MCL - MEDIAL COLLATERAL LIGAMENT
 

 The Injury

The MCL is the large ligament on the inside of the knee that links the femur and the tibia. The injury is usually caused in one of two classic ways. In collision sports it can be damaged when an opponent applies a force to the outside of the leg, just above the knee or the studs get caught in turf and the player tries to turn to the side, away from the planted leg.

 Signs and Symptoms
1st Degree - damage to only a few ligament fibers
There will be pain when the site of the damage is touched. Stressing the ligament (when the knee is slightly bent and the shin is moved inwards in relation to the thigh) is painful; this action is reproduced when standing up from sitting in a chair.
2nd Degree - damage to a more extensive number of ligament fibers - ligament remains intact
The pain is more severe when touched and when the ligament is stressed. There will usually be a swelling of the knee joint, but this may take 24 hours to appear.
3rd Degree - complete rupture of the ligament. 
The pain is excruciating. The knee joint is unstable and activity cannot be continued. There will be a bleed and an inflow of fluid into the joint, but because the capsule that surrounds the joint is also damaged, this fluid may leak out and swelling may not be evident. Because of the force involved in this injury other structures in the knee, such as the meniscus (cartilage) or the ACL can also be damaged.
 

 Treatment

  • In the acute stage of all 3 levels of injury follow the PRICE protocol.
  • In the case of a 1st degree sprain, sports should not be undertaken for about 3 weeks.
  • For 2nd degree sprains, the rehab period will be between 6 and 8 weeks.
  • For a 3rd degree sprain the choice is surgery. The type of reconstruction used will depend on the exact site of the damage and the preference of the surgeon.

 Prevention

  • In the case of someone who has had a previous MCL injury there will always be a weakness, but there are measures that can be taken to help prevent a recurrence. Rehab should include a lot of proprioceptive exercises (these improve the stimuli within the body relating to position and movement), since proprioceptive ability will be affected by the damage to the ligament.

 Rehabilitation

Here we present an example of a rehabilitation program for a with a Grade 2 MCL sprain.
 
Days 1 to 3: Acute Phase
  • Rest from activity
  • Protect the injury site from further damage by using crutches.
  • Apply ice packs or a 'cryo-cuff' device for 20 minutes every 2 hours. This will have pain-relieving effect and also help to control the swelling. Apply a compression bandage to limit the joint swelling. The injured knee should be elevated in order to control and reduce swelling.
  • Oral anti-inflammatory medication may be prescribed by a doctor.
Days 4 to 14: Sub-acute Phase

  • Continue to rest the injured part completely.

  • Continue using crutches. If it is not too painful it may be possible to begin partial weight-bearing while continuing to use the crutches. To further protect the knee a hinged knee brace should be used. This should be locked between minus 10 degrees of extension and 90 degrees of flexion.

  • Once the inflammatory response from the damaged tissue has settled after 3-5 days the ligament begins to lay down scar tissue to repair itself. It is thought that this process can be encouraged with the use of electrotherapy treatments such as ultrasound and pulsed short-wave diathermy.

  • Begin ankle and hip range-of-movement exercises.
Weeks 2 to 4: Early Active Rehabilitation Phase
  • The hinged knee brace should be worn at all times during this phase, and should be set between minus 5 degrees of extension and 110 degrees of flexion. Provided it is not too painful, full weight-bearing should be encouraged and the crutches should be abandoned.
  • A normal gait pattern should be present, with the heel striking the ground first and the toes pushing off for the next step.
  • Isometric quadriceps should be performed in the pain-free range of movement. Straight leg raising should be performed to reinforce quads contractions.
  • Gentle range-of-movement exercises between 90 to 30 degrees of knee flexion.
  • Early proprioception exercises should be initiated.
Weeks 4 to 6: Active Rehabilitation Phase
  • The hinged knee brace should be worn at all times during this phase. There should be no restriction of knee extension or flexion.
  • Range-of-movement exercises should be continued.
  • When range of movement allows, static cycling should be initiated.
  • Isotonic muscle strengthening exercises should be initiated and resistance gradually increased (leg press/squats/ham curls/quads extensions).
  • Continue proprioceptive training.
Weeks 6 to 10: Late Active Rehabilitation Phase
  • The hinged knee brace should be worn, without restriction of knee extension or flexion.
  • Range-of-movement exercises should be continued until full range of extension and flexion is pain free.
  • Isotonic muscle strengthening should continue, so that the affected knee's quads and hamstrings have 90% strength of the unaffected knee.
  • Continue static cycling and increase resistance.
  • Initiate straight line running, gradually increasing the pace. Initiate 'figure-of-eight' running, gradually increasing turns.
  • Begin 'fitter' exercises.
Weeks 10+: Functional Rehabilitation Phase
  • The hinged knee brace should be discarded.
  • Isotonic muscle strengthening should continue.
  • Continue to progress static cycling.
  • Increase speed of running and increase turning angle to 180 degrees.
  • Begin cliniband lateral agility/running exercises and star jumps. Hop distance should be 100% of opposite knee. Kicking the ball/block tackling.

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