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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 motion
Regain 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 1-2
Range 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 3
Range 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