Here we give examples of step by step rehabilitation programs for grade 1, 2 and 3 medial knee ligament sprains. Grade 1 is a mild sprain, grade 2 is moderate and grade three severe or complete tear of the ligament.
The following examples are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation or exercises. It is important to get an accurate diagnosis to determine the grade of your injury.
Aims of rehabilitation
The aims of rehabilitation are:
- to reduce pain and swelling
- restore full mobility
- improve strength and stability
- a gradual return to full training
Grade 1 MCL Rehabilitation
For a grade 1 MCL injury, there may be mild tenderness on the inside of the knee over the ligament and usually no swelling. The rehabilitation guidelines for a mild medial ligament sprain can be split into 4 phases:
Phase 1: immediately following injury
- Duration: 1 week.
- Aim: to reduce swelling (if there is any), ensure the knee can be straightened fully and bent to more than 90 degrees and begin pain-free strengthening exercises.
- Rest from activities that cause pain. As pain allows begin walking normally without support and progress gradually until walking is pain free.
- 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 as it may burn.
- Sports massage techniques can usually be applied from day 2, specifically to the ligament. Ultrasound can also be applied to the ligament area.
- Maintain aerobic fitness with cycling. Apply cold therapy after each strengthening and stretching session.
- Pain-free stretching exercises for quadriceps and hamstring muscles as well as flexion and extension mobility exercises.
- Static strengthening exercises can begin as soon as pain allows. Isometric quadriceps exercises, calf raises with both legs and resistance band exercises for the hamstrings, hip abductors and hip extension but not for adduction as this will stress the medial ligament.
Phase 2: after 1 week
- Duration: 1 week
- Aim: to eliminate swelling completely, regain full range of movement, continue with strengthening exercises and return to slow jogging.
- 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, single leg calf raise, bridging and leg press are suitable exercises if pain allows.
- Cross friction massage to the ligament can be performed on alternate days. Maintain aerobic fitness with cycling, stepping machine, and gentle jogging but no sudden changes of direction.
Phase 3: after 2 weeks
- Duration: 2 weeks
- Aim: to maintain a full range of motion, equal strength of both legs, return to running and some sports specific training.
- 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 and lunges.
- Increase the intensity, weight lifted and a number of repetitions. Aim for between 10 and 20 reps. Increase until the strength is equal in both legs.
- In addition to straight running, start to include sideways and backwards running, agility drills and plyometric exercises. Increase speed to sprinting and changing direction drills.
Phase 4: after 4 weeks
- Duration: 3 to 6 weeks
- Aim: to return to full sports specific training and competition.
- Sports massage for surrounding muscles on a 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 grade 3 sprains, 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
- Duration: 4 weeks
- Aim: to control swelling, maintain the ability to straighten the leg bend the knee to more than 90 degrees, begin strengthening exercises.
- Rest from all painful activities. Use crutches if necessary, non-weight bearing to start with, then partial weight bearing from 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. Mobility exercises should be done in the knee brace.
- 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, hip abduction and extension.
- Knee extension mobility should only be to 30 degrees though. Maintain aerobic fitness on a stationary cycle as soon as pain allows.
Phase 2: Following week 4
- Duration: 2 weeks
- Aim: to eliminate swelling, full weight bearing on the injured knee, full range of motion, injured leg almost as strong as the good one.
- Continue with cold therapy and compression to eliminate swelling following exercises.
- Remove the knee brace at this stage.
- A simple stabilized knee support is more suitable at this stage to apply compression to the knee. A therapist will continue with ultrasound and massage.
- Range of motion exercises should continue along with isometric quadriceps exercises.
- Mini squats, lunges, double leg press, hamstring curls, step ups, bridges, hip abduction, hip extension, and single leg calf raises can begin or be continued.
- It may be possible to begin to swim (not breaststroke!) or use a stepper for aerobic fitness.
Phase 3: after week 6
- Duration: 4 weeks
- Aim: to regain full range of motion, strength, return to light jogging and by week 10 from injury, return to sports specific exercises.
- 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.
- When confident enough plyometric drills, hopping, box jumps and agility drills can begin.
Phase 4: after week 10
- Duration: 2 to 4 weeks
- Aim: to return to full sports specific training and competition without a brace for support, full strength and mobility.
- Gradually bring into training more and more sports specific drills, changing direction and plyometric, hopping and bounding exercises.
- Normal sports specific training can begin.