2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Non-Operative Outcomes After Isolated Medial Collateral Ligament Injury of the Knee: A Systematic Review and Expert Survey

Kishan Ramsodit, Bsc., Amsterdam, North Holland NETHERLANDS
Joyce L. Benner, PhD, Alkmaar, Noord Holland NETHERLANDS
Ruben Zwiers, MD, PhD, Heerhugowaard NETHERLANDS
Gino M. M. J. Kerkhoffs, MD, PhD, Prof., Amsterdam NETHERLANDS
Hendrik Aernout Zuiderbaan, MD PhD, Velsen NETHERLANDS

Amsterdam UMC , Amsterdam, NETHERLANDS

FDA Status Not Applicable

Summary

This study demonstrates that the current literature on non-operative treatment of isolated MCL injuries is scarce and ranges from low to moderate quality of evidence with few studies investigating this. While most orthopedic surgeons agree on the treatment of grade 2 MCL injuries with a hinge brace, agreement on the treatment of grade 1 and grade 3 injuries is yet to be established

Abstract

Objective

Investigate the outcomes of various non-operative treatment modalities employed for isolated MCL injuries in the literature and assess the most common treatment options for isolated MCL injuries amongst Dutch orthopedic surgeons.

Methods

A systematic review was conducted through PubMed (MEDLINE), OVID (Embase), and Cochrane Library databases for articles reporting outcomes after non-operative treatment for isolated medial collateral ligament (MCL) of the knee with the search algorithm (“Medial Collateral Ligament, Knee” AND (injury OR tear OR sprain OR rupture)) AND “Conservative Treatment”. Concurrently, an expert survey was conducted amongst Dutch orthopedic surgeons firstly collecting demographic data, considerations on diagnostic approach, and classification of MCL injuries. Finally, information on non-operative treatment modalities and their specifications based on MCL injury severity as well as potential operative treatments was gathered.

Results

Nine articles were included, reporting on 478 knees, predominantly male (80%). These comprised 2 comparative studies, 1 prospective cohort, and 6 case series of which 7 studies were published before 1995 and the remaining 2 after 2019. Treatment modalities reported varied from immobilization, progressive rehabilitation programs, a combination of both, or injections. Additional variance was found regarding the time to start rehabilitation after injury. Reported outcomes varied between subjective ratings, functional tests, and reinjury rates. All but one study included return to sport as an outcome with varying definitions. The expert survey recorded 119 responses of which 105 were complete. Most respondents used the patient history (69%), physical examination (96%), or MRI scan (83%) as diagnostic tools while ultrasound was used by 3 respondents. Forty-six (42%) respondents reported treating an isolated MCL injury non-operatively regardless of tear location. Regarding the non-operative treatment options, 58% used crutches, 10% used immobilization in extension, 87% reported using a dynamic hinge brace, and 45% reported physiotherapy as a non-operative treatment option. Grade 1 MCL injuries were treated using a dynamic hinge brace by 25 (23%) respondents while 101 (91%) reported using a dynamic hinge brace for grade 2 injuries. Eighty-six surgeons (77%) used a brace when treating grade 3 injuries, while the remaining 23% preferred surgical treatment. Amongst those prescribing a hinge brace, the most common wear period advised was 6 weeks (64%) while wearing the brace constantly. Of the 56 orthopedic surgeons reporting to perform MCL surgery, 32 performed MCL repairs with 74% deeming 2 weeks the time limit for repair. In case of reconstruction, 91% used augmentation, while the most common surgical technique was the anatomic LaPrade (64%).

Conclusion

This systematic review demonstrates that the current literature on non-operative treatment of isolated MCL injuries is scarce and ranges from low to moderate quality of evidence with few studies investigating this. While most orthopedic surgeons agree on the treatment of grade 2 MCL injuries with a hinge brace, agreement on the treatment of grade 1 and grade 3 injuries is yet to be established. Although additional variation is found regarding the specifications of hinge brace use. Future research should focus on establishing a guideline for the optimal non-operative treatment for isolated MCL injuries.