For insight into the fact that ultrasound helps accelerate MCL healing but use of NSAIDs (non-steroidal anti-inflammatory drugs) worrisomely retards such healing, please see the July 2006 article Low-Intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing, by Stuart J. Warden et al., in the Physiotherapy, Rehabilitation, and Post-Operative Aspects Subsection.

Assessment and Treatment of Medial Capsular Injuries, Kevin E. Wilk et al.; Knee Ligament Rehabilitation, edited by Todd S. Ellenbecker. Philadelphia, Pennsylvania: Churchill Livingstone (Harcourt), 2000. Pages 89-105. Comments: The authors discuss diagnostics and rehabilitation from MCL (medial collateral ligament, which is part of the medial capsule) injuries. Most MCL injuries "self-heal" (i.e. scar over) satisfactorily on their own, without surgical intervention. Although such a self-healed ligament is histologically not identical to a natural MCL, it usually provides a satisfactory restraint to valgus-directed forcing. The authors also note the importance of checking for meniscal injuries, particularly for cases in which an ACL injury accompanies the MCL tearing. With regards to bracing: the authors quote studies on prophylactic-type braces as used in the context of MCL injuries, and specially for college football. Given the problems that arise from the use of cheap prophylactic braces, high-quality custom-made functional braces would be a far better choice. High-quality custom-made functional braces provide reliable and dependable protection against sideways forcing (and also injurious hyperextension), thus making them extreme valuable for preventing MCL injuries and re-injuries. It would have been appropriate for the authors to distinguish clearly between custom-made functional braces and cheap off-the-shelf prophylactic braces.

The Treatment of Acute Combined Ruptures of the Anterior Cruciate and Medial Ligaments of the Knee, Frank R. Noyes and Sue D. Barber-Westin; The American Journal of Sports Medicine, Baltimore; Jul/Aug 1995, Vol 23/4, p. 380-391. Comments: This excellent article shows that the best way to deal with MCLs is to give them time to scar-over and self-heal, with surgery being pursued only if said conservative treatment does not work out. A rigorous and thorough study, complemented by a thought-provoking discussion filled with penetrating insight. (The points raised in this study are still very much valid ten years later, and so this article clearly qualifies as a classic in its field.) Note that amongst the knee's four main ligaments, only the MCL has the ability to self-heal. This attribute arises from the MCL's being surrounded by the joint capsule (actually, structurally, the MCL is considered to be part of the joint capsule); this keeps the torn MCL ends close enough together to make useful scarring-over and subsequent self-healing viable. (Note that some of the ACL allografting in this study was supplemented by synthetic ligament-augmentation devices. Due to problems with structural fatigue and the strain-shielding effect, synthetic ACL-graft-augmentation devices are almost never used today.) (Note that for people who have incurred MCL-only injury, this article also shows that it is well worthwhile to allow the damaged MCL time to scar-over and self-heal; this takes roughly 4-6 weeks. Sue Barber-Westin indicates that for MCL injuries, the typical protocol is as follows: long-leg rehabilitative brace, locked at 0°, initially worn after the injury; brace is removed a few times daily for gentle flexion exercises; exercises are limited to straight leg raises and isometrics. As with all knee-rehabilitation programs, this is done under the supervision of a knee-experienced physiotherapist and orthopedic surgeon. Only in cases where the MCL does not self-heal satisfactorily is surgery indicated.)

Treatment of Isolated Medial Collateral Ligament Injuries in Athletes with Early Functional Rehabilitation -- A Five-year Follow-up Study, Bruce Reider et al.; The American Journal of Sports Medicine, Baltimore; July 1993, Vol 22/4, p. 470-477. Comments: In this classic study, Reider et al. found that MCL injuries, even those of considerable severity, are capable of "self-healing" (i.e. scarring over on their own, and thus providing an adequate restraint to inwards forcing). The results are comparable to surgical repair of the MCL. The only caveat with non-surgical rehabilitation and early return-to-activities is that care must be taken to shield the injured MCL from sideways forcing. A functional brace is well-suited to this task. (In this study, low-end prophylactic-type single-upright braces were used; such braces are helpful but not ideal if return-to-sports use is expected. Dual-upright functional braces are stronger and more durable, particularly if subjected to sideways forcing, for example in contact situations of sports.) The authors do note that, even though the self-healing brought good results, persistent symptoms can remain...and so the athlete might want to continue to make use of bracing during knee-demanding activities. Reider et al. make it clear that, despite the MCL's capability for self-healing, this injury is not a trivial one.

Anterior cruciate ligament-medial collateral ligament injury: Nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction: A preliminary report, K. Donald Shelbourne and David A. Porter; The American Journal of Sports Medicine, Baltimore; May/Jun 1992, Vol 20/3, p. 283-286. Comments: A classic article on dealing with combined ACL-MCL tearing. (The MCL's ability to self-heal is unique amongst the four main ligaments of the knee. This self-healing capability is due to the fact that the MCL is surrounded by the joint capsule [retinaculum], which keeps the torn ends of the ligament aligned and in close proximity, thereby enabling useful scarring-over and often-satisfactory regainment of valgus-restraint function. Typically, for roughly 1-2 months after an MCL injury, the knee is protected by a long-leg rehabilitative-type brace; this allows the MCL to scar over without becoming overlength.)

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