Abstract
Background:
The medial collateral ligament (MCL) is often injured after a valgus stress is applied to the knee, which stresses the medial compartment. Pivoting and rotational movements during sports frequently cause MCL injuries.
Indication:
Selection of a surgical treatment option depends on the chronicity of the MCL injury, lower-limb axis alignment, the grade of the MCL injury, and other patient-specific factors.
Technique Description:
A medial hockey stick incision extending from proximal to the medial epicondyle to 7 cm distal to the joint line was made. The gracilis and semitendinosus tendons were identified after dissecting through the sartorial fascia. These tendons were then harvested using an open tendon stripper, leaving their distal tibial insertions undisturbed. A measurement of 6.1 cm distal to the joint line on the tibia was marked, establishing the distal attachment site of the superficial MCL. To better orient the harvested tendons, an anchor was placed in this location. The adductor magnus tendon and adductor tubercle were then identified, and measurements were made 12 mm distal and 8 mm anterior to the adductor tubercle, corresponding to the femoral attachment of the superficial MCL. A guide pin was placed at this location, and the knee was taken through a full range of motion to ensure isometry. A mark was placed 12 mm distal to the joint line, and a second anchor was placed here to recreate the tibial insertion site of the deep MCL. The graft was then passed distal to proximal underneath the plane lying directly over the MCL. The graft was then docked into the femoral socket and secured with a tenodesis screw with the knee in 30° of flexion and slight varus force.
Results:
Patients can expect improved clinical outcomes after posteromedial (PMC) reconstruction of the knee compared with a PMC repair. There is a significant decrease in the risk of failure when surgeons perform a PMC reconstruction.
Discussion/Conclusion:
Patients who undergo isolated MCL reconstruction can expect to remain nonweightbearing for the first 6 weeks after surgery. At 12 weeks postoperatively, patients should achieve a full, painless range of motion. Return to sport is typically between 6 and 9 months after MCL reconstruction.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Background
Medial collateral ligament (MCL) injuries commonly occur in athletes after participation in high-impact sports that add a valgus stress across a flexed knee. 3 The incidence of MCL injury on an annual basis has been reported as 0.24 to 7.3 per 1000 individuals, making it the most common ligament to be injured during knee trauma. 9 This injury type also occurs twice as often in men as in women, with a 2-to-1 ratio.1,9 Additionally, while this injury often is isolated, the anterior cruciate ligament (ACL) is the most common concomitant ligament injury. 6
Injury to the MCL may result in instability during rotational movements or under valgus pressure. 9 Although many MCL injuries can be treated nonoperatively due to their extra-articular location and ability to heal with a robust proximal blood supply,7,8 there are instances in which surgical intervention is necessary to provide an individual with a better quality of life and improved range of motion.
While several surgical treatment options are available to address MCL injuries, many factors dictate the optimal technique—including injury grade, mechanical axis alignment, and injury chronicity.5,7
The following is a case involving a 42-year-old male patient with no previous medical or surgical history who presented 1 month after a noncontact valgus injury to his right knee while playing recreational basketball. He reported persistent medial-sided knee pain, intermittent swelling, and the subjective sensation of knee instability since the injury, despite a trial of oral nonsteroidal anti-inflammatories and the use of an over-the-counter knee brace.
On physical examination, he had a mild effusion and range of motion from 2° of hyperextension to 125° of flexion. He was tender to palpation at the medial epicondyle and the lateral joint line. He had a 2B Lachman and guarded against pivot shift. He had a negative posterior drawer test. He had no significant laxity with valgus stress in full extension, but did have 2B laxity with valgus stress at 30° of flexion. He was neurovascularly intact in the right foot.
Preoperative plain anteroposterior, flexion weightbearing, lateral, and sunrise view radiographs were reassuring, revealing no evidence of fractures or foreign bodies. However, these radiographs did demonstrate mild tricompartmental osteoarthritis (OA). A long limb x-ray demonstrated a varus malalignment of the lower limbs.
Magnetic resonance imaging scans confirmed a full-thickness ACL tear, proximal MCL injury, a lateral meniscal oblique radial tear, mild tricompartmental OA, and a posterior lateral capsule tear. There was no sign of a significant medial meniscal injury.
Surgical intervention was recommended for this patient because of failed conservative treatment with time, nonsteroidal anti-inflammatory drugs, and the use of a brace for more comfortable ambulation. The nature of the injury also led to the recommendation of surgery as the best available treatment option.
Our surgical plan was for a left knee arthroscopy, ACL reconstruction with bone-patellar tendon-bone autograft, lateral meniscal radial repair, meniscectomy, and MCL reconstruction with hamstring autograft.
Technique Description
The patient was placed in a supine position. An examination under anesthesia was performed, which demonstrated a positive anterior drawer test, a positive pivot shift, and a 2B Lachman on the left side.
After an arthroscopic examination, the procedure began with the MCL augmentation. A medial incision was made from just anterior to the medial epicondyle, extending to the distal aspect of the MCL (approximately 7 cm distal to the joint). Skin and subcutaneous tissue were incised, and the infrapatellar branch of the saphenous nerve was identified and protected. The adductor magnus tendon was then identified (Figure 1A).
MCL augmentation technique guide. (A) Identification of the adductor magnus tendon. (B) Harvest of the semitendinosus and gracilis tendons with an open tendon stripper. (C) Placement of an anchor parallel to the native MCL. (D) Passage of the graft to the guide pin and marking of the graft. (E) An anchor placed to mark the tibial insertion of the deep MCL. (F) Graft passed from distal to proximal. (G) The graft docked in the femoral socket. (H) Deep MCL anchor tied over graft. MCL, medial collateral ligament.
An incision was then made distally through the sartorial fascia to identify and harvest the gracilis and semitendinosus tendons using an open tendon stripper (Figure 1B). This was performed to protect the distal insertion site of both the gracilis and semitendinosus tendons.
A spinal needle was placed into the joint line. A distance of 6.1 cm from the joint line was marked on the tibia, corresponding to the site of the distal attachment of the superficial MCL. An anchor was placed in this location to better orient the semitendinosus and gracilis tendons parallel to the underlying native MCL (Figure 1C).
The adductor magnus tendon and adductor tubercle are located to begin the establishment of the femoral socket. Measurements are then made 12 mm distal and 8 mm anterior to the adductor tubercle, and an incision is made at this location. Next, a guide pin is placed at this location. The graft is passed up to this guide pin and marked (Figure 1D). Range of motion tests are conducted to ensure the graft is in an isometric position.
A mark is placed 12 mm distal to the joint line. Another anchor is placed here, which will recreate the tibial insertion site of the deep MCL (Figure 1E). The graft is then passed distal to proximal underneath the plane lying directly over the MCL (Figure 1F). The graft is then placed and docked into the femoral socket, and the knee is placed in 30° of flexion (Figure 1G). A slight varus force is applied to the flexed knee. A tenodesis screw is then used to secure the graft in place. The deep MCL anchor is then tied over the graft to recreate the deep MCL insertion (Figure 1H). Range of motion testing of the knee is performed before closing the incision and completing the case.
Results And Discussion
Limited data are available on the proper treatment of posteromedial corner (PMC) injuries, leaving surgeons with the option to either reconstruct or repair them. However, studies have shown differences in failure rates after MCL reconstruction and MCL repair.1,2,4 Systematic reviews and multicenter randomized controlled trials have demonstrated significantly lower rates of failure after reconstruction procedures when compared with repairs.1,2,4
For isolated MCL reconstruction, the patient is placed in a hinged knee brace locked in full extension immediately postoperatively. For the first 6 weeks, patients remain nonweightbearing and are encouraged to unlock their brace and range the knee up to 90°, with a goal of painless range of motion from 0 to 90 at 6 weeks. From 6 to 12 weeks, patients are weaned from crutches and then the hinged knee brace. Closed-chain strengthening exercises are introduced. By 12 weeks, patients should achieve a full painless range of motion compared with the contralateral side, and strength should be near 80% of the uninjured limb. At 12 weeks, patients progress to more explosive activities such as plyometrics and begin laterally based movements. Running is initiated at 16 weeks using an antigravity treadmill. After 20 weeks, patients begin sport-specific exercises to return to sport between 6 and 9 months postoperatively. In the setting of concomitant ACL reconstruction, return to sport is typically at 9 months.
Conclusion
Patient-reported outcomes after PMC reconstruction have also been found to be significantly better, with reconstructions yielding higher Lysholm and International Knee Documentation Committee scores than PMC repairs. 4 However, objective outcomes and patient satisfaction are not significantly different between these 2 procedures. 4
Footnotes
Submitted April 17, 2025; accepted August 21, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: R.L. reported participating in professional activities with Smith & Nephew. J.C. was a board or committee member for the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, and the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; was a paid consultant for Arthrex, CONMED Linvatec, Ossur, RTI Surgical Inc, Smith & Nephew, and Vericel Corporation; and was a paid presenter or speaker for Smith & Nephew.
