Acute combined ACL–MCL in the elite female footballer—a playbook

Practical tips:

1. Always examine in extension and flexion. If instability is present in both, think complete MCL complex rupture.
2. Save the hamstrings. Use quad or BTB in combined ACL–MCL.
3. Complete tibial MCL injuries behave like Stener lesions. They almost never heal well without surgery.
4. Fluoro is your friend. Anchor malposition is the #1 avoidable cause of stiffness or recurrent instability.
5. Vancomycin soak is cheap insurance. I haven’t had a graft infection since making it routine.
6. Rehab is not ACL rehab. Protect the MCL. Lock down ROM early, then progress slowly.

Common pitfalls:

1. Taking hamstrings on the injured side, you weaken the knee’s backup stabilizers.
2. Ignoring the POL—if extension instability is present, you must address posterior fibers.
3. Over-tightening the LET—will restrict rotation and irritate the lateral joint. Always fix in neutral rotation.
4. Brace unlocked too soon—leads to medial side stretching.

1. First impressions and clinical exam—know what to look for

On clinical examination, the story unfolded as expected but with a few key details that changed everything. In full extension the knee was unstable. In 20 to 30 degrees of flexion, it was unstable again. The Lachman test showed a clear difference compared to the opposite side, and the pivot shift was positive. These findings told me that I was not dealing with a partial tear or an isolated lesion.

The MCL is not one uniform band; it is a complex of structures with different fibers tightening at different angles. When a patient is unstable in both extension and slight flexion, the entire medial complex is compromised—the superficial anterior and posterior bundles, the deep MCL, and the posterior oblique ligament. 

This was the situation here, and it set the stage for my treatment strategy.

2. Imaging confirms the diagnosis

The MRI confirmed what I suspected clinically. The ACL was completely ruptured, and the MCL showed a tibial-side lesion—essentially a Stener-like configuration.

Experience has taught that these tibial-side injuries do not heal reliably without surgical intervention. A femoral detachment may surprise us with good healing potential, but tibial avulsions rarely do. So, at this point, my mind was already turning toward operative management rather than conservative care.

3. Choosing the graft—and why I save the hamstrings

Selecting the graft for ACL reconstruction is always a discussion in its own right, and in this case it was decisive. Many surgeons would instinctively reach for the hamstrings, but I avoid that when the medial side is deficient. The reason is simple: the hamstrings act as secondary stabilizers of the medial knee. When valgus and MCL insufficiency are present, these muscles help hold things together. If I harvest them, I remove a valuable line of defense.

Instead, I favor the quadriceps tendon in such cases. It offers robust graft size, reliable fixation options, and it leaves the hamstrings intact to assist the healing medial structures. In a young female professional, preserving every bit of native stability is critical.

4. The operative sequence

Two days after the trauma, with tissue quality still good, we took her to surgery. I began with a diagnostic arthroscopy, which confirmed the ACL rupture and showed the classic drive-through sign on the medial side. The ACL was reconstructed with a quadriceps tendon autograft, soaked in vancomycin as I now routinely do. For fixation I prefer an adjustable loop on the femoral side and a hybrid construct on the tibia—a PEEK screw supported by a button. This combination gives me confidence that the graft will hold even under the stresses of an early return-to-play program.

Addressing the medial side required precision. I placed two anchors: one to secure the superficial MCL and one for the posterior oblique ligament. Intraoperative fluoroscopy guided me, because anchor malposition on the femur is one of the most common causes of stiffness or residual laxity after MCL repair. Correct placement makes all the difference between a knee that recovers full motion and one that struggles with tightness.

Because this was a young, high-demand athlete with a high-grade pivot shift, I also added a modified Lemaire procedure. Using a strip of iliotibial band, I kept the Kaplan fibers intact, shuttled the graft beneath the lateral collateral ligament, and fixed it proximal and posterior to its femoral insertion. This provides extra anterolateral stability without over-constraining the joint. The combination of ACL, MCL refixation, and LET may sound aggressive, but in this population, it is what keeps them on the field long-term.