Collateral Ligament Injuries

The function of the collateral ligaments of the knee is to stabilise the knee from varus / valgus forces.  Consists of a Medial & Lateral ligament.

Mechanism of injury : 

1. Medial Collateral [ MCL] 

Excessive Valgus forces to partially flexed knee. Direction of force lateral to medial. Can be contact or non-contact.

2. Lateral Collateral Ligament [LCL]: 

Usually a severe, high energy, direct Varus forces. Direction of force, medial to lateral. Less common than MCL strains.

Differential diagnosis?

  • Avulsion of biceps femoris tendon. 
  • Posteriolateral corner tenderness > ACL tear
  • Grade III tear associated with PCL rupture > high instability >surgery
COLLATERAL LIGAMENT INJURIES
COLLATERAL LIGAMENT INJURIES

 

Lateral Collateral Ligament

 

Assessing Severity of Strain Graded 

Grade I :  Mild , [1st degree]. 

  • Local tenderness over MCL and femoral condyle or tibial plateau, minimal  swelling,
  • Testing:  valgus stress at 30° flexion, pain but no laxity

Grade II : Moderate,[ 2nd degree]

  • Marked tenderness, sometimes localized swelling
  • Testing:  valgus stress at 30°flexion, pain, some laxity [typically <5mm], but distinct end point.
  • Ligament integrity is compromised but intact throughout its length.

Grade III: Complete, [3rd degree] , 

  • Instability present. Patient complains of  “wobbly knee”.
  • Pain variable, often not as painful as Grade II
  • Ligament tenderness
  • Testing : Gross laxity. Lacks distinct end feel. 
  • Often associated ACL tear, but rarely meniscus.

Treatment  (see tables)

  • Conservative rehabilitation programme for MCL strains grades I- III
  • Use of hinged knee brace

Rehabilitation  programme Grade I mild MCLStrains

Phase Phase Goals Time Post Injury Physiotherapy Treatment Exercise Programme Functional / Sport Related Activity
1: Control swelling Knee flexion to 100°+ Allow +20 Extension 4/5 Quads strength 4+/5 Hamstring strength 0 – 1 Weeks Cryotherapy Electrotherapy Compression Manual Therapy Gait Re-education Patient education Gentle ROM (flexion) Quads / VMO setting Supported bilateral calf raises Hip abduction/ extension Hamstring (pulleys) Gait re-ed drills Progress to FWB Normalize Gait
2: Eliminate swelling Full Flexion ROM 4+/5 Quads strength 5/5 Hamstring strength Return to light jogging 1 – 2 Weeks Cryotherapy Electrotherapy Compression Manual Therapy Gait Re-education Exercise modification & supervision ROM drills Quads / VMO setting Mini squats & Lunges Leg press ( dbl then single) Step –ups Bridges (dbl then single) Hip abd/ extension ( theraband) Gait re-ed drills Straight line jogging Swimming (light kick) Road Bike : with hinged knee brace
3: Full ROM Full Strength Full squat Dynamic proprioception Return to running Restricted sport specific drills 2 – 4 Weeks Manual Therapy Exercise/ activity modification & supervision As above. Increase difficulty [ reps weights] Jump / land skills Agility drills Progressive running Swimming Road Bike Sport specific skills
4: Full, strength, ROM and endurance Return to sport specific drills & restricted training/ match play 3 – 6 Weeks As above High level sport –specific strengthening required Return to sport specific drills & restricted training/ match play with hinged brace

Rehabilitation programme Grades II – III moderate to severe  MCLStrains

Phase Phase Goals Time Post Injury Physiotherapy Treatment Exercise Programme Functional / Sport Related Activity
1: Control swelling Knee flexion to 90°+ Allow +30 Extension 4/5 Quads strength 4+/5 Hamstring strength 0 – 4 Weeks Limited motion brace (0-30°) Cryotherapy Electrotherapy Compression Manual Therapy Gait Re-education Patient education Exercises done in brace Gentle ROM (flexion) Extension ROM to 30° Quads / VMO setting Supported bilateral calf raises Hip abduction/ extension Hamstring (pulleys) Gait drills Initially NWB/ PWB Progress to FWB Walking / normal Gait
2: FWB Eliminate swelling Full ROM 4+/5 Quads strength 5/5 Hamstring strength Return to light jogging 4 – 6 Weeks Removal of Knee brace Cryotherapy Electrotherapy Compression Manual Therapy Gait Re-education Exercise modification & supervision ROM drills Quads / VMO setting Mini squats & Lunges Leg press ( dbl then single) Step –ups Bridges (dbl then single) Hip abd/ extension ( theraband) Single legged calf raises Balance & proprioceptive drills Swimming (light kick) Road Bike Walking
3: Full ROM Full Strength Full squat Dynamic proprioception Return to light jogging Return to running & Restricted sport specific drills 8 – 10 Weeks Manual Therapy Exercise/ activity modification & supervision As above. Increase difficulty [ reps weights] Jump / land skills Agility drills Straight line jogging with hinged knee brace [ no earlier than 6 wks] Running Swimming Road Bike Sport specific drills, ie fwd back side running, kicking
4: Full, strength, ROM and endurance Return to sport specific drills & restricted training/ match play 8 – 10 Weeks As above High level sport –specific strengthening required Return to sport specific drills & restricted training/ match play with hinged brace


 

References

  • Image from OpenI – Licensed by CC
  • Image from OpenI – Licensed by CC

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