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.
Darragh
Hi Guys great thread,
Quick question I have a grade 2-3 mcl tear,grade 3 acl tear,meniscus lateral tear and dislocated knee got while playing football…I am rehabbing my mcl tear without surgery for 8 weeks and then getting acl and meniscus surgery when I can bend my knee properly so that it won’t affect my knee!do grade 2-3 tear of mcl usually rehab on their own without surgery!its still sore 4 weeks later and I’m able to bend it to about 110 degrees!advice would be great I’m only 27 years old
Howard J. Luks, MD
Keep plugging away… these are tough injuries with a long recovery process.
Darin
Good Morning Dr. Luks,
On Jan 2 my 15 year old daughter who is a competitive gymnast tore her ACL and possibly her MCL. We had an MRI done and have seen 2 different Surgeons. The first doesn’t believe she tore the MCL and thinks what is showing on the MRI is shadowing which makes it appear to have a slight tear. But will confirm when doing surgery and if it is will suture. The first is recommending we do the Patella graft for the ACL. He has said the Patella is the “Gold standard” for ACL and especially since our daughter is still wanting to compete and is working to obtain a Gymnastics scholarship for College.
The second surgeon we met with when looking at the MRI says it does appear that the MCL does have a slight tear which would be sutured at the same time as doing the ACL. We advised the second surgeon that she is still wanting to compete and hopes to compete at the collegiate level as well. He is recommending we do the Hamstring graft as the best option. When I asked the second surgeon about doing the Patella he advised he could do that but doesn’t recommend it because there could be lingering knee pain when kneeling/squatting and a higher risk of having knee cap fractures, he also said that the Hamstring graft would be stronger then the Patella graft.
At the moment my daughter is in a full knee brace, has not had any swelling, has full extension with a little bit of pain and has knee flexion of probably about 90-95 degrees.
We obviously want the best solution/fix for our daughter that will allow her to return to gymnastics, a sport she has been doing since she was 4. But we are at a loss of knowing which option would be the best for her.
I have overloaded myself with information from the internet and have seen the pros/cons for both grafts – the 2 things that stick out the most to me is it appears that for any young competitive athlete still wanting to compete the preferred option is the Patella. For the Hamstring graft, what sticks out the most is reading that females have weaker hamstrings and when using a hamstring graft you lose 10-20% strength of the hamstring that you never get back. It also appears to be about a 50/50 mix on which is stronger (Patella/Hamstring)
Any insight you could offer me would be greatly appreciated.
Thank you
Howard J. Luks, MD
1. ACL tears at this age mean that your daughter has nearly a 44% chance of reinjury or injuring the other ACL. Rehab should continue for nearly one year prior to return to sports. Strongly consider a formal ACL prevention course after her rehabilitation and before return to sports.
2. A hamstring is not a stronger graft. Women do tend to be quadriceps dominant and for a gymnast they can lose that explosive strength… I would avoid a hamstring graft. There has been a lot of relatively recent interest in the quadriceps tendon as a great graft choice too.
3. Complete MCL tears are easy to diagnose on physical exam. If it is not completely torn it does not require suturing. Grade 1 and grade 2 MCL tears heal.
4. Rehab her knee and start quad sets and quad activation exercises asap. Prehab or rehab before surgery improves chances of a better, stronger and faster return after surgery
5. The risk of patella fracture is really really low. If your surgeon bone grafts the patella after the surgery that risk goes to nearly zero.
Good luck
Michele Sabri
Hi Dr. Luks, thank you for the information. As you said, it is difficult to find specialists familiar with multi ligament injuries and it is also difficult to find information! On 2/16/19 I fell skiing and dislocated my left knee. Over the following week I had various clinical visits that resulted in a diagnosis of a tibial plateau fracture, a PCL sprain, an ACL rupture and a ruptured MCL with an avulsion fx . I am – 50 year old female. On 2/15/19 I had surgery by ortho trauma and they put in a plate and screws and stabilized the tibial fx and they reattached the MCL with huge screws! Lol. I am 4 weeks post op and still having pain. Doing PT gentle rom since 2/27/19. I just feel like my knee will never bend!! What are the risks of bending the knee too much with a reattached MCL? Obviously the pain (and tension) stop me from doing it too much, but can I actually impede the healing process? I want to ski again- the surgeon says I will not likely ski again and he would recommend not getting the ACL repaired unless necessary for stability. My desire is to ski again (carefully and minding my speed in the future). Should I have the ACL repaired if that is my goal? I don’t want to go against him but I do feel like he just wants to protect my knee and skiing is risky but my boyfriend of two years is avid and goes all around the world skiing. I want to do this with him (even if we end up skiing very different levels). Thoughts? If too many questions my main concern is about hurting the MCL by trying for range. I am non weight bearing until at least June 17. Thanks in advance!!!
Howard J. Luks, MD
HI Michelle… Sorry to hear about your injury. The recovery from these injuries can take a very long time. Up to a year in some instances. With the screws in your tibia, it is unlikely that a new ACL can be placed at this time. The screws would need to be removed first. Since I did not fix your fracture I cannot tell you what your rehab should or shouldn’t be. Many people return to an active lifestyle after these injuries. You need to have a deep discussion with your doc about motion and rehab.
Dallas
Hello Dr. Luks,
My name is Dallas. I injured my knee while skiing on 3/22/19. The accident occurred on to the right medial side with several small popping sensations. Knee buckling on the medial side was present with quite a bit of pain. X ray showed no bone damage. MRI impression revealed posterior lateral tibial plateau fracture with up to 2mm of boney depression with adjacent bone contusion along posterior aspect of proximal tibia; a proximal mcl grade 2 sprain near femoral attachment, ACL tear, and possible vertical tear along lateral meniscal posterior horn. Ortho surgeon scheduled surgery for 5/6/19 for acl allograft reconstruction and lateral meniscus repair. No recommendation for MCL or fracture. I decided to postpone surgery when I read the Ortho evaluation as it said I was stable posterior varus and valgus, but positive Lachman exam and equivocal McMurray exam. No such exams were conducted on my knee at all. In addition, pre-op paperwork had the surgery on the non injured leg until I had them correct. All that aside, would the minimally displaced tibial plateau fracture be a concern over the ligament injury? The pain generally seems to be from the mcl sprain medial side near femoral attachment. I have been doing quad settings and heel slides for ROM. I am also on crutches and attempt slight weight bearing occasionally. Some days are better than others. Any advise would be helpful. Thank you.
Howard J. Luks, MD
HI Dallas… No doubt MCL injuries usually hurt the most of all the things you mentioned. If the MCL is stable then we wait until the fracture has healed and your range of motion and strength have improved before moving forward with the ACL surgery. Depending on your age and activity level I would also question if an allograft is best. YOu need to trust your surgeon… so it seems like you made the right call. Good luck moving forward.
Dallas Tripp
Thank you for your reply Dr. Luks. It helps greatly
Jenny
My foot got caught in the sand in an undertow, and my right knee was hit from the left side by a wave. I saw an orthopedist 3 days after the injury, who said I tore my MCL and LCL and that they would heal on their own. He put me in a full leg brace for 8 weeks, increasing the range of motion every 2 weeks. It has been 8 weeks since I had the injury, and I find it impossible to sleep at night. The pain wakes me up every hour or 2, and I cannot rest one knee on top of the other due to the pain. Also, any turning of the knee, especially to the left results in pain. I also have pain on the back knee, and on the side an inch or so from where the orthopedist “feels” to see if I have pain. I have only 90 degrees of motion in the injured knee. He said it would heal on its own and that no MRI was needed. As far as the pain on the underside of my knee, he said it is tendonitis. Should I have an MRI? I am due to start physical therapy today, but is that wise due to the continued pain?
Howard J. Luks, MD
So.. Our exam can often tell us which ligaments are injured. But we will study the knee with an MRI to rule out cartilage or meniscus injuries which can occur at the same time. In addition, tearing both the MCL and LCL without an ACL or PCL injury would be very rare. Perhaps another opinion might help sort this out. You will need to know what was injured to know what type of PT is needed. Good luck ~!