1. Who is this?

2. What Happened?

3. How much rain?

4. Medial Collateral Ligament

5. 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.

7. One of the most common knee ligaments injuries in sports

8. 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

10. Dynamic stabilizers of medial knee Semimembranous complex Quadriceps Pes anserine

11. 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.

14. 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.

15. Symptoms 67% of patients with complete tear could walk into the office unaided Pain was worse with incomplete rather than complete

16. X-rays Anteroposterior Lateral Merchant view

19. 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.

20. 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.

21. 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.

22. MCL injuries Isolated Combined with other injuries

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

25. 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

26. Rehabilitation Early protected ROM Strengthening Laxity of knee in extension – red flag

27. 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

28. 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.

29. Phase 1: Week 1-2 Range of Motion: Passive ROM, No limits Aggressive Patella mobility Ankle pumps Gastroc-soleus stretches Wall slides Heel slides

30. 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

31. Balance Training: Weight shifts (side/side, fwd/bkwd) Single leg balance Plyotoss

32. Weight Bearing: Wt bearing as tolerated Crutches until quad control is gained, then discontinued

33. Bicycle: May begin when 110 ° flex is reached

34. Modalities: E-stim/biofeedback as needed Ice 15-20 minutes with knee at 0 ° ext

35. 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

36. Goals for Phase 1: ROM

37. Phase 2: Week 3 Range of Motion: Passive ROM, No limits Aggressive Patella mobility

38. 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

39. Weight Bearing: Full weight bearing

40. Bicycle: Increase tension

41. Balance Training: Balance board/2 legged Cup walking/hesitation walk Single leg balance Plyotoss

42. Modalities: E-stim/biofeedback as needed Ice 15-20 minutes with knee at 0 ° ext

43. Goals for Phase 2: ROM 0-125 ° Increase muscle strength and endurance Restore proprioception

44. 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

45. Phase 3: Week 4 Range of Motion: Passive ROM, No limits Aggressive Patella mobility

46. 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

47. Weight Bearing: Begin jogging Progress functional agility exercises as tolerated

48. Bicycle: Increase tension

49. Balance Training: Balance board/2 legged Cup walking/hesitation walk Single leg balance Plyotoss

50. Modalities: E-stim/biofeedback as needed Ice 15-20 minutes with knee at 0 ° ext

51. Brace: None

52. Goals for Phase 3: ROM Full Increase muscle strength and endurance Jogging Functional Agility Exercises

53. Phase 4: Week 5-6 Range of Motion: Passive ROM, No limits Aggressive Patella mobility

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

55. Weight Bearing: Functional agility exercises as tolerated Progress to sprinting Progress to sports specific agility drills

56. Bicycle: As needed

57. Balance Training: Steam boats in 4 planes Single leg stance with plyotoss Wobble board balance work-single leg ½ Foam roller work

58. Modalities: E-stim/biofeedback as needed Ice 15-20 minutes with knee at 0 ° ext

59. Goals for Phase 4: ROM Full Increase muscle strength and endurance Sprinting Sport Specific Agility Exercises

60. 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