Rehabilitation of MCL Injuries

Aims of rehabilitation:

• Reduce pain and swelling.
• Restore full mobility.
• Improve strength and stability of the joint.
• Return to full activity.

Grade 1 Sprain:

The rehabilitation guidelines for a grade 1 and 2- or mild medial ligament sprain can be split into 4 phases:

Phase 1: Immediately following injury

Aims - to reduce swelling (if any), ensure the knee can be straightened fully and bent to more than 90 degrees, begin pain free strengthening exercises.

Duration - 1 week

• Rest from activities that cause pain. As pain allows, aim to walk normally without support or pain.
• Apply cold therapy and a compression support to limit 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 over the next few days. Do not apply ice directly to the skin (ice burns!)
• Pain free stretching exercises for quadriceps and hamstring muscles as well as flexion / extension mobility exercises.
• Static strengthening exercises as soon as pain allows.
• Sports massage techniques can usually be applied from day 2, specifically to the ligament.
• Maintain aerobic fitness with cycling.
• Apply cold therapy after each strengthening / stretching session.

Phase 2: After 1 week

Aims - Eliminate any swelling completely, regain full range of movement, continue with strengthening exercises and return to slow jogging.

Duration - 1 week.

• Rest from painful activities, however the athlete may be able to jog slowly as long as it is not painful.
• Apply cold therapy following exercise or rehabilitation exercises.
• Continue with stretching and strengthening exercises from phase 1.
• Introduce dynamic strengthening exercises such as knee extension, knee flexion, half squats, step ups, hip raises and hip strengthening exercises and single leg calf raises.
• Cross friction massage on alternate days.
• Maintain aerobic fitness with cycling, stepping machine and gentle jogging (no sudden changes of direction though).

Phase 3: After 2 weeks

Aims - Maintain full range of motion, equal strength of both legs, return to running and some sports specific training.

Duration - 2 weeks.

• Continue to apply cold therapy after training sessions.
• Continue with sports massage techniques every 3 days.
• Continue with stretching exercises.
• Build on dynamic strengthening exercises such as leg extension and leg curls exercises as well as squats to horizontal. Increase the intensity / weight lifted and number of repetitions. Aim for between 10 and 20 to failure. Increase until your strength equals the other leg.
• In addition to straight running, start to include sideways and backwards running, increasing speed to sprinting and changing direction drills.

Phase 4: After 4 weeks

Aims - To return to full sports specific training and competition.

Duration - 3 to 6 weeks.

• Sports massage for surrounding muscles on as weekly basis.
• Continue with strength training as above but start to include hopping and bounding exercises.
• The athlete should now be ready to gradually return to full sports specific training and then competition.
• A knee support or a strapping / taping techniques may provide extra support on return to full training, however do not become reliant on this. It will weaken the joint. Use initially for confidence building.

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:

Phase 1: Immediately following injury

Aims - Control swelling, maintain ability to straighten the leg bend the knee to more than 90 degrees, begin strengthening exercises.

Duration - 4 weeks.

• Rest from all painful activities. Use crutches if necessary - non weight bearing to start with, then partial weight bearing (week 2) and by end of week 4 aim to be walking normally.
• Wear a hinged or stabilised knee brace to protect the medial ligament.
• Apply cold therapy and compression. Apply ice / cold therapy for 15 minutes every 2 hours for the first 2 days and gradually reduce the frequency to 3 times a day over the next week.
• Pain free stretches for the hamstrings, quads, groin and calf muscles in particular.
• Sports massage (gentle cross frictions) may be possible from day 2 but allow a week for more severe injuries.
• As pain allows, static quads and hamstring exercises, double leg calf raises.
• Maintain aerobic fitness on stationary cycle as soon as pain allows.

Phase 2: Following week 4

Aims - Eliminate swelling, full weight bearing on the injured knee, full range of motion, injured leg almost as strong as the good one.

Duration - 2 weeks.

• Continue with cold therapy and compression to eliminate swelling following exercises.
• Introduce dynamic strengthening exercises - knee flexion, knee extensions, half squats (both legs), step ups, hip raises, hamstring curls and single leg calf raises.
• It may be possible to begin to swim (not breaststroke!) or use stepper for aerobic fitness.

Phase 3: Following week 6

Aims - Full range of motion, strength, return to light jogging and by week 10 from injury, return to sports specific exercises.

Duration 4 weeks.

• Continue with cold therapy following training sessions. Wear a brace or support as required.
• Sports massage techniques to the ligament 2 to 3 times a weeks.
• Strengthening exercises as above increasing intensity and moving double leg exercises to single.
• After week 6, no sooner, begin to run if comfortable- no sudden changes of direction though.
• After week 8 begin to run sideways and backwards so by week 10 the athlete is able to begin to change direction at speed.
• For footballers, kicking may now be possible.

Phase 4: Following week 10

Aims - Return to full sports specific training and competition without a brace for support, full strength and mobility.

Duration - 2 to 4 weeks.

Gradually bring into training more and more sports specific drills, changing direction and plyometric (hopping and bounding) exercises.