MCL Reconstruction / Repair

Why this approach — at MOS

Our approach to MCL injury follows a strict conservative-first philosophy for isolated tears. The MCL's inherent healing biology means that most Grade III tears heal sufficiently without surgery when properly protected. We do not rush to operate on MCL injuries in isolation, and we communicate realistic timelines to patients — recovery from a Grade III MCL injury with conservative management takes 6–12 weeks, not 1–2 weeks, and rushing back to sport before adequate healing is a leading cause of chronic instability.

In the context of combined ligament injuries — the more frequent surgical indication — we evaluate all injured structures comprehensively before planning. The MCL's involvement in a multiligament injury changes the surgical plan significantly. We address medial and intraarticular reconstruction in a coordinated fashion, planning simultaneous or staged procedures based on the swelling, tissue quality, and injury pattern.

For patients across Montgomery County presenting with combined ACL + MCL injuries, our common approach is to stage surgery: brace the knee until the acute swelling and stiffness resolve (typically 3–6 weeks), perform ACL reconstruction, and address the MCL at the same time if it has not healed sufficiently by that point.

Who is a candidate?

Indications

• Complete MCL tear (Grade III) with persistent valgus instability after 6 weeks of conservative bracing and therapy
• Combined ligament injury (MCL + ACL, MCL + PCL) requiring medial reconstruction concurrent with or staged with intraarticular ligament surgery
• Acute MCL avulsion with bony fragment that will not heal in position
• Proximal MCL avulsion ("Stener lesion equivalent") where the ligament end is interposed in scar tissue blocking healing
• Chronic MCL insufficiency with ongoing functional instability

Contraindications

• Isolated Grade I or II MCL sprain — virtually always managed conservatively
• Isolated Grade III MCL tear in an anatomically favorable pattern that is braced and healing on schedule
• Active infection
• Medically unstable patient

Conservative Treatment First

Isolated MCL injuries — at all grades — are treated conservatively first. A hinged knee brace is applied immediately after injury to protect the healing ligament from valgus stress while allowing range of motion. Physical therapy emphasizes quadriceps and hamstring strengthening, and proprioceptive training. Most Grade I injuries heal in 1–2 weeks; Grade II in 3–6 weeks; Grade III isolated injuries typically stabilize functionally in 6–12 weeks. Surgery is considered when instability persists after a full conservative trial, or when the MCL injury is part of a combined multiligament pattern that cannot be managed non-surgically.

The procedure

What Is MCL Reconstruction / Repair?

MCL reconstruction or repair is a surgical procedure that rebuilds or stitches the medial collateral ligament — the ligament on the inner side of the knee that resists valgus (inward-bending) forces — when it is torn and does not heal adequately with conservative management. Most isolated MCL tears heal without surgery; reconstruction is reserved for complete tears with persistent instability, or for combined ligament injuries.

The medial collateral ligament (MCL) has a remarkable healing capacity compared to the ACL. Unlike intraarticular ligaments, the MCL is extraarticular — bathed in the surrounding tissue environment where blood supply and healing potential are much better. Grade I (sprain) and Grade II (partial tear) MCL injuries almost universally heal with conservative management. Even many Grade III (complete) MCL tears in isolated injuries heal sufficiently with bracing and therapy.

Surgery becomes necessary when a complete MCL tear does not heal adequately — leaving persistent medial instability — or when the MCL is injured in combination with other ligaments (ACL, PCL, or posterolateral corner), where the combined instability cannot be managed non-surgically. In a multiligament injury, the MCL is typically addressed through primary repair (stitching the torn ends together) if the tissue quality is good and the tear is acute, or through reconstruction using a tendon graft if the tissue has retracted or degenerated.

The MCL includes multiple layers — the superficial MCL is the primary static restraint to valgus stress, while the deep MCL and posterior oblique ligament provide additional stability and rotational control. Comprehensive medial reconstruction addresses all damaged layers.

What Happens During MCL Reconstruction / Repair?

The procedure is performed at the ambulatory surgery center under general or regional anesthesia. The patient is positioned supine. An incision is made over the medial side of the knee.

For primary repair (acute, high-quality tissue), the torn MCL is identified. The ends are retrieved and sutured together in anatomic position with heavy non-absorbable sutures or anchors. The posterior oblique ligament is evaluated and repaired concurrently if disrupted.

For reconstruction (chronic insufficiency, poor tissue quality, or retracted tears), a graft — most commonly gracilis and/or semitendinosus autograft — is harvested and prepared. Anatomic fixation points are identified: the proximal attachment on the medial femoral condyle and the distal attachment on the medial tibial shaft approximately 6–7 cm below the joint line. The graft is secured at both attachments with suture anchors or interference screws, reconstructing the course and function of the superficial MCL.

If concurrent ACL or PCL reconstruction is being performed, the MCL work is typically done through the same or adjacent incisions. The medial knee dissection must be careful to preserve the saphenous nerve branches running through this area.

Closure is performed in layers. A hinged brace is applied in the operating room.

Recovery timeline

Frequently Asked Questions