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.
Trisj
Dear Dr. Lurks,
On February 11th of this year I tripped over the dog and hit my knee so hard that it dislocated and I heard an awful popping sound as soon as it dislocated and I had significant swelling and bruising within the first ten minutes and I couldn’t move and even in the brace I can’t bear weight on my leg because of awful pain on the outside of my knee middle of my knee and in the back of my knee. I still have significant swelling. I can keep my leg straight but can’t bend it. Do you think I may have torn my ACL and possibly other ligaments as my PCP suspects? I see Orthopedics this Friday. Thank you for your time.
Howard J. Luks, MD
Only a good exam will be able to tell for sure. Good Luck !
Hadeth
Hello Dr. Luks,
I love your website its helped me so much! I has ACL surgery on march 3rd 2016 after waiting 7 months for my mcl tear to heal as well and i was doing PT for 6 months post initial injury in September 2015. Im about 6 weeks post op and my mcl KILLS like it hurts when i walk i feel it stretching almost. I know there is an incision there like where they took the graft from but should it hurt this much? I thought it would be healed by now! it wasnt a serious mcl injury or else my surgeon would have done something. Do you think its an issue??
Thank you Doctor
Howard J. Luks, MD
Thanks for the kind praise.
unfortunately without examining you I really can not tell why that area would be bothering you.
Hadeth
Oh i see, its okay I’m seeing the surgeon on the 25th, I’m just scared that i retore it and thats why all the stress is on the mcl. Thank you for the reply!
Xue
Hello Mr Luks,
I have torn both my MCL and ACL, partly injured my LCL while skiing on May 7th 2016. I had my MCL repaired with a 2.35 cm screw fixing on the Tibia on May 16th 2016 . And at the meantime I am recovering from the MCL operation, the doc said the LCL is healing itself. It is now the seventh week PO and my knee is able to bend 120 degree. Although I am still wearing brace with the assistance of crutches, I feel my knee is not stable while walking, especially I land the leg with a degree of bending if not completely straighten. Is it normally or bcos of the torn ACL that there is not enough support to the knee?
Is it a general process of repairing MCL first then ACL if both of them are torn and why?
Another question is that I will hopefully have my ACL reconstruction 5~6 months later. Is it still a good time to do so or should be sooner?
Many thanks!
Howard J. Luks, MD
Managing a multiple ligament injured knee is difficult. Some of us fix everything at once, some will fix the MCL then come back and reconstruct the ACL later. 5 months is a long time to wait… if done as a two stage procedure then we can usually proceed with step two when the MCL heals (2-3 months) and your motion is near normal. The LCL component can be worrisome… LCL or postero-lateral corner injuries do not tend to heal if anything is torn. That can produce a very unstable knee. Without examining you I do not know what the issue is with your knee. You may consider a second opinion… but you need to find a doc who is fluent and comfortable with multi-ligament injuries- not many are.
brittany beck
Hi, My name is Brittany.
I have tore my ACL on the right twice in the past 2yrs both playing soccer.
I heard the same popping and I have the same pain when I fell during lacrosse.
Im not sure if it is the ACL for the 3rd time or not.
I am only 16 years old. So i dont think it should be anything with bad bones.
What do you think it is?
Is it possible to re-tare for a third time?
Thanks so much!
brittany beck
hello?