PHYSIOTHERAPY TREATMENT OF MCL INJURIES
MECHANISM OF INJURY
The MCL is often injured as a result of a valgus force or combined valgus and external rotation forces. This injury can be caused by an external force such as a blow to the lateral aspect of the knee or fall to the side with the ipsilateral leg kept firmly fixed. Injury to the MCL is often associated with contact sports such as football in which there are frequent blows to the lateral side of the knee. The deep portion of the MCL attaches to the periphery of the medial meniscus, and this firm attachment can often cause a peripheral tear due to a valgus force.
TREATMENT OF MCL INJURIES
The literature suggests that certain conditions must be met before optimal healing of the MCL can occur:
1) The torn ligament fibers must remain in continuity or be confined within a well-vascularized soft tissue bed;
2) Controlled, functional stresses help stimulate and direct the healing process and
3) There must be some protection against harmful stresses during collagen synthesis and the remodelling or maturation phases. Thus we have to come to adopt the following criteria for surgical repair of the medial collateral ligament;
1) Failed conservative non-operative treatment.
2) Complete rupture of the MCL with concomitant anterior cruciate ligament instability. The severity of injury determined on physical examination determines the rehabilitation course and duration. The rehabilitation program is the same.
3) MCL sprains. However, the duration of treatment in each phase may be extended. The non-operative rehabilitation of MCL sprains is based on five basic rehabilitation of MCL sprains is based on four basic rehabilitation principles:
- The effects of immobilization must be minimized.
- Never over stress healing tissue.
- The patient must fulfil specific criteria to progress from stage to stage.
- The program must be adaptable to each patient.
With these basic principles in mind, our rehabilitation program is based on early motion, early weight bearing, early control of pain and effusion, and retardation of muscle atrophy (especially the quadriceps).
The program is divided into four phases: maximal protection, moderate protection, minimal protection phase and return to activity/maintenance.
In the first phase, the maximal protection phase; goals are to
1) Achieve early protected range of motion
2) Prevent quadricep atrophy, and
3) Decrease pain and effusion. The treatment consists of ice, compression, elevation and a brace that will allow a full non-painful range of motion.
In addition, crutches are used for the first few days for protection and weight bearing as tolerated. Immediately following the injury, aggressive supervised physical therapy is initiated immediately retarding muscle atrophy and restoring full range of motion.
Electrical muscular stimulation is used to re-educate the quadriceps muscle and also to retard quadriceps muscular atrophy.
A range of motion exercises is initiated immediately using a passive and active-assisted range of motion and then progressing to active range of motion.
The purpose of the range of motion exercises is to re-establish normal range of motion and also to allow proper alignment of newly synthesized collagen tissue.
This ensures strong elastic scar formation. Other advantages to early motion include retarding capsular contractures, maintaining articular cartilage nutrition, and decreasing disuse effects. By the end of the first week, more aggressive strengthening exercises such as mini squats, leg press, and quadriceps eccentrics can be initiated. The patient who has a nearly full range of motion, minimal tenderness, and no change in instability or swelling can progress to phase 2, the moderate protection phase.
The goals in this phase are to regain the remaining range of motion, achieved unrestricted ambulation without assistive devices, and restore muscular strength, power and endurance. The emphasis of this phase is strengthening. More aggressive strengthening exercises are begun ( Isokinetic, heavy progressive resisted exercise, and also a pool running program). In addition, flexibility and Proprioceptive training are emphasized. The progressive resisted exercise program for knee extension must be monitored for patella femoral joint irritation, crepitation and pain. If this occurs the program must be modified to a range that is pain-free and crepitus free to prevent further articular cartilage breakdown.
The next phase of the program is the minimal protection phase. In this phase, the goals are to increase strength, power and endurance and to improve neuromuscular coordination. The emphasis is now on functional return and the exercises are geared toward function. A running program is initiated as well as high-speed exercise.
Agility drills, balance drills, and endurance bouts are used. In this phase, we emphasize functional exercises in the closed kinetic chain. The final phase, return to activity and maintenance, is initiated once the patient fulfils specific criteria.
The patient must present with no pain or tenderness, no instability, an Isokinetic test that fulfils specific criteria, and a satisfactory clinical examination. An athlete who obtains these parameters can return to sports training and begin a maintenance program.