and hamstring (semitendinosus). I am currently walking on it carefully with the brace and doing ROM and non-weight bearing muscle strengthening exercises. I have stiffness and range of motion about 0 to 95 right now, but very little pain as long as I am careful to keep it aligned and not sleep on my side. I’m a 54 year old female. Does this, including the hybrid graft, sound like a reasonable approach? Will I be likely to lose hamstring strength long term? I intend to ski again and the surgeon said I should be able to do so after PT and the complete healing process, which he thinks will take 8 months post surgery. Also, I will have the choice of general or spinal for the surgery. I’m leaning toward getting a spinal. Are there any advantages/disadvantages to either of those for this type of surgery? Thanks so much.
Howard J. Luks, MD says
HI … there is typically no rush to reconstruct the ACL in these settings. Most sports docs prefer that your knee have normal motion and strength before proceeding with ACL surgery. Otherwise, the risk of significant stiffness after surgery is very high. There’s no much data on hybrid grafts. Theoretically, if just one hamstring tendon is harvested then you should not have much weakness. But you will be losing one hamstring, and many women are quadriceps dominant, so the hamstring may be more important to some athletes vs others.
liane mair says
Hello Dr.Luks,
I am an expert skiier who yesterday had a humbling entanglement getting off a chair on the mountain. I did the splits and rotated my right knee, completely tearing the MCL (level 3), ACL (level 3) and with differing opinions about the state of the meniscii. I was advised after the MRI to let the swelling go down for at least 2 weeks while I pursued surgery options. Not being a professional athlete, I’m wondering if separate operations are better than one combined?
Your opinion most welcome!
Howard J. Luks, MD says
Good question… This is one of those skill sets that experienced docs have that are hard to explain. There are folks who may be able to have the MCL repaired and the ACL reconstructed at the same time, and there are folks who should have the MCL repaired and a delayed ACLR. Our physical examination matters a lot in this scenario. Some grade 3 tears on MRI– are not grade 3 on the exam. Most of those grade 2’s will heal without surgery.