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Orthopedics & Traumatology

MCL Tear, Grade II/III, Left Knee

ICD-10 Code
S83.412A_2

Clinical diagnosis and template for MCL Tear, Grade II/III, Left Knee.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with acute left knee pain following a valgus stress injury. Reports localized medial joint line pain, swelling, and subjective instability. Difficulty with weight-bearing and ambulation noted. No history of locking or mechanical symptoms suggestive of meniscal pathology.

Clinical Examination Findings

Left knee examination reveals localized tenderness along the medial collateral ligament (MCL) course. Significant laxity noted on valgus stress testing at 30 degrees of flexion, consistent with Grade II/III MCL injury. Endpoint is soft/absent. Lachman and posterior drawer tests negative. Neurovascular status intact distally.

Treatment Protocol

Initiate RICE protocol (Rest, Ice, Compression, Elevation). Immobilization in a hinged knee brace locked in extension or limited range of motion as tolerated. Non-steroidal anti-inflammatory drugs (NSAIDs) for pain management. Physical therapy referral for progressive range of motion and quadriceps strengthening. Follow-up in 2-4 weeks.

Detailed clinical guide coming soon.