1. Rehabilitation of medial collateral ligament Dr. Ali Abd El-Monsif Thabet

2. Valgus stress testing of the MCL The patient is in the supine position with the knee flexed 25-30 The examiner places one hand on the lateral knee and grasps the medial ankle with the other hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or tearing of the MCL. The patient is in the supine position with the knee flexed 25-30 The examiner places one hand on the lateral knee and grasps the medial ankle with the other hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or tearing of the MCL. Perform the same technique as above with the knee extended. If excessive knee joint laxity and pain are still noted, injury to the anterior cruciate ligament also may be present. Perform the same technique as above with the knee extended. If excessive knee joint laxity and pain are still noted, injury to the anterior cruciate ligament also may be present.

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

4. Stress X-rays may be useful. The X-rays will show a widening of the joint space on that side if instability is present. Stress X-rays may be useful. The X-rays will show a widening of the joint space on that side if instability is present. Magnetic resonance imaging (MRI) may be ordered if there is evidence that multiple injuries have occurred, Magnetic resonance imaging (MRI) may be ordered if there is evidence that multiple injuries have occurred,

5. Rehabilitation of MCL injury Goals: Goals: 1) Resolve pain 1) Resolve pain 2) Gain full ROM 2) Gain full ROM 3) Improve muscular strength and endurance 3) Improve muscular strength and endurance 4) Normalize gait pattern without assistive device 4) Normalize gait pattern without assistive device 5) Return to sports activities. Functional brace may be warranted to provide medial and lateral knee support. 5) Return to sports activities. Functional brace may be warranted to provide medial and lateral knee support.

6. 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

7. 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: 1 week Duration: 1 week

8. 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

9. 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 specific training 3- return to running and some sports specific training Duration: 2 weeks Duration: 2 weeks

10. 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 exercises 4- 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

11. Phase 4: After 4 weeks Aims: Aims: To return to full sports specific training and competition To return to full sports specific training and competition Duration: 3 to 6 weeks Duration: 3 to 6 weeks

12. 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

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

14. Phase 1: Immediately following injury Aims Aims 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. Duration - 4 weeks. Duration - 4 weeks.

15. 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.

16. Phase 2: Following week 4 Aims – Aims – 1- Eliminate swelling, 1- Eliminate swelling, 2- full weight bearing on the injured knee 2- full weight bearing on the injured knee 3- full range of motion 3- 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 Duration - 2 weeks. Duration - 2 weeks.

17. Phase 2: Following week 4 1- Continue with cold therapy and compression to eliminate swelling, particularly following exercises. 2- Progress knee flexion and extension to full ROM 3- 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 tolerated 7- Full weight bearing, no crutches.

18. Phase 3: Following week 6 Aims – Aims – 1- Full strength 1- 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. Duration 4 weeks. Duration 4 weeks.

19. Phase 3: Following week 6 1- Continue with cold therapy following training sessions 2- 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 exercises 5- 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.

20. Phase 4: Following week 10 Aims – Aims – 1- Return to full sports specific training and competition 1- Return to full sports specific training and competition Duration - 2 to 4 weeks. Duration - 2 to 4 weeks.

21. 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

22. Safely return to your sport or activity Starting from the top of the list and progressing to the end, each of the following is true: Starting from the top of the list and progressing to the end, each of the following is true: Your injured knee can be fully straightened and bent without pain. Your injured knee can be fully straightened and bent without pain. Your knee and leg have regained normal strength compared to the uninjured knee and leg. Your knee and leg have regained normal strength 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 limping. You are able to jog straight ahead without limping. You are able to sprint straight ahead without limping. You are able to sprint straight ahead without 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 and jump on the injured leg without pain. You are able to jump on both legs without pain and jump on the injured leg without pain.