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Medial Collateral Ligament

MCL• The medial collateral ligament

(MCL) is one of four ligaments that are critical to the stability of the knee joint.

• A ligament is made of tough fibrous material and functions to control excessive motion by limiting joint mobility.

• The MCL resists widening of the inside of the joint, or prevents "opening-up" of the knee.

One of the most common knee ligaments injuries in sports

Anatomy -Three layers

• Superficial MCL – primary static stabilizer (under the satorial fascia) – valgus and ER

• Deep MCL – middle third of medial capsule

• Posterior Oblique Ligament – 3 attachments functions with semimembranosus

Dynamic stabilizers of medial knee

• Semimembranous complex

• Quadriceps

• Pes anserine

MCL Injuries

• Because the MCL resists widening of the inside of the knee joint, the ligament is usually injured when the outside of the knee joint is struck.

• This force causes the outside of the knee to buckle, and the inside to widen.

• When the MCL is stretched too far, it is susceptible to tearing and injury. • An injury to the MCL may occur as an isolated injury, or it may be part of a

complex injury to the knee.

• Other ligaments, most commonly the ACL, or the meniscus, may be torn along with a MCL injury.

Symptoms of MCL Tears

• The most common symptom following an MCL injury is pain directly over the ligament.

• Swelling over the torn ligament may appear, and bruising and generalized joint swelling are common 1 to 2 days after the injury.

• In more severe injuries, patients may complain that the knee feels unstable, or feel as though their knee may 'give out' or buckle.

• Symptoms of a MCL injury tend to correlate with the extent of the

injury. MCL injuries are usually graded on a scale of I to III.

Symptoms

• 67% of patients with complete tear could walk into the office unaided

• Pain was worse with incomplete rather than complete

X-rays

• Anteroposterior

• Lateral

• Merchant view

Grade I MCL Tear

• This is an incomplete tear of the MCL. • The tendon is still in continuity, and the symptoms are

usually minimal.

• Patients usually complain of pain with pressure on the MCL, and may be able to return to their sport very quickly.

• Most athletes miss 1-2 weeks of play.

Grade II MCL Tear

• considered incomplete tears of the MCL.

• These patients may complain of instability when attempting to cut or pivot.

• The pain and swelling is more significant, and usually a period of 3-4 weeks of rest is necessary.

Grade III MCL Tear

• A grade III injury is a complete tear of the MCL.

• Patients have significant pain and swelling, and often have difficulty bending the knee.

• Instability, or giving out, is a common finding with grade III MCL tears.

• A knee brace or a knee immobilizer is usually needed for comfort, and healing may take 6 weeks or longer.

MCL injuries

• Isolated

• Combined with other injuries

Knee in 30 degrees of flexion compare to other knee – degree of opening and the end feel

Surgery for MCL Tears:

• Surgery for MCL tears is controversial.

• There are many studies that document successful nonsurgical treatment in nearly all types of MCL injuries.

• patients who complain of persistent knee instability,, surgery is reasonable.

• Some surgeons advocate surgical treatment of grade III MCL tears in elite athletes or in those athletes with multiple ligament injuries in the knee

Rehabilitation

• Early protected ROM

• Strengthening

• Laxity of knee in extension – red flag

Treatment

• Treatment of an MCL tear depends on the severity of the injury.

• Treatment always begins with allowing the pain to subside, beginning work on mobility, followed by strengthening the knee to return to sports and activities.

• Bracing can often be useful for treatment of MCL injuries.

• Fortunately, surgery is not necessary for the majority

Rehabilitation Protocol • MCL injuries who require an early return to high level activity

following injury.

• Goals of rehabilitation are to: Control joint pain, swelling Regain normal knee range of motionRegain a normal gait pattern Regain normal lower extremity strength Regain normal proprioception, balance, and coordination

• The physical therapy is to begin as soon as possible after the injury.

Phase 1: Week 1-2Range of Motion:

• Passive ROM, No limits• Aggressive Patella mobility• Ankle pumps• Gastroc-soleus stretches• Wall slides• Heel slides

Strength:

• Quad sets x 10 minutes• SLR (flex, abd, add)• Multi-hip machine (flex, abd, add)• Mini squats (0-45 °)• Multi-angle isometrics (90-60 °) (No tension on MCL)• When working adductors stress point should be superior to knee• Calf Raises

Balance Training:

Weight shifts (side/side, fwd/bkwd)

Single leg balance

Plyotoss

Weight Bearing:

Wt bearing as tolerated

Crutches until quad control is gained, then discontinued

Bicycle:

May begin when 110 ° flex is reached

Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

Brace:

Wear brace at all times with the following exceptions:

Remove brace to perform ROM and PT activities

Immobilizer is D/C'd at 2 weeks pending physician exam

Goals for Phase 1:

ROM

Phase 2: Week 3Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

Strength:

• Continue remedial strengthening as needed• Leg press• Step up, step down• Stairmaster• Leg curl• Multi-hip machine (flex, abd, add)• When working adductors stress point should be superior to knee• Calf Raises

Weight Bearing:

Full weight bearing

Bicycle:

Increase tension

Balance Training:

• Balance board/2 legged• Cup walking/hesitation walk• Single leg balance• Plyotoss

Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

Goals for Phase 2:

ROM 0-125 °

Increase muscle strength and endurance Restore proprioception

Brace:

Wear brace at all times with the following exceptions:

Remove brace to perform ROM and PT activities

immobilizer is D/C'd at 2 weeks pending physician exam

Phase 3: Week 4

Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

Strength:

• Progressive resistance exercises• Smith press• Leg press• Step up, step down• Stairmaster• Leg curl• Multi-hip machine (flex, abd, add)• When working adductors stress point should be superior to knee• Calf Raises

Weight Bearing:

Begin jogging

Progress functional agility exercises as tolerated

Bicycle:

Increase tension

Balance Training:

• Balance board/2 legged• Cup walking/hesitation walk• Single leg balance• Plyotoss

Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

Brace:

None

Goals for Phase 3:

• ROM Full• Increase muscle strength and endurance• Jogging• Functional Agility Exercises

Phase 4: Week 5-6

Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

Strength:

• Progressive resistance exercises• Smith press• Leg press• Step up, step down• Stairmaster• Leg curl• Multi-hip machine (flex, abd, add)

Weight Bearing:

Functional agility exercises as tolerated

Progress to sprinting

Progress to sports specific agility drills

Bicycle:

•

As needed

Balance Training:

Steam boats in 4 planes

Single leg stance with plyotoss

Wobble board balance work-single leg

½ Foam roller work

Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

Goals for Phase 4:

ROM Full

Increase muscle strength and endurance

Sprinting

Sport Specific Agility Exercises

Return to sport

• is allowed when the patient can perform sprinting and sports specific agility drills in an unrestricted manner.

• This usually occurs at the 5-6 week post-injury date