Research Article| Volume 37, 102110, February 2023

The MCL apprehension sign: A novel test for MCL instability

Published:January 18, 2023DOI:



      This study describes a new clinical sign to diagnose clinically relevant medial collateral ligament (MCL) injury and evaluates its use in diagnosis and planning treatment for MCL injuries.


      A total of 30 consecutive patients with suspected MCL injury, visiting the sports knee clinic were screened by the senior author and the knee fellow for any clinical laxity. Of these, 9 patients did not have any clinically demonstrable laxity but did have MRI evidence of MCL injury. The presence of apprehension sign was compared against the standard criteria for MCL laxity and was evaluated as a novel test to diagnose clinically significant MCL laxity.


      Of the 21 patients who were diagnosed to have MCL laxity, 18 had a positive apprehension sign at the time of presentation. Eight out of the nine patients who were negative for MCL laxity, did not have a demonstrable apprehension sign. According to the gold standard index, the apprehension sign had a sensitivity of 85.7% and a specificity of 88.8%. The positive and negative predictive values were 94.7% and 72.7% respectively. The pre-test probability of MCL laxity based on the diagnostic criteria was 70% and increased to 94.7% with a positive apprehension sign.


      A positive apprehension sign is suggestive of MCL injury requiring active treatment. It also helps in deciding the length of bracing required and the need for further operative treatment. The authors recommend its use as a reliable & reproducible adjunct to standard clinic-radiological work-up for MCL injuries.


      To read this article in full you will need to make a payment
      <-- details> One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Use these links to purchase access

      Purchase access to this article Visit ScienceDirect.

      If you are a member of the Delhi Orthopaedics Association (DOA), claim your access now.

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bollier M.
        • Smith P.A.
        Anterior cruciate ligament and medial collateral ligament injuries.
        J Knee Surg. 2014; 27: 359-368
        • Encinas-Ullán C.A.
        • Rodríguez-Merchán E.C.
        Isolated medial collateral ligament tears: an update on management.
        EFORT Open Rev. 2018; 3: 398-407
        • Roach C.J.
        • Haley C.A.
        • Cameron K.L.
        • et al.
        The epidemiology of medial collateral ligament sprains in young athletes.
        Am J Sports Med. 2014; 42: 1103-1109
        • Reider B.
        • Sathy M.R.
        • Talkington J.
        • et al.
        Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation: a five-year follow-up study.
        Am J Sports Med. 1994; 22: 470-477
        • Phisitkul P.
        • James S.L.
        • Wolf B.R.
        • et al.
        MCL injuries of the knee: current concepts review.
        Iowa Orthop J. 2004; 26: 77
        • Warren L.F.
        • Marshall J.L.
        The supporting structures and layers on the medial side of the knee: an anatomical analysis.
        J Bone Joint Surg Am. 1979; 61: 56-62
        • Hughston J.C.
        • Eilers A.F.
        The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee.
        J Bone Joint Surg. 1973; 55: 923-940
        • Fetto J.F.
        • Marshall J.L.
        Medial collateral ligament injuries of the knee: a rationale for treatment.
        Clin Orthop Relat Res. 1978; 132: 206-218
        • Parikh R.
        • Mathai A.
        • Parikh S.
        • et al.
        Understanding and using sensitivity, specificity and predictive values.
        Indian J Ophthalmol. 2008; 56: 45
        • Deeks J.J.
        • Altman D.G.
        Diagnostic tests 4: likelihood ratios.
        BMJ. 2004; 329: 168-169
        • Perryman J.R.
        • Hershman E.B.
        The acute management of soft tissue injuries of the knee.
        Orthop Clin N Am. 2002; 33: 575-585
        • Sims W.F.
        • Jacobson K.E.
        The posteromedial corner of the knee: medial-sided injury patterns revisited.
        Am J Sports Med. 2004; 32: 337-345
        • Wood L.
        • Peat G.
        • Wilkie R.
        • et al.
        A study of the noninstrumented physical examination of the knee found high observer variability.
        J Clin Epidemiol. 2006; 59: 512-520
        • Hughston J.C.
        • Andrews J.R.
        • Cross M.J.
        • et al.
        Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments.
        J Bone Joint Surg. 1976; 58: 159-172