Passive to Active Protocol Progression for MCL Partial Tear

A medial collateral ligament (MCL) tear represents a complex mechanical pathology in the field of sports medicine, facilitating the need for a deeper understanding of corrective surgical and non-surgical procedures. 

A well-defined pattern emerges on further observation of knee-specific injuries which result in an eventual tissue failure.

MCL tears, along with lateral compartment bone bruise and lateral meniscus tear, stem from the application of a valgus force at the knee.

The initial phase of treatment follows a detailed evaluation of the medial compartment in order to clearly define the extent of pathology to the medial ligament system, and to control the direction of the evaluation forces and unwanted secondary motion.

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It is essential to avoid external tibial rotation whilst carrying out such an evaluation, as this would create tension in the posterior medial corner, thereby casting a negative result.

Medial injuries can be classified into three types - Grade 1 or medial pain with no increase in translation; Grade 2 or medial pain with increased translation of up to 5mm; and Grade 3 or medial pain with increased translation in excess of 10mm.

It is highly recommended that a magnetic resonance imaging (MRI) be performed to identify any internal joint derangements; this would aid in the development of a comprehensive treatment program.

In the case of Grade 2 sprains, there is an incomplete rupture of the collagen fibres which are found at the ends of the femur and the tibia.

The acute phase of the passive rehabilitation program lasts three days, protecting the site of injury from damage by using crutches to keep any weight off the injured leg.

Cryotherapy or the application of ice packs/‘cryo-cuff’ devices, is recommended to relieve pain and control the swelling. Joint swelling is further limited by applying compression bandages.

The patient is also, advised to sit with the knee elevated above the heart level, to help control any substantial swelling.

The sub-acute phase of the program involves prolonged resting of the injured leg and protection of the affected site from further damage, with the use of crutches.

A hinged knee brace, locked between minus 10 degrees of extension and 90 degrees of flexion, can also be used to further protect the knee by avoiding any stress on the medial ligament.

Electrotherapy treatments such as ultrasound and pulsed short-wave diathermy, encourage the ligament to lay down scar tissue and start the process of repairing itself. It is at this point that ankle and hip range-of-movement exercises begin.

It is during the early active rehabilitation phase that the hinged knee brace is set between five degrees of extension and 110 degrees of flexion. Worn at all times, the crutches are abandoned at this point and full weightbearing is slowly and cautiously encouraged.

It is important to look out for a normal gait pattern, from heel-strike to toe-off. 

The patient starts gentle range-of-movement exercises, which fall between 90 to 30 degrees of knee flexion.

Active rehabilitation begins in the fourth week of program, with the hinged knee brace worn at all times and the patient continuing previous range-of-movement exercises. There should be no restriction of knee extension and flexion.

Depending on the progress made, static cycling is slowly incorporated into the routine along with isotonic muscle strengthening exercises and proprioceptive training.

These are continued further into the late active rehabilitation phase, which also involves straight line running and ‘figure-of-eight’ running. The hinged knee brace is worn throughout this phase.

In week 10 of the functional rehabilitation phase, the patient is able to remove the hinged brace. Isotonic muscle strengthening and progress static cycling continue, with the speed of running increased along with the turning angle, which is set to 180 degrees.

Cliniband lateral agility/running exercises and star jumps are commenced in this phase, which complete the rehabilitation programme.

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