Summary of Condition
Conservative treatment of MCL injuries has shown to be successful with isolated MCL injuries. More severe, grade III sprains, and combined ligamentous injuries may use conservative treatment, but surgical interventions may be necessary. Here we will discuss the conservative treatment of MCL sprains without surgical intervention.
The major problems associated with MCL sprains that can benefit from PT interventions are:
-pain over the medial aspect of the knee which increases with weight bearing
-swelling
-a feeling of "giving way" during ambulation
-impaired knee ROM
-impaired strength
-impaired proprioception and balance
Guide to PT Practice-Practice Pattern and Suggested Management[1]
http://guidetoptpractice.apta.org/content/current
A ligamentous sprain of the knee can be included in the following practice pattern:
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
expected range of number of visits per episode of care: 3 to 36
Interventions include:
- Therapeutic Exercise: gait training, aquatic programs, balance training, neuromuscular reeducation, strength power and agility training, flexibility exercises
- Manual Therapy: manual traction, massage, mobilization, PROM
- Electrotherapeutic Modalities: EMS electrical muscle stimulation, NEMS neuromuscular electrical stimulation, TENS transcutaneous electrical nerve stimulation, iontophoresis
- Physical Agents and Mechanical Modalities: cryotherapy, hydrotherapy, infrared light, laser, phonophoresis, ultrasound, dry heat, hot packs, paraffin, taping, compression devices, CPM continuous passive motion, traction
- Functional Training: ADLs, IADLs, injury prevention
- Prescription, Application, and Fabrication of Devices and Equipment: assistive devices, orthotics, braces
Treatment[2][3][4]
Physical Therapy treatment can be broken down into 4 phases. Patients progression from one phase to the next should be determined by the physical therapist.
PHASE I
Relieve Pain and Reduce Swelling
- Cryotherapy:preferably, ice massage, as often as possible, before and after exercise sessions.
May apply ice with compression wrap for 20 minutes every 3-4 hours for the first 24-48 hours after injury.
- Hinged brace allowing for non-painful range of motion *further information on brace use is presented under special considerations
- Partial to full weight bearing in brace with crutches as tolerated
- Non-steroidal anti-inflammatory medications (NSAID’s) as prescribed by physician
Improve ROM and increase Strength
Range of motion and Strengthening exercises should be performed 3x per day
Exercises include:
Heel Slides
Isometric Quadriceps Sets
Straight Leg Raises
Standing Knee Flexion, Knee Extension, Hip Flexion, and Terminal Knee Extension (TKE), Seated Isometric Ball Squeezes, Stationary bicycle riding with seat as low as tolerated
Progress to Phase II when Phase I can be completed with little or no discomfort, increase in swelling, or point tenderness.
PHASE II
Increasing Strength and Improving Range
- Continue all strengthening exercises using Progressive Resistance Exercises Principle
- Begin Side Step-Ups with 1 1/2” - 3” step
- Begin static stretching as tolerable.
Progress to Phase III when Phase II can be completed with:No increase in pain or swelling, Normal Gait, and Normal knee stability.
PHASE III
Improving Strength and Progress Functional Activities
- Continue ice after exercise sessions if pain and/or swelling is present.
- Discontinue use of brace for daily activities with physician approval
- Continue SLR PRE’s and add:
Standing sport cord TKE’s,
Leg Press 90° - 0° as tolerated
- Begin walk/jog program on flat, smooth surface
Progress to Phase IV when 50 yard jog can be completed with little or no limping and/or pain.
PHASE IV
Progress Functional Activities and Improve Balance
- Continue PRE’s.
- Progress walk/jog program to include sprints and agility drills, running backwards, Figure 8’s, and Zig-Zag Drills
- Wobble Boards and Bosu Activities
Return to desired activity when:
Phase IV can be completed without pain, swelling, or limp,
Bilateral girth and range of motion measurements are equal,
Strength measurements are 85% of contralateral side, and
Clearance from physician.
Modality Use
- Ultrasound[5]- Ultrasound is often used in conservative management of MCL sprains and is thought to increase blood flow to the area to promote healing and reduce pain. Currently there is insufficient evidence to support the use of ultrasound in humans with MCL sprains although studies on its usefulness in animal models does exist. In a study by Warden SJ et. al. they studied low-intensity pulsed ultrasound in 60 adult rat who had an MCL transected. After 2 weeks of ultrasound intervention, ligaments treated with active low-intensity pulsed ultrasound were 34.2% stronger, 27.0% stiffer, and could absorb 54.4% more energy before failure than could ligaments treated with sham ultrasound.
In a case study by Nobes et. al.[6] ultrasound was used during the treatment of a professional football player with a grade II MCL sprain. For the one subject they used low-intensity pulsed ultrasound, along with a stretching and strengthening program. Their entire program was successful. Randomized Controlled Trials on human subjects are needed to show the effectiveness of ultrasound for patients with MCL tears.
- NMES[7]- Neuromuscular electrical stimulation to the quadriceps may be used in order to reduce muscle atrophy. The use of NMES has been greatly studied in patients with ACL injuries, but evidence does not support the use of NMES for MCL sprain rehabilitation. IN a review of the literature, In patient with ACL injuries NMES with exercise had been found to be more effective at improving quadriceps strength than exercise alone.
Special Instructions
- Prophylactic Knee Bracing[8]: bracing can be used initially for both pain reduction and added stability during weight bearing activities
Bracing can continue to be used when the patient returns to sports in order to prevent re-injury with valgus forces
Bracing recommendations:
grade I sprain- may be donned when participating in contact sports*
grade II sprain- use of long leg brace for ambulation WBAT, first 1-2 weeks post injury. Use of brace is discontinued when pain is reduced and anatomical alignment is accurate
grade II sprain- Immobilization into extension with long leg brace for 3-6 weeks post injury.
*use of knee bracing with return to sport is a controversial issue. In a 2005 study by Najibi et. al., they compared the risk of MCL re-injury in football players who wore prophylactic knee braces during practice and games vs. players who did not wear a brace. All 987 players had a past history of medial collateral ligament sprain. They concluded that wearing a knee brace offered 20-30% protection to the MCL towards a valgus force in contact sports. Despite this finding many players reported negative effects on performance level, increased leg cramping, increasing energy expenditure, restricting agility and increased fatigue of the LE muscles associated with wearing a brace during activity. Due to the negative effects on performance, compliance with brace use has become a challenge in the athletic population.
