Rehabilitation protocol

The typical features of a conservative post-injury rehabilitation program are

highlighted below:
1. Early management
 NSAIDS are usually not recommended in the first four days post
injury, as they have the ability to delay ligament healing. They are
generally reserved for any ongoing knee-joint inflammation after the
first four days if necessary(21).
 Ice and compression for 20 minutes every hour for the first eight
hours. This is then reduced to 20 minutes every three hours for the
next two days.
 Crutches may be required in grade-II and grade-III injuries until the
athlete feels comfortable walking with a hinged knee brace in situ
(see figure 1).
 Use of electrical muscle stimulation (EMS) in the atrophy mode is
recommended, with exercises such as straight leg raise and inner
range quads or protected weight bearing squats, if EMS is available.
This will maintain quadriceps bulk whilst the athlete is recovering in a
protected range knee splint.
2. Knee bracing
 Grade-I injuries: Hinged knee bracing (see figure 1) is usually
unnecessary; however the clinician may decide to brace the knee in
15 to 100-degree range for the first 3-4 days purely for comfort and
protection.
 Grade I+ injuries with slight medial knee joint gapping:
 Brace at 30-90 degree for the first 5-7 days.
 15-100 degrees for the next 5-7 days.
 Overall, the patient may be braced for 10-14 days.
 At day 5, the clinician assesses the end feel of the valgus
stress test and if it has improved, the brace may be opened up
to 15 to 100 degrees at day 5. If it still has similar residual laxity
then it is left at the chosen angle until day 7.
 Grade-II injuries:
 30 to 90 degrees for 10-14 days.
 15 to 100 degrees for 10-14 days.
 Fully opened after 14 days.
 Brace removed after a maximum of 4 weeks.
 Grade-III injuries.
 30 to 90 degrees for 15-28 days.
 15 to 100 degrees for 15-42 days.
 Fully opened after this stage.
  Brace removed after a maximum of 8 weeks.
 In the knee brace, quads activation and gentle adduction exercises
with a Theraband may commence early. With adduction exercises,
light-load valgus force on the knee can increase collagen deposition
in the MCL in the early rehabilitation stage.
Figure 1: Hinged knee brace.

3. Strengthening exercises
 With the hinged brace in situ, the athlete can be progressed safely
through leg press (see figure 2), single-leg squat (see figure 3), leg
 extension, split squat and single-leg Romanian deadlifts early in the
rehabilitation process. The range is limited by the brace. This can
start as early as the athlete feels comfortable with the pain.
 Calf and ankle strengthening exercises can be unlimited.
 Unlimited core exercises can be performed with the brace in situ.
 When the brace is removed, generally deep knee flexion movements
(such as deep squat) should be avoided until return to competition,
as the knee may experience a valgus force in deep squat positions.
 It is appropriate in the early stages to incorporate occlusion training
and muscle stimulation to facilitate type-2 muscle fiber hypertrophy
(see issue I57 of Sports Injury Bulletin for a detailed description of
occlusion training).
 Specific knee-strength exercises incorporating slight valgus forces
can be incorporated with slide boards, Swiss ball kicks and (in the
late stages) side planks, with the affected limb supported on an
elevation.
Figure 2: Single leg press with a brace on

Figure 3: Quadricep dominant single leg squat on

slant board
  

4. Balance and proprioception

 In brace, single-leg balance exercises can be started early on
balance/wobble/rocker boards. This can be progressed to more
challenging movements such as an ‘Arabesque’ on a BOSU ball (see
figure 4).
 In brace, gentle jumps and lands may be performed off boxes 6 to 12
inches in height.
 When the brace is removed, higher level proprioception on
trampolines and in sandpits may commence.
Figure 4: High-level proprioception drill ‘Arabesque’
on BOSU ball
 5. CV exercise
 Maintain upper body fitness with upper limb ergometer, seated
boxing, swimming (no kicking) in the early braced stage.
 In the second brace stage (as the brace is opened up to 100
degrees), the knee will have enough motion to perform stationary
bike and stair climber training.
 Straight-line running may commence immediately after brace
removal. It is generally preferred that this is performed with the knee
protectively strapped. The typical progression in running is:
 A straight line 10 x 50m. Build speed as able. Build over a few
sessions to get to full speed.
 ‘S’ runs in a 5m x 60m rectangle. Build to 6 repeats of 60m with
comfortable speed, and eventually attempting full speed when
able.
 Side shuffles over 5m with forwards acceleration/deceleration
over 10m. These are added together in a forward direction to
resemble a zigzag motion over 60m.
 Hard stepping and cutting with no opposition.
 Hard cutting and pivoting drills in pressure situations with
opposition.
Return-to-sport guidelines
The decision to return to sport following an injury to the MCL is determined
by the sport played and meeting the exit criteria suggested below. This
decision may be made with the athlete wearing protective strapping –
assuming they intend to compete with the strapping in place. These
guidelines are:
1. May return to competition if the athlete has minimal pain, close to
full range of motion, and 90 percent of normal strength.
2. Crossover hop test score reaches 90% of the unaffected side (see
Sports Injury Bulletin issue 141).
3. Athlete feels confident in skills and change of directions.
4. Continue to use brace/strapping for all sports participation for the
remainder of the season.
As mentioned above, in certain sports and in certain positions in those
sports, the decision may be made to risk the knee if the athlete does not
encounter significant change of direction forces on the knee. For example,
a front row forward in Rugby Union may have little need to perform hard
changes of direction in a game, as this position does not require this as
much as would be needed in a more mobile position such as center or
winger.
Conclusion
Injuries to the medial collateral ligament (MCL) are a common injury in
sports that require aggressive change of direction and cutting actions, and
in contact sports where valgus forces to the knee are often encountered.
The majority of these injuries are managed conservatively with aggressive
rehabilitation, using a motion limiting brace in place until ligament healing
has occurred. This article outlines in detail the key features that need to be
factored in when rehabilitating the athlete back to full function following this
injury.