MCL Sprain Rehab
The medial collateral ligament (MCL) is the most commonly injured knee ligament among soccer players. Injuries to the MCL make up approximately 4% of all soccer-related injuries.
This is typically a contact injury caused by a direct blow to the lateral (outside) aspect of the knee while the foot is planted. In soccer, this tends to happen when a player is tackled from the side or when sliding/tackling another opponent. Although less common, about 30% of these injuries are non-contact, as a result of pivoting/twisting.
(It is interesting to note, the reverse is true with anterior cruciate ligament (ACL) injuries, where the majority are non-contact related.)
Unsurprisingly, most MCL sprains occur in contact sports such as football, soccer, rugby, and hockey. However, we do also see these in skiing due to the rotational and valgus forces that occur while the foot is fixed. Male athletes are more than twice as likely to sprain their MCL compared to females.
What are the symptoms?
Many athletes will have:
Pain on the inside of the knee
Swelling at the inside of the knee
Stiffness and limited range of motion
Difficulty bending or straightening the knee
Potential instability and difficulty squatting or using stairs
Painful passing and shooting with the inside of the foot
Athletes may also feel or hear a “pop” at the time of injury
Risk Factors
Previous knee injury
MCL, ACL or meniscus primarily
Contact sports
Soccer, football, rugby, hockey, etc
There may be more or less risk of injury with certain positions.
Higher level of play
Anatomy Review
The medial collateral ligament (MCL) is a broad, thick band found on the inside of the knee. It runs from the upper/inside surface of the shin bone (tibia) to the bottom/inside surface of the thigh bone (femur). There is a superficial band or layer, and a deep layer. The deep layer can also be described as a thickening of the joint capsule and has attachments to the medial meniscus as well as the semimembranosus (hamstring muscle).
The MCL is located outside of the joint, also known as extra-articular. As a result, it has a better blood supply then the ACL for example, and therefore much greater healing potential. The main function of the medial collateral ligament is to provide stability to the inside of the knee. It is the primary restraint to valgus stress and tibial rotation. It also provides a secondary restraint to anterior tibial translation.
If you would like a more detailed description of the anatomy of the MCL and other structures at the medial knee, check out this article by Chapman and colleagues.
How do you know if you have this injury?
As we covered previously, symptoms may include swelling and pain at the inner knee, stiffness and limited motion, instability, and pain with cutting, passing, and shooting.
You may perform a self valgus stress test as well to assess this ligament. This test is performed with the lower leg fixed, and a valgus force applied to the outside of the knee. We will perform this test with the knee straight, and flexed to 20-30 degrees. The MCL is isolated with the knee bent to 30 degrees, whereas testing in full extension also stresses the ACL/PCL and posteromedial capsule.
MCL Sprain Grading
Grade 1 (minor)
Pain is common with minimal swelling and no laxity or “looseness” with valgus stress test.
1-2 week return to sport
Grade 2 (moderate)
Valgus laxity at 30 degrees, but not fully extended.
2-4 week return to sport
Grade 3 (severe)
Laxity at both 0 and 30 degrees.
6-8 weeks RTS if the MCL is the only injured structure.
Athletes tend to make a full recovery even with severe grade III MCL injuries and surgery is very rarely performed. The exception to this is if other ligaments or structures are also injured. If you have any doubt, get it checked out.
Do you need imaging?
Review the Ottawa Knee Rules -
If any one of the following is present, you should get x-rays:
Age >55 years
Patellar/kneecap tenderness w/out other bone tenderness
Tenderness of the fibular head (below the outside of the knee)
Inability to flex the knee to 90°
Inability to bear weight immediately after injury and in the emergency department (4 steps)
Significant swelling in the knee may also indicate need for imaging.
(As always, follow the advice and recommendations of your health care provider.)
Rehab and Return to Play
As mentioned earlier, even severe medial collateral ligaments injuries rarely require surgery unless another structure or ligament (such as the ACL) is also injured. Most footballers will make a full recovery and return to sport in less than 8 weeks.
Phase 1: (0-2 weeks)
(Strengthening exercises should be performed at minimum 2x/week, range of motion and stretching daily. These are general guidelines, rehab protocols are never one size fits all. Some athletes will progress much faster and others more slowly. If you have a low grade sprain or these exercises become too easy, move onto the next phase.)
Goals for this stage:
Manage pain and swelling
Regain knee ROM
Full weight bearing
Prevent valgus/side-to-side stress
If you have a more severe injury, you may need crutches and/or a brace for the first 1-2 weeks to prevent knee valgus. Early weight bearing and knee range of motion exercises are key and should be performed as soon as possible/tolerated. You should not be using crutches much longer than 2 weeks, if that.
There are multiple studies showing early ROM is preferable and players who wore a stabilizing brace for grade I or II injuries had longer recovery times compared to players who did not brace.
Phase 2: (2-4 weeks)
You may begin jogging when you have full knee ROM.
Hold off on passing and shooting until you can run pain free.
Continue to progress strengthening.
Phase 3: (4-8 weeks)
Continue to progress strengthening.
Begin sprinting, cutting, plyometrics.
Gradually return to training.
Return to sport
Before returning to sport, you should have full knee range of motion, minimal pain, normal quad and hamstring strength, and the ability to perform all agility and kicking pain free. The average return to sport time for this injury is right around 30 days.
Should you continue to wear a brace?
Bracing is usually not indicated after recovery with a few exceptions based on sport and position, such as a lineman in American football. For most soccer players, if you do still need to wear a brace, you’re probably not ready to return to sport yet.
Key Takeaways:
The MCL is the most commonly injured knee ligament in soccer players.
It is usually a contact injury caused by a direct blow to the lateral (outside) aspect of the knee while the foot is planted.
Athletes tend to make a full recovery even with severe grade III MCL injuries, and most return to sport in less than 8 weeks.
Range of motion and weight bearing should begin as soon as possible.
Immobilizing and using a brace for lower grade (I-II) injuries may delay recovery.
Surgery is rarely needed unless another structure, such as the ACL, is also injured.
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Giannotti BF, Rudy T, Graziano J. The non-surgical management of isolated medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev. 2006 Jun;14(2):74-7.
Lundblad M, Waldén M, Magnusson H, Karlsson J, Ekstrand J. The UEFA injury study: 11-year data concerning 346 MCL injuries and time to return to play. Br J Sports Med. 2013 Aug;47(12):759-62.
Lavoie-Gagne OZ, Retzky J, Diaz CC, et al. Return-to-Play Times and Player Performance After Medial Collateral Ligament Injury in Elite-Level European Soccer Players. Orthopaedic Journal of Sports Medicine. 2021;9(9).
Buckthorpe M, Pisoni D, Tosarelli F, et al. Three Main Mechanisms Characterize Medial Collateral Ligament Injuries in Professional Male Soccer-Blow to the Knee, Contact to the Leg or Foot, and Sliding: Video Analysis of 37 Consecutive Injuries. J Orthop Sports Phys Ther. 2021 Dec;51(12):611-618.
Chapman G, Vij N, LaPrade R, Amin N. Medial-Sided Ligamentous Injuries of the Athlete's Knee: Evaluation and Management. Cureus. 2023 Mar 19;15(3)
Kim C, Chasse PM, Taylor DC. Return to Play After Medial Collateral Ligament Injury. Clin Sports Med. 2016 Oct;35(4):679-96.
Reider B, Davies GJ, Provencher MT. Orthopaedic Rehabilitation of the Athlete: Getting Back in the Game. Elsevier/Saunders; 2015.
Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther. 2012 Mar;42(3):221-33.
Encinas-Ullán CA, Rodríguez-Merchán EC. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev. 2018 Jul 2;3(7):398-407.
Edson, C. J. (2006). Conservative and Postoperative Rehabilitation of Isolated and Combined Injuries of the Medial Collateral Ligament. Sports Medicine and Arthroscopy Review, 14(2), 105–110.
Lundblad M, Hägglund M, Thomeé C, et al. Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3692-3698.
Reider B, Sathy MR, Talkington J, Blyznak N, Kollias S. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med. 1994 Jul-Aug;22(4):470-7.
Ren D, Liu Y, Zhang X, Song Z, Lu J, Wang P. The evaluation of the role of medial collateral ligament maintaining knee stability by a finite element analysis. J Orthop Surg Res. 2017 Apr 21;12(1):64.