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Who is this?. What Happened?. How much rain?. Medial Collateral Ligament. MCL. The medial collateral ligament (MCL) is one of four ligaments that are critical to the stability of the knee joint.

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slide5
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.
anatomy three layers
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
Dynamic stabilizers of medial knee
  • Semimembranous complex
  • Quadriceps
  • Pesanserine
mcl injuries
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
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
Symptoms
  • 67% of patients with complete tear could walk into the office unaided
  • Pain was worse with incomplete rather than complete
x rays
X-rays
  • Anteroposterior
  • Lateral
  • Merchant view
grade i mcl tear
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
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
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 injuries1
MCL injuries
  • Isolated
  • Combined with other injuries
surgery for mcl tears
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
r ehabilitation
Rehabilitation
  • Early protected ROM
  • Strengthening
  • Laxity of knee in extension – red flag
treatment
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
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
Phase 1: Week 1-2Range of Motion:

• Passive ROM, No limits

• Aggressive Patella mobility

• Ankle pumps

• Gastroc-soleus stretches

• Wall slides

• Heel slides

strength
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
Balance Training:

Weight shifts (side/side, fwd/bkwd)

Single leg balance

Plyotoss

weight bearing
Weight Bearing:

Wt bearing as tolerated

Crutches until quad control is gained, then discontinued

bicycle
Bicycle:

May begin when 110 ° flex is reached

modalities
Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

brace
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 2 week 3 range of motion
Phase 2: Week 3Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

strength1
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 bearing1
Weight Bearing:

Full weight bearing

bicycle1
Bicycle:

Increase tension

balance training1
Balance Training:

• Balance board/2 legged

• Cup walking/hesitation walk

• Single leg balance

• Plyotoss

modalities1
Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

goals for phase 2
Goals for Phase 2:

ROM 0-125 °

Increase muscle strength and endurance

Restore proprioception

brace1
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
Phase 3: Week 4

Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

strength2
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 bearing2
Weight Bearing:

Begin jogging

Progress functional agility exercises as tolerated

bicycle2
Bicycle:

Increase tension

balance training2
Balance Training:

• Balance board/2 legged

• Cup walking/hesitation walk

• Single leg balance

• Plyotoss

modalities2
Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

brace2
Brace:

None

goals for phase 3
Goals for Phase 3:

• ROM Full

• Increase muscle strength and endurance

• Jogging

• Functional Agility Exercises

phase 4 week 5 6
Phase 4: Week 5-6

Range of Motion:

Passive ROM, No limits

Aggressive Patella mobility

strength3
Strength:

• Progressive resistance exercises

• Smith press

• Leg press

• Step up, step down

• Stairmaster

• Leg curl

• Multi-hip machine (flex, abd, add)

weight bearing3
Weight Bearing:

Functional agility exercises as tolerated

Progress to sprinting

Progress to sports specific agility drills

bicycle3
Bicycle:

As needed

balance training3
Balance Training:

Steam boats in 4 planes

Single leg stance with plyotoss

Wobble board balance work-single leg

½ Foam roller work

modalities3
Modalities:

E-stim/biofeedback as needed

Ice 15-20 minutes with knee at 0 ° ext

goals for phase 4
Goals for Phase 4:

ROM Full

Increase muscle strength and endurance

Sprinting

Sport Specific Agility Exercises

return to sport
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