Isolated Lateral Collateral Ligament Injuries: Introduction
- William G. Clancy, MD
Epidemiology
- •
Frequency: relatively uncommon
- •
Age: under 30 years of age
- •
Sex: predominantly males
- •
Sport: football, wrestling, soccer
Pathophysiology
Traumatic Factors
- •
Isolated lateral collateral ligament injuries, although not rare, are still relatively uncommon and frequently go unrecognized. The major reasons why it is infrequent is that the necessary varus force to the knee is often blocked by the opposite leg with a resulting valgus to the protecting knee.
- •
Wrestling, soccer and football have produced more isolated lateral collateral ligament injuries in the author’s experience.
- •
In wrestling this injury can occur when the referee places the wrestlers in the neutral position in which one wrestler is standing while the other is put in the kneeling position facing his opponent. At the referee’s whistle, the knee-lying player shoots for the inside knee of his opponent, while at the same time his hand grasps the foot of the same knee. With the foot now fixed there can be a significant varus load applied to the opponent’s knee.
- •
In soccer, this injury may occur when an opposing player attempts to slide tackle the ball from a player where the ball is on the foot of the player’s extended outside leg. If the opposing player’s body or leg hits the inside of the player’s outside leg or knee, a varus load can be applied to that knee producing injury to the lateral collateral ligament.
- •
In football, isolated lateral collateral ligament injuries occur more frequently in a pile up in which the player’s foot is fixed by the bodies of fallen players and his upper body is adducted away from the fixed foot producing a varus load at the knee.
- •
Classic Pathological Findings
- •
Stable to varus stress at full extension
- •
No appreciable laxity at 30° to varus stress in first- or second-degree sprains
- •
Mild laxity at 30° varus stress; minimal at 0° and no palpable fibular collateral ligament in the figure-four position for a third-degree sprain
Clinical Presentation
Physical Examination
Abnormal Findings
- •
Minimal knee effusion
- •
Minimal to mild laxity at 30° knee flexion but none at full extension ( Figure 35-1 )
FIGURE 35-1
Varus stress lest. A, In extension. B, In flexion. Minimal to mild laxity at 30° knee flexion but none at full extension.
(From Reider B: The orthopaedic physical examination, ed 2. Philadelphia; WB Saunders, 2005.)
- •
Pain to palpation of the intact lateral collateral in the figure four position for 1° and 2° sprains
- •
No palpable lateral collateral ligament in a figure four position in 3° sprains
- •
Careful examination will localize the pain to the lateral collateral ligament, particularly when the knee is placed in a figure four position allowing for palpation of the ligament. The lateral knee pain should be isolated only to palpation of the ligament and not the anterolateral or posterolateral joint line. If there is a complete tear, the ligament will not be palpable and there should be mild increase in varus laxity at 30° of knee flexion but no appreciable laxity at full extension. Gollehon et al in their report of sectioning of only the lateral collateral ligament found that there was only a 1° to 4° increase in external rotation at 30° of knee flexion and that varus laxity at 30° of knee flexion only increased from 1 to 4 mm. This study appears to correlate with our clinical findings that there is no appreciable laxity at 0° and 30° of knee flexion in isolated first and second degree lateral collateral ligament sprains. In isolated third degree sprains there should be only mild increase in varus laxity at 30° of knee flexion and minimal if at all at full extension. If there is moderate laxity at 0° and 30° of knee flexion this would suggest that there is also at least some injury to the posterolateral structures and perhaps to the cruciate ligaments.
- •
Varus stability is evaluated in the horizontal plane at 0° and 30° of flexion and should be equal to that of the opposite leg. External tibial rotation is measured at 30° and 90° of knee flexion. If the injury also involves a complete tear of the posterior cruciate ligament there is a marked increase in external rotation at 90° as compared to the rotational laxity measured at 30° of knee flexion as noted by Gollehon et al and Grood et al . In those with either an acute or chronic injury the dial test, either prone or supine performed at 30° and 90°, should establish that there is a significant difference in external tibial rotation between the normal and injured knee. However, when there has been an isolated posterior cruciate ligament injury one must maintain the neutral position of the tibia when performing the dial test otherwise the posterior tibial subluxation and coupled normal tibial external rotation may appear to be greater than it is due to the increase in posterior tibial translation. If there is normal varus laxity at 0° and 30° of knee flexion one must be suspect as to whether there is a significant injury to the posterolateral structures. A reverse pivot shift test as described by Jakob is usually a sign of at least a severe posterolateral injury and a possible injury to the posterior cruciate ligament. In this test the tibia is externally rotated and flexed to 90°. A valgus load is applied and maintained as the tibia is extended while maintaining the external tibial rotation. At approximately 30° knee flexion one should feel a sudden pivot and reduction of the tibia. One must make sure this pivoting produces an anatomic reduction. In some cases this pivot-like sensation could actually be an anterior tibia subluxation due not to posterolateral laxity but due to anterior cruciate insufficiency. The pivot shift test for anterior cruciate ligament insufficiency, which is the reduction of the abnormal anterior translation, occurs at the same angle of knee flexion as does the reduction of the abnormal externally rotated tibia in those with posterolateral injury.
Pertinent Normal Findings
- •
No or minimal knee effusion
- •
Negative Lachman’s test and negative posterior drawer test
- •
No appreciable increase in external rotation at 30° and 90° of knee flexion
Imaging
( Figure 35-2 )
- •
MRI should be able to differentiate a lateral collateral ligament tear from a meniscal injury, and can document if there is some additional injury to the posterolateral structures and cruciate ligaments.
- •
Roentgenography: normal
- •
MRI: no lateral meniscus tear
- •
Edema of the lateral collateral ligament with partial or complete tear of only the lateral collateral ligament
Differential Diagnosis
- •
Lateral meniscus tear
- •
Lateral side soft tissue contusion
- •
Some isolated lateral collateral ligament injuries are often unrecognized due to the fact that they often do not produce severe knee pain nor produce a detectable knee effusion in first- or second-degree sprains. Often the initial diagnosis is that of a possible lateral meniscus tear.
- •
Lastly there is another abnormal entity that involves the posterolateral corner of the knee. This author has termed this entity functional symptomatic posterolateral laxity .
- •
These patients have no prior history of injury or have a history of a minimal injury.
- •
They all have complaints of frequent episodes of functional instability even when walking straight ahead.
- •
They do not have symptoms of an unstable lateral meniscus as seen in those with popliteomeniscal injuries or root avulsions and at the time of arthroscopy they do not have any signs of posterior nor posterolateral meniscal laxity.
- •
These patients usually have very significant increase in bilateral external tibial rotation with no increase in varus laxity at 0° or 30° of knee flexion. A dial test usually does not delineate any difference in external rotation. A reverse pivot shift test often reproduces their pain but they do not have a positive reverse pivot shift test.
- •
A number of these patients can reproduce their mechanism of instability. When sitting if they place the foot of the involved leg on a small stool with their knee approximately flexed 45° to 60° they can then readily sublux their tibia posterolaterally and then they can actively reduce it. This finding is similar to those patients who can voluntarily sublux their shoulder posterior or anteriorly and then voluntarily reduce it. In the shoulder, it is called electrical disassociation first described and documented in the shoulder with EMG by Rowe. It appears that the biceps muscle, subluxes the tibia posterolaterally and the popliteus muscle then reduces the subluxation.
- •
Treatment
Nonoperative Management
- •
The literature is extremely deficient in the treatment and follow-up of isolated lateral collateral ligament injuries. The only study in the literature is that of Kannus, who reported on the follow up of nonoperative treatment of isolated grade II and grade III lateral collateral ligament sprains. He noted that all the non-operated grade II sprains had good to excellent results whereas the non-operated grade III sprains did not fare well. The grade III sprains for the most part in this study were not isolated grade III sprains of the lateral collateral ligament as most if not all had additional injuries to the anterior cruciate and/or posterior cruciate ligament. MRI evaluations were not available at the time of this study.
- •
It has been the author’s experience and Harner’s report that in surgery of the acute and chronic cases of lateral and posterolateral corner injuries that the posterior cruciate ligament must be reconstructed if injured for any successful repair of the lateral and posterolateral repairs and/or reconstructions. In the acute case all structures should be repaired or reconstructed. Non-bony avulsion injury to the popliteus tendon requires a reconstruction at the time of surgery. Thus one is creating a ligament to substitute for the popliteus muscle tendon complex. This is our treatment also for those with symptomatic physiologic posterolateral instability. The lateral collateral ligament might need an augmentation in the acute case or a graft substitute which is often needed in the chronic case. We as well as others have reported on techniques that appear to yield highly successful results. The surgical technique should include reconstruction of the popliteal ligament as it is the strongest and prime stabilizer of the posterolateral corner of the knee. In those patients with chronic instability who have a varus alignment and/or a varus thrust, a valgus osteotomy should be performed prior to or during the reconstructive procedure.
Surgical Indications
- •
Surgery indicated only when either cruciate ligament is torn.
Evidence
Multiple-Choice Questions
- QUESTION 1.
In examining a patient with suspected isolated lateral collateral ligament injury, which of the following would be the most likely clinical finding?
- A.
Significant knee effusion, lateral joint line pain, mildly positive Lachman’s test and mild varus laxity at full extension
- B.
Lateral knee pain, knee effusion, pain at the anterolateral joint line, negative Lachman’s test, palpable and painless fibular collateral ligament
- C.
Lateral and posterior knee pain, mild knee effusion, moderate varus laxity at full extension and a positive posterior drawer test
- D.
Lateral knee pain, no effusion, negative Lachman’s and negative posterior drawer test. No varus laxity at full extension, nor at 30° flexion and pain to palpation of an intact fibular collateral ligament
- E.
Lateral knee pain with mild varus laxity at full extension and moderate laxity at 30° knee flexion and noticeable increase in external rotation at 30° knee flexion
- A.
- QUESTION 2.
Isolated sectioning of the lateral collateral ligament:
- A.
Produces no significant increase in varus laxity at full extension but marked increase in varus laxity at 30° knee flexion
- B.
Produces marked increase in varus laxity at both full extension and 30° knee flexion
- C.
Can produce a positive reverse pivot shift test
- D.
Produces only a very minimal increase in varus laxity and external rotation at 30° of knee flexion
- E.
Produces marked increase in external tibia rotation at 30° of knee flexion but none at full extension
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Pathophysiology )
- QUESTION 2.
Correct answer: D (see Physical Examination )
Combined Lateral Collateral Ligament and Posterolateral Ligamentous Injuries: Introduction
- William G. Clancy, MD
Epidemiology
- •
Age: usually under 30 years of age
- •
Sex: male more predominate than females
- •
Sport: football, wrestling, soccer
Pathophysiology
Intrinsic Factors
- •
Severe injuries to the lateral and posterolateral structures are rarely if ever isolated injuries. These injuries, although rare, are seen in contact sports mainly football, wrestling, and soccer. Severe injuries to these structures will involve injuries to either or both of the cruciate ligaments and possibly the common peroneal nerve and to a lesser extent the popliteal artery. The structures vital to lateral and posterolateral stability include the lateral collateral ligament, the popliteofibular ligament, the popliteus muscle tendon complex, the posterolateral capsule including the arcuate ligament and the biceps muscle tendon complex. These structures combine to provide lateral stability and control tibial external rotation.
- •
In order to understand the importance of the lateral and posterolateral structures of the knee and the role they play in functional stability one needs to know the normal range of external tibial rotation and the biomechanical strength of the static stabilizers. Wang and Walker in their study on eight cadaver knees reported that there was approximately 8° of external rotation present at 25° of knee flexion with a minimum of 6° and a maxiumum of 10°. Fukubayashi et al. documented that there is a coupled translation and rotation with anterior and posterior forces applied to the knee. With a posterior force there is a coupled posterior translation and an external rotation. They noted with a 100 N load that the greatest amount of external rotation was approximately 8° at 25°, 12° at 75°, and 6° at 90° of knee flexion.
- •
Biomechanical studies of sectioning of the various lateral structures and the effects on external rotation have been performed by numerous authors. Nielsen et al. noted that the popliteus tendon as a passive stabilizer was the prime stabilizer to posterolateral stability due to its attachments to both the arcuate ligament and the tibia as documented by Last. Nielsen’s study also documented that marked posterolateral instability was impossible with an intact popliteus tendon. Gollenhon et al. and Grood et al. noted that sectioning of all the posterolateral structures with an intact posterior cruciate ligament produced significant increase in external rotation most notably at 30° of knee flexion and additional sectioning of the posterior cruciate ligament further increased abnormal external rotation most notably at 90° of flexion.
- •
A summation of the reports in the literature on the biomechanical strengths of the lateral structures noted that the load to failure of the lateral collateral ligaments in 49 knees (age range 40 to 93 years) was 513 N (range 295 to 746 N). The maximum load to failure for the popliteofibular ligament in 37 knees (age range 40 to 93 years) was 132 N (range of 42 to 298 N). This structure which is a branch of the popliteus tendon appears to be the weakest of all the lateral stabilizers but is still an important stabilizer. The maximum load to failure for the popliteus muscle tendon complex in 8 knees (average age of 57 years) was 700 N. The popliteus muscle tendon complex is the strongest static stabilizer but of more importance is its strong muscular contraction counteracting excessive posterolateral rotation.
Extrinsic Factors
- •
Pile-up in football
- •
Takedown from the neutral position in wrestling
- •
Sliding tackle in soccer
Traumatic Factors
- •
A varus blow to the knee with a planted foot or an anterior varus blow to the knee with a planted foot
Classic Pathological Findings
- •
Anterior cruciate and/or posterior cruciate ligament with injury to the lateral collateral ligament, popliteal fibular ligament with injury to the popliteus muscle tendon complex, biceps tendon, common peroneal nerve, and possibly the popliteal artery
Clinical Presentaition
History
- •
A contact injury with a varus load to the knee either flexed or extended with the foot planted with ensuing severe lateral knee pain
Physical Examination
Abnormal Findings
- •
Marked varus laxity at 0° flexion
- •
Positive Lachman’s test and/or a positive posterior drawer test. There may be neurologic findings such as inability to dorsiflex the foot and toes and loss of sensation on the lateral side of the leg and dorsum of the foot
Pertinent Normal Findings
- •
Usually intact medial structures without valgus laxity at 30° and 0° of flexion
Imaging
- •
MRI findings
- •
Tear of the ACL and/or PCL
- •
Tears of the lateral collateral ligament, the popliteal fibular ligament, lateral capsule and injury to the popliteus muscle tendon complex and the biceps tendon
- •
Differential Diagnosis
- •
This entity should not be confused with any other except in those with open physeal growth plates, where a physeal fracture may also be present.
Treatment
Surgical Indications
- •
Reconstruction of the appropriate cruciate ligaments
- •
Repair and when necessary augment or reconstruct the appropriate lateral stabilizing structures especially the popliteus tendon complex
- •
Valgus tibial osteotomy in chronic cases with varus alignment or varus thrust prior to or at the time of reconstruction
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
If there is a physeal fracture it should be stabilized first, after which the soft tissue injuries should be repaired or reconstructed.
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
First the anterior and/or posterior cruciate ligaments need to be reconstructed and then the lateral and posterolateral structures need to be stabilized at the same operation and not staged. The common peroneal nerve needs to be explored as the nerve curves around the fibular neck and the fibrotic band under the anterolateral muscles needs to be released when present.
Evidence
Biomechanical
Clinical
Multiple-Choice Questions
- QUESTION 1.
In order to produce a reverse pivot shift there must be complete disruption of the:
- A.
Fibular collateral ligament
- B.
Fibular collateral ligament and the anterior cruciate ligament
- C.
Fibular collateral ligament and popliteomeniscal ligaments
- D.
Isolated sectioning of the posterior cruciate ligament
- E.
Fibular collateral ligament, popliteofibular ligament and popliteus tendon posterolateral capsule/arcuate ligament
- A.
- QUESTION 2.
In those patients with chronic lateral, posterolateral, and posterior cruciate ligament injuries one needs to treat:
- A.
Only the posterior cruciate ligament
- B.
Only the posterolateral structures
- C.
Only the posterior cruciate ligament and the posterolateral capsule
- D.
Only the popliteus muscle complex
- E.
The posterior cruciate ligament and all of the posterolateral structures
- A.
- QUESTION 3.
In those patients with an acute combined anterior cruciate, posterior cruciate and lateral and posterolateral corner injuries without popliteal or peroneal nerve injury the most appropriate treatment is:
- A.
No operative management
- B.
Reconstruct the anterior cruciate ligament first then at a later date surgically treat the other injuries
- C.
Reconstruct the posterior cruciate first then at a later date surgically treat the other injuries
- D.
Reconstruct the anterior and posterior cruciate ligaments first and at a later date treat the posterolateral corner injuries
- E.
Reconstruct the anterior cruciate, posterior cruciate ligament and the lateral and posterolateral corner injuries all at the same time
- A.
Answer Key
- QUESTION 1.
Correct answer: E (see Pathophysiology )
- QUESTION 2.
Correct answer: E (see Pathophysiology )
- QUESTION 3.
Correct answer: E (see Pathophysiology )
Nonoperative Rehabilitation of Lateral Collateral Ligament Sprains
- William G. Clancy, MD
- Kevin E. Wilk, PT, DPT
- Leonard C. Macrina, MSPT, SCS, CSCS
- Kevin E. Wilk, PT, DPT
- •
Initial focus of the rehabilitation should work to decrease pain and swelling while minimizing the effects of immobilization and muscular atrophy.
- •
Never overstress the healing tissue.
- •
Allow enough time for adequate healing to occur which will allow the athlete to return to sports without long-term deleterious effects
Phase I (weeks 0 to 4 to 6 postinjury)
Goals
- •
Early protected ROM
- •
Prevent quadriceps atrophy
- •
Decrease effusion/pain
| PHASE I (Maximal Protection, weeks 1 to 6) | PHASE II (Intermediate Phase, weeks 6 to 10) | PHASE III (Advanced Phase, weeks 10 to16) | PHASE IV (Maintenance Program) | ||
|---|---|---|---|---|---|
| Week 1 | Week 2 | Week 6 |
|
|
|
|
|
| |||
Protection
- •
The knee is protected by placing the knee in a brace, typically locked at 0°, while walking on crutches to slightly unweight the injured extremity.
Management of Pain and Swelling
- •
The patient is instructed to ice and elevate the extremity for 20 minutes every hour throughout the first 2 weeks or until adequate swelling control is attained. Icing should be performed in full knee extension to prevent a flexion contracture from forming.
- •
A compression sleeve or ace wrap may be utilized to keep swelling to a minimum.
- •
Weight bearing may be allowed immediately, however, in a brace locked at 0° and while using crutches.
- •
Analgesic and antiinflammatory medications may be utilized to decrease pain and swelling.
- •
Low-level laser therapy (cold laser) may be utilized to improve tissue healing ( Figure 35-3 ).
FIGURE 35-3
Low level laser therapy to promote a healing response at the site of the injury.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
The rehabilitation specialist may begin patella mobilizations immediately to tolerance. Also, gentle manual passive range of motion of the knee may be initiated to neuromodulate pain and aid in collagen alignment of the healing ligamentous tissue.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
The athlete may begin some gentle calf and hamstring stretching to maintain flexibility and assist in maintaining full knee extension.
Other Therapeutic Exercises
- •
Neuromuscular electrical stimulation to the quadriceps is initiated immediately during straight leg raises.
- •
Hip adduction and external and internal rotation may also be performed. Sidelying hip abduction should be avoided to decrease stresses on the lateral knee soft tissue structures.
- •
Ankle, hip, and core strengthening may be initiated as long as there are no deleterious stresses on the lateral knee structures.
- •
Hamstring and calf stretching may be performed to maintain lower leg flexibility
Activation of Primary Muscles Involved
- •
Quadriceps, hip abductors, adductors, extensors, external rotators
Sensorimotor Exercises
- •
Passive/active joint repositioning may be utilized to initially improve joint proprioception and awareness.
Open and Closed Kinetic Chain Exercises
- •
Straight leg raises, four-way ankle with resistance tubing
Neuromuscular Dynamic Stability Exercises
- •
Forward/backward weight shifting onto the involved extremity followed by lateral weight shifting as long as there’s no lateral knee pain. Single leg stance activities may be initiated as tolerated to further challenge the patient’s dynamic stability.
Functional Exercises
- •
Crutch training while in the brace locked at 0 degrees.
Milestones for Progression to the Next Phase
- •
Minimal pain or swelling
- •
Physical exam shows minimal to no lateral knee opening with varus stressing
- •
Good quadriceps control with straight leg raises with no quadriceps lag
- •
Voluntary quadriceps activation
Phase II (weeks 6 to 10)
Goals
- •
Full painless ROM
- •
Restore strength
- •
Ambulation without crutches
Protection
- •
Crutches no longer needed
- •
Brace used with walking but unlocked to available range of motion
- •
Progress to hinged-upright brace (DonJoy Playmaker) for medial/lateral stability
Management of Pain and Swelling
- •
Continue ice, compression, and elevation particularly after the rehabilitation visit. May initiate moist hot packs before the treatment to bring blood to the area and improve soft tissue mobility. PROM also utilized to decrease pain and stiffness.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue to progress passive range of motion to relative tolerance with careful attention to avoid over stressing the lateral knee.
Soft Tissue Techniques
- •
Soft tissue mobilization to the quadriceps and hamstrings may aid in improving flexibility. Cross friction massage to the LCL may aid in tissue healing and collagen alignment.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
The athlete may work on a complete stretching program for the quadriceps, hamstring, iliotibial band, and gastrocnemius-soleus complex.
Other Therapeutic Exercises
- •
Progress weight-bearing strengthening exercises
- •
Bicycle
- •
Leg press (0° to 80°)
- •
Knee extensions 60° to 0°
- •
Multi Hip machine
- •
Hip external/internal rotation
- •
Wall squats 0° to 60°
- •
Sidelying clams
- •
Lateral step-downs
- •
Resisted lateral walking (monster walks)—resistance should be just proximal to the knee joint and closely monitored for pain
- •
Single-legged balance on foam
- •
Light perturbations
- •
- •
Activation of Primary Muscles Involved
- •
Weight-bearing strengthening to include the quadriceps, hamstring, hip musculature with particular attention to the abductors, extensors, and external rotators.
Sensorimotor Exercises
- •
Tilt board minisquat, single leg stance activities on unstable surfaces, light perturbation training
Open and Closed Kinetic Chain Exercises
- •
See abovementioned exercises
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See abovementioned exercises
Neuromuscular Dynamic Stability Exercises
- •
As mentioned, perturbation training on unstable surfaces once the athlete demonstrates good leg control with ambulating and demonstrates adequate baseline strength
Functional Exercises
- •
Normalize gait; progressively challenging single leg balance activities; eccentric quadriceps strengthening. May initiate aquatic therapy including jogging and lateral movements
Sport-Specific Exercises
- •
See combination of above exercises
Milestones for Progression to the Next Phase
- •
Full, pain-free PROM and AROM
- •
Stable knee without excessive varus laxity on physical examination
- •
>4+/5 MMT for involved lower extremity musculature including the quadriceps, hamstrings, gluteals, hip rotators
Phase III (weeks 10 to 16)
Goals
- •
Increase strength and power
Protection
- •
Hinged knee brace ( Figure 35-4 ) or a custom knee brace to protect the lateral collateral ligament
FIGURE 35-4
Hinged knee brace (Playmaker, DJO Global, Vista, California) used to give lateral stability as the patient progresses through the rehabilitation program.
Management of Pain and Swelling
- •
Cryotherapy as needed in response to each treatment session
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue to maintain passive range of motion to full and work flexibility for the entire lower body.
Soft Tissue Techniques
- •
For lower extremity musculature, if lacking full excursion a foam roller may be utilized as an adjunct treatment to release trigger points
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
See above
Other Therapeutic Exercises
- •
Continue with machine weights to entire lower body musculature
- •
Progressive body weight exercises including
- •
Forward and lateral lunges
- •
- •
Sports cord exercises to work on NM control, dynamic stability and hand-eye coordination ( Figure 35-5 )
FIGURE 35-5
Sport cord lateral lunging while catching a ball to promote dynamic stability, neuromuscular control and hand-eye coordination.
- •
Core stabilization
Activation of Primary Muscles Involved
- •
Continue to progress complete lower body strengthening to quadriceps, hip musculature
Sensorimotor Exercises
- •
Perturbation training on unstable surfaces
- •
BOSU squats ( Figure 35-6 )
FIGURE 35-6
BOSU squat on an unstable surface while catching a basketball.
- •
Single leg stance drills including:
- •
Star drill
- •
Ball toss
- •
Open and Closed Kinetic Chain Exercises
- •
See previous strengthening exercises
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progressive resistance exercises, aerobic conditioning including stationary bike, elliptical, swimming and pool running
Neuromuscular Dynamic Stability Exercises
- •
See above
Plyometrics
- •
May initiate light plyometric exercises on leg press toward the end of this phase depending on strength and tissue healing
- •
Two-legged hops in place
- •
Two-legged hops forward/back emphasizing landing technique
Functional Exercises
- •
Pool exercises including swimming, running, antigravity treadmill as long as no increase in symptoms.
- •
Progression to treadmill running as long as the patient completes previous functional exercises without difficulty or pain.
Sport-Specific Exercises
- •
See functional exercises above
Milestones for Progression to the Next Phase
- •
Full PROM and AROM, pain free
- •
No effusion through joint line and suprapatella girth measurements
- •
No lateral instability with clinical examination
- •
Muscle strength 85% contralateral side per isokinetic testing
- •
No tenderness to palpation over the LCL
- •
No changes in posterolateral laxity
- •
May use Dial test
- •
Varus laxity testing at 0° and 25°
- •
- •
Quadriceps peak torque to body weight 60% to 65% on isokinetic testing
Phase IV (weeks 16+)
Protection
- •
Functional knee brace if prescribed by the MD
Management of Pain and Swelling
- •
As needed. See previous sections
Techniques for Progressive Increase in Range of Motion
Soft Tissue Techniques
- •
Soft tissue mobilization as needed to lower extremity musculature as the patient progresses through higher level strengthening to diminish delayed onset muscle soreness (DOMS)
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Dynamic flexibility exercises before the athlete begins workouts.
- •
Static stretching may be employed as needed after exercising.
Other Therapeutic Exercises
- •
Continue total leg strengthening with progressive resistive exercises
- •
Gradually progress running on treadmill and slowly progressing to field work
- •
Initiate agility drills to focus on cutting and start-stop drills
Activation of Primary Muscles Involved
- •
Quadriceps, gastrocnemius-soleus complex, hip musculature
Sensorimotor Exercises
- •
Continued balance activities and perturbation training on unstable surfaces, incorporating functional activities including throwing and catching
Open and Closed Kinetic Chain Exercises
- •
Continue aforementioned exercises and progress plyometrics to include box jumps, skip jumps, and scissor jumps to improve power and endurance.
- •
Verbal cueing is utilized to ensure the athlete is landing correctly and with even weight distribution bilaterally to prevent compensation.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See above
Neuromuscular Dynamic Stability Exercises
- •
See above
Plyometrics
- •
See above
Functional Exercises
- •
Progression through running program depending on sport ( Box 35-1 )
Box 35-1
Interval Running Program
- •
FORWARD RUNNING: Run at ______% of maximal effort for a distance of _____ feet straight ahead. Perform _____ times.
- •
BACKWARD RUNNING: Run backwards at _____% maximal effort for a distance of ___ feet. Repeat ____ times.
- •
SIDE SHUFFLE: Begin by standing side-ways, step out with the lead foot and follow with the back foot in a side-stepping motion. Perform at ____% of maximal effort for a distance of _____ feet. Repeat in opposite direction. Perform _____ times in each direction.
- •
START & STOP: Run straight forward at ____% of maximal effort for a distance of ____feet then stop as quickly as possible. Perform ____times.
- •
FIGURE of 8: Place two cones _____ feet apart. Start by standing in between cones and run a circle around one cone, then back to the starting position. Continue around opposite cone in a figure of 8 pattern. Perform at _____% maximal effort. Perform ____ times.
- •
45-DEGREE CUTS: Run at ____% maximal effort for a distance of ____ feet, plant the involved leg and change direction such that the subsequent path you are running makes a 45-degree angle with the original path. Repeat the process while cutting on the uninvolved extremity. Perform ____ times.
- •
90-DEGREE CUTS: Run at ____% maximal effort for a distance of ____ feet, plant the involved leg and change direction such that the subsequent path you are running makes a 90-degree angle with the original path. Repeat the process while cutting on the uninvolved extremity. Perform ____ times.
- •
FOUR-CORNERS DRILL: Place four cones in a square at a distance of ____ feet apart. Run forward at _____% maximal effort. Plant on the involved leg while maintaining the same body direction, then side step to the next cone. Backpedal to the next cone and another side step to the final cone. Repeat ____ times.
Indoor Interval Running Program
- •
Jog ~18 laps around the basketball court (~1 mile). Stop immediately if you begin to limp or feel any pain. If pain-free:
- •
Run____ lengths of the gym at
speed. If no pain, then:
- •
Run____ lengths of the gym at
speed. If no pain, then:
- •
Run____ lengths of the gym at full speed. If no pain, then:
- •
Run____ lengths, cutting by planting on involved leg, at full speed. If pain free:
- •
Perform 10 minutes of running or jumping drills related to your sport. When you have completed the entire program, you are ready to return to competition.
- •
If you do not complete the entire program on a particular day, you should begin at the first step the following day.
- •
Each running session must be followed by a good stretching program for each major muscle group of the lower extremities, along with ice application for 15 minutes.
- •
Outdoor Interval Running Program
- •
Jog 1 mile. Stop immediately if you begin to limp or feel any pain. If pain-free:
- •
Perform six 80-yard sprints at
speed. If no pain or limp:
- •
Perform six 80-yard sprints at
speed. If no pain or limp:
- •
Perform six 80-yard sprints at full speed. If no pain or limp:
- •
Perform six 80-yard sprints with cutting at
speed. If no pain:
- •
Perform six 80-yard sprints with cutting at
speed. If no pain:
- •
Perform six 80-yard sprints with cutting at full speed. Always plant on the outside foot to cut. If no pain:
- •
Perform 10 minutes of running and/or jumping drills related to your sport. When the entire program has been completed, you are ready to return to competition.
- •
If you do not complete the entire program on a particular day, you should begin at the first step the following day.
- •
Each running session must be followed by a good stretching program for each major muscle group of the lower extremities, along with ice application for 15 minutes.
- •
Outdoor Track Interval Running Program
- •
Run on an outdoor track. Run at ____% of maximum on the straightaways and slow to a walk when going around the curves. Perform ____ laps.
- •
- •
Agility drills
- •
Lateral cariocas
- •
Figure of 8’s
- •
Shuttle runs
- •
Interval sprinting program
- •
Specific sport drills and activities
- •
Sport-Specific Exercises
- •
On field drills simulating the patient’s sport
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Full Strength 5/5 manual muscle test
- •
Full PROM and AROM
- •
Isokinetic testing criteria:
- •
Quadriceps torque to body weight ratio ≥ 65%
- •
Hamstrings/quadriceps ratio within 70%
- •
Bilateral comparison of quadriceps within 90%
- •
Bilateral hamstrings within 100%
- •
Acceleration rate at 0.2 seconds (80% of quads peak torque)
- •
- •
No pain with functional activities including running, jumping and cutting
- •
>85% proprioception on Biodex Stability System
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or more Intensive Intervention
- •
Continued pain
- •
Varus laxity that has progressed beyond 1+ end feel
- •
Unable to return to sports after 3+ months of nonoperative treatment
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Able to perform all activities without increase in symptoms
- •
Satisfactory physical examination
- •
Clearance by physician
Evidence
Multiple-Choice Questions
- QUESTION 1.
The initial focus of rehabilitation after an LCL sprain is:
- A.
Immobilization of the lower extremity for 4 to 6 weeks to allow for appropriate healing
- B.
Prevention of full knee extension as to not overstress the ligament
- C.
Decreasing pain and swelling and allowing time for healing to occur
- D.
Weight bearing strengthening exercises to increase muscle strength.
- A.
- QUESTION 2.
During Phase I of rehab for an LCL sprain, all of the following are appropriate therapeutic exercises for the patient, with the exception of:
- A.
Electrical stimulation of the quadriceps musculature
- B.
Sidelying hip abduction
- C.
Hamstring and calf stretching
- D.
Forward/backward weight shifts
- A.
- QUESTION 3.
Choose the TRUE statement from the following:
- A.
During Phase II of rehab, the patient’s knee brace should be locked in full knee extension at all times.
- B.
In order to progress to Phase II, the patient must have 5/5 MMT for lower extremity musculature.
- C.
The time frame of Phase II consists of weeks 3 to 6.
- D.
During Phase II, light perturbation training and proprioception exercises on unstable surfaces can be initiated.
- A.
- QUESTION 4.
Light plyometric exercises can be initiated with your patient, if the patient demonstrates adequate strength and tissue healing, at approximately what stage during rehabilitation?
- A.
Weeks 4 to 6
- B.
Never before week 16
- C.
Weeks 8 to 10
- D.
Weeks 14 to 15
- A.
- QUESTION 5.
Identify below one of the correct criterion for progressing the patient to sport specific training and conditioning.
- A.
Greater than 60% proprioception on Biodex Stability System
- B.
The patient is able to complete 1 mile of treadmill running pain free in under 10 minutes and 30 reps pain free on the leg press machine with 150 lb
- C.
Isokinetic test within 15% of contralateral extremity at 180 degrees and 300 degrees
- D.
A score of Greater than 70/80 on the Lower Extremity Function Scale
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Guiding Principles of LCL Sprain box)
- QUESTION 2.
Correct answer: B (see Phase I )
- QUESTION 3.
Correct answer: D (see Phase II )
- QUESTION 4.
Correct answer: D (see Phase III )
- QUESTION 5.
Correct answer: C (see Phase IV )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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