Rehabilitation of Rehabilitation of medial collateral medial collateral

ligamentligamentDr. Ali Abd El-Monsif ThabetDr. Ali Abd El-Monsif Thabet

Valgus stress testing of the Valgus stress testing of the MCL MCL

The patient is in the supine position with The patient is in the supine position with the knee flexed 25-30 The examiner the knee flexed 25-30 The examiner places one hand on the lateral knee and places one hand on the lateral knee and grasps the medial ankle with the other grasps the medial ankle with the other hand. Then the knee is abducted. Pain and hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or excessive laxity indicate stretching or tearing of the MCL. tearing of the MCL.

Perform the same technique as above Perform the same technique as above with the knee extended. If excessive knee with the knee extended. If excessive knee joint laxity and pain are still noted, injury joint laxity and pain are still noted, injury to the anterior cruciate ligament also may to the anterior cruciate ligament also may be present.be present.

Apley compression testApley compression test, the , the patient is prone, and the examiner patient is prone, and the examiner stabilizes the patient's thigh. The stabilizes the patient's thigh. The examiner flexes the patient's knee examiner flexes the patient's knee 90° then rotates the lower leg while 90° then rotates the lower leg while pulling it away from the knee pulling it away from the knee (distraction). Pain during distraction (distraction). Pain during distraction and knee rotation suggests a and knee rotation suggests a ligamentous or joint capsule injury.ligamentous or joint capsule injury.

Stress X-raysStress X-rays may be useful. The X- may be useful. The X-rays will show a widening of the rays will show a widening of the joint space on that side if instability joint space on that side if instability is present. is present.

Magnetic resonance imagingMagnetic resonance imaging (MRI) (MRI) may be ordered if there is evidence may be ordered if there is evidence that multiple injuries have occurred,that multiple injuries have occurred,

Rehabilitation of MCL Rehabilitation of MCL injury injury

Goals:Goals: 1) Resolve pain1) Resolve pain 2) Gain full ROM2) Gain full ROM 3) Improve muscular strength and 3) Improve muscular strength and

enduranceendurance 4) Normalize gait pattern without assistive 4) Normalize gait pattern without assistive

devicedevice 5) Return to sports activities. Functional 5) Return to sports activities. Functional

brace may be warranted to provide medial brace may be warranted to provide medial and lateral knee support.and lateral knee support.

Phase 1: Immediately following injury

1- Apply ice as soon as possible following injury to reduce pain and any swelling . Apply ice for 15 minutes every 2 hours for the first day. The frequency can be gradually reduced to 3 times a day 2- Apply a compression bandage to reduce swelling 3- Rest from aggravating activities. 4- Providing there is no pain, try to walk normally without a brace/support 5- Start gentle stretching for the hamstrings and quadriceps, providing there is no pain 6- Try the flexion/extension exercises 7- As soon as pain allows begin static strengthening exercises. If possible dynamic strengthening exercises for quadriceps and hamstring muscles

Phase 2: 1 week Phase 2: 1 week

•Aims:Aims: 1-Eliminate any swelling completely,1-Eliminate any swelling completely, 2- regain full range of motion,2- regain full range of motion, 3- progress strengthening exercises 3- progress strengthening exercises

•Duration:Duration: 1 week 1 week

Phase 2: 1 week

1- Apply cold therapy and compression 3 times a day for 15 minutes, particularly following exercise or rehabilitation exercises.2- Continue with stretching and strengthening exercises from phase 1. 3- In addition include half squats, step-ups, hip raises and hip strengthening exercises and single leg calf raises. 4- Cross friction massage on alternate days. 5- Maintain aerobic fitness with cycling, stepping machine and gentle jogging (no sudden changes of direction though) 6- The athlete may be able to jog slowly as long as it is not painful

Phase 3: 2 weeks Phase 3: 2 weeks

•Aims:Aims: 1- Maintain full range of motion, 1- Maintain full range of motion, 2- equal strength of both legs,2- equal strength of both legs, 3- return to running and some sports 3- return to running and some sports specific training specific training

•Duration:Duration: 2 weeks 2 weeks

Phase 3: 2 weeks

1- Continue with sports massage techniques every 3 days 2- Continue with stretching exercises 3- Build on dynamic strengthening exercises such as leg extension and leg curls exercises4- Increase the intensity / weight lifted and number of repetitions 5- In addition to straight running, start to include sideways and backwards running, increasing speed to sprinting and changing direction drills

Phase 4: After 4 weeks Phase 4: After 4 weeks

•Aims:Aims: To return to full sports specific training and To return to full sports specific training and competition competition

•Duration:Duration: 3 to 6 weeks 3 to 6 weeks

Phase 4: After 4 weeks

1- Continue with strength training as above but start to include hopping and bounding exercises

2- The athlete should now be ready to gradually return to full sports specific training and then competition

Grade 2 or 3 Sprain:Grade 2 or 3 Sprain: For a grade 2 and particularly 3 For a grade 2 and particularly 3

sprain it is important that the ends sprain it is important that the ends of the ligament are protected and of the ligament are protected and left to heal without continually being left to heal without continually being disrupted. The rehabilitation disrupted. The rehabilitation guidelines for a grade 2 or 3 medial guidelines for a grade 2 or 3 medial ligament sprain (more severe) can ligament sprain (more severe) can be split into 4 phases:be split into 4 phases:

Phase 1: Immediately following injuryPhase 1: Immediately following injury

•AimsAims 1- Control swelling, 1- Control swelling, 2- maintain ability to straighten the leg 2- maintain ability to straighten the leg 3- bend the knee to more than 90 degrees, 3- bend the knee to more than 90 degrees, 4- begin strengthening exercises. 4- begin strengthening exercises.

•DurationDuration - 4 weeks. - 4 weeks.

Phase 1: Immediately following injury

1- Rest from all painful activities. Wear a hinged knee brace locked from 0 to 90 degrees.2- Ambulation with crutches. - non weight bearing to start with, then partial weight bearing (week 2) and by end of week 4 aim to be walking normally. 3- Apply cold therapy and compression. Apply ice / cold therapy for 15 to 20 minutes every 2 hours for the first 2 days and gradually reduce the frequency to 3 times a day. 4- ROM exercises Ankle ROM exercises Active knee flexion to 90 degrees knee extension, pain free stretches for the hamstrings, quads and calf muscles in particular. 5- Static quads and hamstring exercises, straight leg raising : prone, supine, abduction (NO ADDUCTION), double leg calf raises. 6- Oral NSAIDs.

Phase 2: Following week 4Phase 2: Following week 4

•AimsAims – – 1- Eliminate swelling, 1- Eliminate swelling, 2- full weight bearing on the injured knee2- full weight bearing on the injured knee 3- full range of motion3- full range of motion 4- injured leg almost as strong as the good one.4- injured leg almost as strong as the good one. 5- Proprioceptive training 5- Proprioceptive training

•DurationDuration - 2 weeks. - 2 weeks.

Phase 2: Following week 41- Continue with cold therapy and compression to eliminate swelling, particularly following exercises.2- Progress knee flexion and extension to full ROM3- Strengthening exercises - static quadriceps contractions, half squats (both legs), step ups, hip raises, Begin Stair Climber activities hamstring curls and single leg calf raises.4- Begin progressive resistive exercises 1 to 10 lbs.5- Proprioceptive training 6- Begin bicycling when ROM is sufficient . Stationary bicycle riding with seat as low as tolerated7- Full weight bearing, no crutches.

Phase 3: Following week 6Phase 3: Following week 6

•AimsAims – – 1- Full strength1- Full strength 2- return to light jogging and 2- return to light jogging and 3- By week 10 from injury, return to 3- By week 10 from injury, return to sports specific exercises. sports specific exercises.

•DurationDuration 4 weeks. 4 weeks.

Phase 3: Following week 6 1- Continue with cold therapy following training sessions2- Sports massage techniques to the ligament 2 to 3 times a weeks. 3- Strengthening exercises as above increasing intensity and plyometric (hopping and bounding) exercises. 4- Slide Board exercises5- Allow functional activities , after week 6, no sooner begin to run - straight-ahead, after week eight begin to run sideways and backwards so by week 10 the athlete is able to begin to change direction at speed figure-eight running.. 6- For footballers, kicking may now be possible.

Phase 4: Following week 10Phase 4: Following week 10

•AimsAims – – 1- Return to full sports specific training 1- Return to full sports specific training and competitionand competition

•DurationDuration - 2 to 4 weeks. - 2 to 4 weeks.

Phase 4: Following week 10

•Gradually bring into training more and more sports specific drills, starting one contact competition, and gradually introduce them to the demands of competition

Safely return to your sport Safely return to your sport or activityor activity Starting from the top of the list and progressing Starting from the top of the list and progressing

to the end, each of the following is true: to the end, each of the following is true: Your injured knee can be fully straightened and Your injured knee can be fully straightened and

bent without pain. bent without pain. Your knee and leg have regained normal strength Your knee and leg have regained normal strength

compared to the uninjured knee and leg. compared to the uninjured knee and leg. Your knee is not swollen. Your knee is not swollen. You are able to jog straight ahead without You are able to jog straight ahead without

limping. limping. You are able to sprint straight ahead without You are able to sprint straight ahead without

limping. limping. You are able to do 45-degree cuts. You are able to do 45-degree cuts. You are able to do 90-degree cuts. You are able to do 90-degree cuts. You are able to do 20-yard figure-of-eight runs. You are able to do 20-yard figure-of-eight runs. You are able to do 10-yard figure-of-eight runs. You are able to do 10-yard figure-of-eight runs. You are able to jump on both legs without pain You are able to jump on both legs without pain

and jump on the injured leg without pain. and jump on the injured leg without pain.