Degenerative Meniscus

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

Image showing the Adductor Muscle anatomy

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.
References

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

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