Introduction
- Michael J. Battaglia, MD
Epidemiology
Age
- •
20 to 29
Gender
- •
68% men, 32% women
Sport
- •
In general, virtually any sport, especially those involving contact or pivoting. Football, rugby, soccer, basketball and skiing are specific examples.
Position
- •
An isolated medial collateral ligament (MCL) injury may occur in virtually any player. There is a greater likelihood for players involved in contact.
Anatomy
- •
The MCL of the knee originates on the medial femoral condyle and approximately 5 cm distal to the joint line on the tibia. It has an average length of 11 cm and a width of 1.5 cm.
- •
The medial side of the knee is composed of three layers. The MCL resides in layer 2. It is composed of a superficial and deep band and is the primary stabilizer to the medial knee ( Figure 34-1 ). The superficial MCL converges with the posterior oblique ligament, forming the posteromedial joint capsule. This structure has recently been shown to play an important role in stability as well. The deep MCL forms a thickening in the middle portion of the medial joint capsule and has attachments to the medial meniscus. The MCL also has attachments to the semimembranosus muscle via several fibrous bands ( Figure 34-2 ).
FIGURE 34-1
The superficial medial collateral ligament (medial aspect, left knee).
FIGURE 34-2
The medial knee bony attachment sites (medial aspect, left knee). ( AMT, adductor magnus tendon; AT, adductor tubercle; GT, gastrocnemius tubercle; ME, medial epicondyle; MGT, medial gastrocnemius tendon; MPFL, medial patellofemoral ligament; POL, posterior oblique ligament; SM, semimembranosus; VMO, vastus medialis obliquus .)
- •
The MCL functions as a static stabilizer of the medial knee, resisting valgus and external rotation stresses. The superficial MCL is the primary restraint to valgus stress when the knee is positioned in slight flexion ( Figure 34-3 A,B ).
FIGURE 34-3
A , The medial right knee in extension. The entire medial collateral ligament (MCL) complex is on tension; however, the anterior aspect of the superficial MCL is slightly slackened versus the posterior components. AMT, Adductor magnus tendon; MGT, medial gastrocnemius tendon; MPFL, medial patellofemoral ligament; POL, posterior oblique ligament; SM, semimembranosus muscle; sMCL, superficial medial collateral ligament; VMO, vastus medialis obliquus muscle. B, The medial knee in flexion. Illustrates the posterior oblique ligament on slack and the anterior superficial MCL on greater tension than the posterior aspect. The darkened region denotes the deep MCL. The posterior oblique fibers become tenser in flexion.
- •
Most injuries to the MCL occur with a direct blow to the lateral knee while in slight flexion.
- •
The severity of MCL injuries is graded on a scale from I to III.
- •
In a grade I injury, there is partial tearing of the ligament without laxity.
- •
Grade II injuries consist of partial tissue tearing with laxity of up to 5 mm of joint opening.
- •
Complete MCL ligament tears are grade III injuries and lead to joint instability with greater than 10° of joint opening.
- •
Pathophysiology
Intrinsic Factors
- •
Valgus deformity (increased Q angle) ( Figure 34-4 )
FIGURE 34-4
Valgus deformity.
- •
Hip anteversion
- •
Previous injury (anterior cruciate ligament [ACL]) deficiency
Extrinsic Factors
- •
No difference between natural and synthetic surfaces in football
- •
Ski type/binding type (occurs more frequently with skiing than in snowboarding)
Traumatic Factors
- •
As the primary restraint to valgus instability, the MCL is most commonly injured by a direct blow to the lateral aspect of the knee with the foot planted ( Figure 34-5 ).
FIGURE 34-5
Lateral blow to the knee with foot planted.
- •
The MCL also provides significant restraint to external rotation of the tibia. Other mechanisms of injury include forced external rotation of the tibia with the foot planted ( Figure 34-6 ) or forced external rotation with excessive valgus force in the unloaded extremity.
FIGURE 34-6
Forced valgus with external rotation of tibia with foot planted.
Classic Pathological Findings
- •
Local pain and edema
- •
Tenderness to palpation: careful palpation to determine exact site of injury (distal versus proximal MCL)
- •
Limited range of motion (ROM)
- •
Valgus laxity ( Figure 34-7 )
FIGURE 34-7
Valgus stress test with palpation for joint gapping.
Clinical Presentation
History
- •
Blunt force to outside of knee
- •
Foot stuck, knee/body kept going (lateral or rotatory direction)
- •
Medial knee pain
Physical Examination
Abnormal Findings
- •
Positive valgus stress test for pain and/or laxity
- •
Tenderness to palpation: proximal or distal to medial joint line
- •
Local edema
- •
Limited ROM
Pertinent Normal Findings
- •
No anterior laxity
- •
ROM is limited by pain, no hard end-feel
- •
Negative meniscus signs
Imaging
- •
Radiographs to rule out avulsion fracture
- •
Magnetic resonance imaging (MRI) scans if suspected injury to other structures. Coronal T1-weighted images may show edema of the lateral femoral condyle. Posterior coronal cuts can be useful to confirm disruption of the MCL fibers.
Differential Diagnosis
- •
Meniscus: no pain/laxity with valgus stress test; on careful palpation, MCL proximal or distal to joint line, meniscus will be tender over the joint line ( Figure 34-8 A, B, and C ).
FIGURE 34-8
A, Palpation of proximal medial collateral ligament (MCL) insertion. B, Palpation of distal MCL insertion. C, Palpation of medial joint line.
- •
Combined ACL/MCL injury: knee effusion and anterior laxity with ACL rupture. Valgus laxity in extension may be indicative of concomitant ACL rupture ( Figure 34-9 A, B, and C ).
FIGURE 34-9
A, Valgus stress in flexion and extension. Stress in extension tests the medial collateral ligament and the posteromedial capsule. Stress in 30° of flexion tests only the medial collateral ligament. B, Valgus stress test in slight flexion. C, Valgus stress test in extension.
Treatment
Nonoperative Management
- •
R est, I ce, C ompression, E levation (RICE)
- •
Nonsteroidal antiinflammatory drugs (NSAIDs)
- •
Supervised physical therapy (PT) (see nonoperative rehabilitation section for details)
- •
Bracing: dependent on severity of injury and player demands
- •
Limited weightbearing: with higher-degree injuries only
Guidelines for Choosing Among Nonoperative Treatments
- •
Severity of injury: More severe injuries require more involved treatment, such as bracing, limited weightbearing, PT (see nonoperative rehabilitation section).
- •
Sport demand: use of bracing for play, time until return to play
Surgical Indications
- •
Surgery is not indicated for most isolated MCL tears. Grades I and II isolated MCL injuries are always treated nonsurgically.
- •
Surgery is indicated in cases of combined injury, such as ACL/MCL.
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Surgery may be indicated in cases of persistent, significant laxity that prevents full return to sport. Surgery may also be appropriate in cases of persistent pain.
Aspects of History, Demographics, and Examination Findings that Affect Choice of Treatment
- •
Sport and position: Wide receivers and defensive backs will not return to play as quickly as linemen.
- •
Level of competition (recreational vs. collegiate/professional): Rehabilitation will likely be more aggressive with higher-level athletes, and return to participation will be quicker
- •
Severity of injury (grade I vs. III): Higher-grade injuries will require more care, progression to return to sport will be slower.
- •
Injury to other structures
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Complete ACL/MCL combined injury
- •
Possible as early treatment for complete proximal rupture or bony avulsion (confirmed by MRI)
- •
Failure of nonoperative treatment
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is not an accurate list of factors that contribute to MCL injuries in the knee?
- A.
Valgus deformity, direct blow to the lateral knee, hip anteversion
- B.
Direct blow to the lateral knee, hip anteversion, synthetic playing surface
- C.
Valgus deformity, forced external rotation of the tibia, direct blow to the lateral knee
- D.
Previous injury, forced external rotation of the tibia, hip anteversion
- A.
- QUESTION 2.
Which of the following is not an appropriate initial treatment option for isolated MCL injuries of the knee?
- A.
R est, I ce, C ompression, E levation (RICE)
- B.
NSAIDs and bracing
- C.
Surgical reconstruction
- D.
PT
- A.
- QUESTION 3.
When is surgery indicated as an initial treatment?
- A.
When there is a combined ACL/MCL injury
- B.
In cases of acute, severe pain and edema
- C.
In highly competitive, skilled athletes
- D.
None of the above
- A.
- QUESTION 4.
Which of the following are abnormal examination findings following isolated MCL injury of the knee?
- A.
Limited ROM, positive valgus stress test, anterior laxity, pain with palpation at the medial epicondyle
- B.
Limited ROM, positive valgus stress test, local edema, pain with palpation at the medial epicondyle
- C.
Limited ROM, positive valgus stress test, local edema, pain with palpation over the medial joint line
- D.
Limited ROM, anterior laxity, pain with palpation over the medial epicondyle, medial knee pain
- A.
- QUESTION 5.
Which of the following is the most common mechanism of injury for isolated MCL tears of the knee?
- A.
Direct blow to the lateral aspect of the knee with the foot planted
- B.
Forced external rotation of the tibia with the foot planted
- C.
Forced external rotation of the tibia with valgus force in an open kinetic chain
- D.
None of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Pathophysiology )
- QUESTION 2.
Correct answer: C (see Treatment )
- QUESTION 3.
Correct answer: A (see Treatment )
- QUESTION 4.
Correct answer: B (see Clinical Presentation )
- QUESTION 5.
Correct answer: A (see Pathophysiology )
Nonoperative Rehabilitation of Medial Collateral Ligament Injuries
- Robert J. Bradbury, BS, PT, OCS
- Michael J. Battaglia, MD
- •
Protect healing tissues
- •
Reduce/control edema
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Regain/maintain mobility and strength
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Maintain endurance
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Safe return to sports activities
- •
Medial collateral ligament (MCL) injuries of the knee are one of the most common injuries in sports and occur either in noncontact (pivoting) or, commonly, in contact sports caused by a direct blow to the lateral knee that results in valgus stress.
- •
Surgical reconstruction is almost never required, and therefore both accurate initial diagnosis and grading of the injury are critical prognostic factors in predicting return to play.
- •
Return to play can be recommended fairly early in grade I or II injuries and with treatment and bracing for up to 8 weeks in grade III tears.
- •
A coordinated treatment plan developed by the physician and therapist will allow the athlete to have realistic expectations for progress.
Phase I (weeks 0 to 2)
Protection
- •
Crutches as needed to minimize gait deviations and weightbearing as tolerated
- •
Bilateral hinged brace, 0° to 30°
- •
Grade I injuries typically do not require any bracing, because there is no joint laxity associated with this injury.
- •
Grades II and III injuries do involve varying degrees of joint laxity and need to be protected during the initial phases of healing.
- •
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) | PHASE IV (weeks 8 to 12) |
|---|---|---|---|
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|
|
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) |
|---|---|---|
|
|
|
Management of Pain and Swelling
- •
R est, I ce, C ompression, E levation (RICE)
- •
Ultrasound: Nonthermal effects of ultrasound are most beneficial for tissue healing, so it is recommended that lower-duty cycles (i.e., pulsed ultrasound) be used for the treatment of acute injuries. (Daniel Lorenz, course notes for “Thermal Agents in Rehabilitation: Evidence-Based Update,” 2010)
- •
Electrical stimulation
- •
Transcutaneous electrical nerve stimulation (TENS)
- •
TENS provides temporary pain relief
- •
- •
Interferential current (IFC)
- •
IFC provides pain relief and also has antiinflammatory and edema reduction properties
- •
- •
High-voltage pulsed electrical stimulation (HVPS)
- •
HVPS promotes soft-tissue healing
- •
- •
Neuromuscular electrical stimulation (NMES)
- •
NMES may be used for quadriceps facilitation if the athlete has a decreased ability to fully contract the quadriceps musculature.
- •
- •
It is recommended that IFC or HVPS be used for treatment during this initial phase of rehabilitation.
- •
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Patellofemoral mobilizations
Soft-Tissue Techniques
- •
Gentle effleurage massage for edema reduction
- •
Cross-friction massage over healing tissue to promote tissue healing and optimize collagen organization
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Passive/active/active-assisted range of motion (PROM/AAROM/AROM) to tolerance
- •
Hamstrings
- •
Quadriceps
- •
Gluteals
- •
Hip adductors and abductors
- •
Gastroc-soleus
- •
The ability to fully stretch the musculotendinous unit will depend on the available ROM at the knee. As an example, if knee flexion ROM is limited caused by pain or to protect the healing MCL, the quadriceps muscles will not be able to be fully stretched.
- •
The MCL complex is reinforced by the pes anserine and by direct attachments to the vastus medialis and semimembranosus tendons. It can be hypothesized that placing excess tension through these tendons may lead to increased strain on the healing MCL complex.
Other Therapeutic Exercises
- •
Total body strengthening (TBS)
- •
The athlete should continue with the usual exercise regimen as much as possible to maintain conditioning for the specific sport as well as to promote strength in noninjured limbs.
- •
Some lower-body training may have to be limited or modified. Trunk strength and core stabilization exercises should continue with planks in the frontal and sagittal planes, abdominal exercises, and spinal extensor strengthening.
- •
- •
Total arm strengthening (TAS)
- •
Upper-body training should continue with minimal restrictions. Care should be taken to protect the injured knee in the gym with careful positioning or use of a brace, using parameters based on grade of injury.
- •
- •
Total leg strengthening (TLS)
- •
Lower-body strengthening will be limited, depending on the severity of the injury.
- •
Full lower-body strengthening workouts should be resumed as quickly as possible following grade I injuries.
- •
Protective bracing should be used with weight training initially following grades II and III injuries. As ROM improves and the athlete demonstrates good functional stability with single-limb stance activities on the involved lower-extremity, the brace may be discontinued during workouts.
- •
Safe closed-chain strengthening exercises of the contralateral limb should be initiated immediately following injury.
- •
- •
Activation of Primary Muscles Involved
- •
The quadriceps muscles, hamstrings, and gastocnemius directly affect the knee joint.
- •
Exercises to facilitate and maintain strength of these muscle groups are outlined below under open and closed kinetic chain (OKC/CKC) exercises.
- •
In addition to maintaining strength of the local musculature, it is imperative to maintain proximal strength and core stability. Weakness at the hip, specifically weakness of the hip extensors and abductors, creates unwanted joint reaction forces at the knee with weightbearing activities. During dynamic activities, weakness in hip abduction causes the knee to fall into a position of excess valgus, potentially placing excessive loads across the MCL.
Sensorimotor Exercises
- •
Single-limb stance (SLS) activities
- •
SLS should initially be performed on a stable surface with the eyes open. Once this is performed with ease, closing the eyes will eliminate visual input and provide greater challenge to the proprioception system.
- •
SLS activities can be progressed by creating perturbations during the activity. Initially, these perturbations may be created by having the athlete perform an activity, such as upper movements with resistance or movements of the contralateral leg while standing on the injured leg ( Figure 34-10 ). Perturbations may also be created manually by the therapist.
FIGURE 34-10
Single-limb stance with upper extremity perturbation.
- •
Once the athlete demonstrates good dynamic control on a stable surface, these activities should be performed on an unstable surface such as Biomechanical Ankle Platform System (BAPS) board, an air disc, or foam mat, or Bosu ball ( Figure 34-11 ).
FIGURE 34-11
Single-limb stance on air disc for proprioception training.
- •
OKC and CKC Exercises
- •
OKC
- •
Three-way leg raises: Straight-leg raise (SLR), abduction, and extension. No adduction as this will place a valgus stress across the knee.
- •
Short arc quadriceps/terminal knee extension (TKE): Full TKE may be restricted initially following grade III injuries.
- •
Prone and standing hamstring curls
- •
- •
CKC
- •
Three-way leg raises with tubing/exercise band: abduction, extension, flexion ( Figures 34-12 to 34-14 )
FIGURE 34-12
Closed kinetic chain extension. Involved lower extremity is the stance limb. Movement of the opposite lower extremity creates perturbations for the stance limb.
FIGURE 34-13
Closed kinetic chain flexion. Involved limb is weightbearing.
FIGURE 34-14
Closed kinetic chain abduction. Involved limb is the stance limb.
- •
Minisquats ( Figure 34-15 )
FIGURE 34-15
Forward stepdown.
- •
Leg press
- •
Step-ups/step-downs ( Figure 34-16 )
FIGURE 34-16
Minisquat with resisted abduction.
- •
Lunges ( Figure 34-17 )
FIGURE 34-17
Lunge with resisted abduction.
- •
Heel raises
- •
Lateral steps with exercise band
- •
Lateral steps with squat (with band)
- •
Bridges/Swiss ball bridges
- •
Eccentric hamstrings
- •
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Strengthening exercises should be performed as noted above during Phase I of MCL rehabilitation.
- •
Muscular endurance training can be achieved with high repetitions during exercise and use of stationary cycling (when ROM allows) or an elliptical trainer.
- •
Power training should not be undertaken during Phase I.
Neuromuscular Dynamic Stability Exercises
- •
See Sensorimotor Exercises above
Functional Exercises
- •
Single-limb stance progression as outlined above
- •
Step-up/step-down
- •
Partial squats
- •
Lunges ( Figure 34-18 )
FIGURE 34-18
Lunge with upper-extremity resisted diagonal, perturbations created with upper-extremity movement.
Sport-Specific Exercises
- •
Functional exercises can be performed or modified as needed to match the athlete’s sport-specific needs.
Milestones for Progression to the Next Phase
- •
Full ROM with minimal to no pain
- •
Restoration of normal gait pattern
Phase II (weeks 2 to 4)
Protection
- •
Crutches as needed (wean as able): Use of crutches should be discontinued for injuries of all severities, and gait pattern should normal by 4 weeks postinjury.
- •
Bracing may be continued as needed. If continued bracing is required, full ROM should be allowed. Bracing is often an individual choice with MCL injuries, and continued use of a brace depends on the athlete’s sport, position, and mobility required. For example, in football, a lineman will likely continue protective bracing, whereas receivers or defensive backs may choose not to wear a brace when returning to sports activity.
Management of Pain and Swelling
- •
Use of modalities can be continued as needed for pain control and decreased inflammation.
Techniques for Progressive Increase in ROM
Manual Therapy Techniques
- •
Patellofemoral mobilizations as needed
- •
Tibiofemoral mobilizations may be used at this stage if there is persistent stiffness in end-range flexion or extension.
- •
Anterior glides of the tibia on the femur will assist in improving knee-extension ROM.
- •
Posterior glides will improve flexion ROM in cases of persistent joint stiffness.
- •
Caution should be used with grade III injuries, as tibiofemoral mobilizations may create unwanted strain to other ligaments, such as the anterior cruciate ligament (ACL), especially if mobilizations are performed in slight flexion.
Soft-Tissue Techniques
- •
Retrograde effleurage should continue in cases of persistent edema.
- •
Cross-friction massage should be continued over the injured portion of the ligament to promote ideal collagen construction and repair.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Flexibility exercises for the lower extremity should be performed without limitations, and ROM should be increased to equal that of the contralateral limb.
- •
In cases of grade III injuries adductor stretching may need to be progressed more slowly, and full ROM may not be achieved until Phase III of rehabilitation. Pain is to be used as a guide.
Other Therapeutic Exercises
- •
TBS: During Phase II, TBS and core training should return to full level for grades I and II injuries. For those with grade III injuries, TBS should continue to be gradually progressed to the athlete’s normal level of training with use of a brace if needed.
- •
TAS should be performed without restrictions for all grades of injury.
- •
TLS should be returned to the athlete’s normal level of training. Deep squats, lunges, or full-range leg presses should be avoided in cases of grade III injuries.
Activation of Primary Muscles Involved
- •
Exercises that specifically affect the muscles that perform knee motions should be progressed to normal levels. See Phase I above for specific exercises.
Sensorimotor Exercises
- •
SLS stance activities should be progressed at this stage, with perturbations increasing in amplitude and/or frequency.
- •
As discussed under this topic for Phase I of rehabilitation, perturbations may be created manually by the therapist, by the athlete via movements of other limbs, or with the use of exercise bands, tubing, or resistance cables.
- •
OKC and CKC Exercises
- •
OKC exercises should continue as outlined under Phase I.
- •
Adduction SLR may be added for all athletes.
- •
For athletes with grade III injuries, any weight added for adduction SLR should be placed proximal to the knee.
- •
Full-ROM quadriceps isotonic exercises may also be initiated at this stage.
- •
CKC exercises may be performed with larger ROM as pain allows.
- •
Flexion angles greater than 90° should be avoided in cases of grade III injuries.
- •
Exercises should be performed without use of protective bracing if the athlete demonstrates normal functional stability and full confidence with CKC activities.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Clean
- •
Snatch
- •
Push–pull
- •
Squats
- •
Initiate running program (grade II and III injuries)
- •
Strengthening exercises should be progressed to normal levels during this phase of rehabilitation.
- •
Resistance and speed of movement should be increased to tolerance.
- •
To maintain and/or improve muscular endurance, aerobic-type exercises can be progressed by increasing resistance, velocity, and/or duration.
Neuromuscular Dynamic Stability Exercises
- •
Plyometrics
- •
Bilateral hopping on level surface
- •
During plyometric and jumping activities, close attention must be paid to landing mechanics to ensure proper lower-extremity alignment to avoid excessive valgus forces through the knee. Sufficient hip and core strength is required to maintain proper positioning during eccentric landing. Foot and ankle mechanics must also be assessed for excessive pronation with landing, as this mechanical fault may lead to excessive valgus stress at the knee.
- •
Functional Exercises
- •
Functional exercises should be continued as listed under Phase I and progressed as the athlete tolerates. These exercises should become more sport-specific as tolerance improves.
- •
Athletes with grade II injuries are likely ready or close to ready to return to full sports activity toward the end of Phase II, so the program will consist mostly of sport-specific exercises.
- •
For athletes with more severe injuries, lower-level, uniplanar functional exercises may have to be continued for a longer period of time.
Sport-Specific Exercises
- •
See Sensorimotor Exercises and Functional Exercise sections above.
Milestones for Progression to the Next Phase
- •
Full ROM without pain
- •
No increase in swelling with light activity
- •
No functional instability
Phase III (weeks 4 to 8)
Protection
- •
Crutches should no longer be used.
- •
Bracing may be continued based on individual preferences.
Management of Pain and Swelling
- •
Ice and IFC electrical stimulation may be continued in cases of persistent edema.
- •
All other modalities should be discontinued during this phase of recovery.
Techniques for Progressive Increase in ROM
Manual Therapy Techniques
- •
Tibiofemoral mobilizations
- •
Anterior or posterior glides may be used at end ranges of physiologic ROM if there is any joint stiffness.
- •
Rotational mobilizations may be required to restore concomitant external rotation at TKE or internal rotation with end-range flexion.
- •
Soft-Tissue Techniques
- •
Cross-friction massage may be continued over the healing ligament and should be performed directly over the site of the tear.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Lower-extremity stretching should continue without restrictions and at this point should be at preinjury levels.
- •
Proprioceptive neuromuscular facilitation (PNF) may be used for dynamic stretching. PNF is also facilitatory and will improve neuromuscular responses to dynamic loads across the lower extremity. Hip and knee patterns are most effective in cases of injuries to the knee.
- •
Dynamic stretching or warmup should be performed prior to sport activities. The Sportmetrics warm-up for injury prevention and performance program and Santa Monica sports medicine research foundation prevent injury, enhance performance are good examples of a thorough dynamic stretching routine for the lower extremities.
Other Therapeutic Exercises
- •
At this stage of recovery, exercise regimens should be at preinjury levels for athletes with any severity level of isolated MCL injury.
- •
TBS, TAS, and TLS exercises can be performed without restrictions; however, athletes with more severe injuries may wish to continue to wear a brace when performing dynamic multiplanar activities.
Activation of Primary Muscles Involved
- •
Training of local musculature is now unrestricted, and all exercises should be performed to the athlete’s tolerance and at full speed if not already done.
Sensorimotor Exercises
- •
Sensorimotor exercises should be performed to tolerance with use of protective bracing if needed.
OKC and CKC Exercises
- •
Exercise regimens should return to preinjury levels during this phase of rehabilitation.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
As stated under the previous topic, at this point following injury, there are no restrictions on exercise.
Neuromuscular Dynamic Stability Exercises
- •
Dynamic stability exercises should continue to be progressed to meet the athlete’s sport-specific demands.
Plyometrics
- •
Box jumps
- •
Zig-zag hops
- •
Squat jumps
- •
Split jumps
- •
Plyometric exercises can be progressed as the athlete tolerates. Jumping activities may also be progressed to unilateral take-offs and landings with the involved lower extremity.
Functional Exercises
- •
Running and agility training should continue to be progressed.
- •
Agility drills should be specific to the athlete’s sport.
- •
Some athletes with grade III injuries will return to live practice activities at this stage, and most athletes with grade II MCL tears will already have returned to sports participation.
Sport-Specific Exercises
- •
See above.
Milestones for Progression to the Next Phase
- •
Successful completion of a running program
- •
90% of normal strength in isokinetic testing or passing grade on functional testing
Phase IV (weeks 8 to 12)
Protection
- •
Protective bracing is no longer required; however, some athletes will continue to use a hinged knee brace.
- •
In cases where external support is needed but use of a bulky brace is not practical, tape may be applied to provide support to the medial knee. The reader is referred to athletic training textbooks and taping manuals for further information on taping techniques.
Management of Pain and Swelling
- •
Ice can continue to be applied after exercise as needed.
- •
IFC electrical stimulation may be used in cases of edema following activity.
Techniques for Progressive Increase in ROM
Manual Therapy and Soft-Tissue Techniques
- •
Manual therapy and soft-tissue techniques are no longer required and should be discontinued.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
The athlete is now able to perform their normal stretching routine and may do so independently or with a trainer.
Other Therapeutic Exercises
- •
There are no restrictions to exercise.
- •
Exercise programs should return to preinjury levels, and the athlete may fully participate in team’s regular training routine.
- •
The athlete should return to full sports participation during this stage of rehabilitation.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Surgical treatment is not indicated in cases of isolated grade I or II MCL injuries.
- •
It has been demonstrated that joint laxity may persist following tissue healing in grade III injuries. Despite persistent joint laxity, functional outcomes are similar with operative vs. conservative care. The authors choose to treat all isolated grade III injuries nonoperatively; however, surgical repair may be required in cases of chronic instability or persistent pain.
- •
Surgery is required in cases of combined injuries. Treatment of combined injuries is beyond the scope of this chapter and thus is not discussed here.
Milestones and Criteria-Based Rehabilitation Guidelines to Progress to Sport-Specific Training and Conditioning
- •
As discussed under Phase III, the athlete must successfully complete a running program without increased pain, swelling, or sense of instability.
- •
Isokinetic strength testing
- •
In order for the athlete to return to participation in his or her sport, they either must be at 90% of normal or of the contralateral limb or they must achieve a passing score with functional testing
- •
- •
Return to sport participation should be graded and incremental. After demonstrating readiness to progress to sports activity, the athlete should participate in practice drills. If participation in basic practice drills is successful, the athlete may participate in team scrimmage activities. If there is no adverse reaction with participation in scrimmage, the athlete may return to full competition.
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Progression to performance enhancement should occur during Phase III or IV of rehabilitation. At this stage of recovery, physiologic tissue repair is stable, ROM should be full, and strength should be normal. Therapy sessions may continue less frequently, as needed, to monitor the athlete’s status and progress.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Performance enhancement can be achieved by progressing agility activities, such as T-runs, side-step drills, or agility ladder exercises. Performance enhancement activities should be specific to the athlete’s sport-specific demands. Speed, agility, and power training should be employed and tailored to match the athlete’s needs.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Normal strength (isokinetic)
- •
Completion of running and/or agility program
- •
Passing score on functional testing
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is the most effective type of electrical stimulation to control pain and edema following an acute MCL injury?
- A.
Neuromuscular electrical stimulation (NMES)
- B.
Interferential current (IFC)
- C.
High-voltage pulsed electrical stimulation (HVPS)
- D.
B and C
- A.
- QUESTION 2.
Which of the following is not an appropriate OKC exercise to perform during Phase I of rehabilitation following an acute MCL injury?
- A.
Straight-leg raise
- B.
Hip adduction
- C.
Short-arc knee extensions
- D.
Prone hamstring curls
- A.
- QUESTION 3.
Single-limb stance activities may be performed with perturbations created by the athlete or therapist. These activities can be progressed by increasing which of the following?
- A.
Amplitude and/or frequency
- B.
Amplitude only
- C.
Frequency only
- D.
None of the above
- A.
- QUESTION 4.
An athlete must meet which of the following milestones to return to sport following an isolated MCL injury of the knee?
- A.
Normal strength, completion of a running program, passing score on a functional testing protocol
- B.
Full ROM, normal strength, able to run without pain
- C.
Normal gait pattern, passing score with functional testing, no joint laxity
- D.
No functional instability, normal strength, completion of a running program
- A.
- QUESTION 5.
MCL injuries are treated nonoperatively in most cases, but surgical intervention may be required for which of the following reasons?
- A.
Persistent pain
- B.
Chronic instability
- C.
Combined injuries
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Phase I : Treatment for Pain and/or Swelling)
- QUESTION 2.
Correct answer: B (see Phase I : OKC and CKC exercises)
- QUESTION 3.
Correct answer: A (see Phase II : Sensorimotor Exercises)
- QUESTION 4.
Correct answer: A (see Phase IV )
- QUESTION 5.
Correct answer: D (see Criteria for Abandoning Rehabilitation)
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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