Rehabilitation Program
Physical Therapy
The type of physical therapy (PT) treatment indicated for a medial collateral ligament (MCL) injury depends on the severity of the injury. [8, 16] Recommendations for treatment include the following:
-
Grade I - Compression, elevation, and cryotherapy are recommended. Short-term use of crutches may be indicated, with weight-bearing–as–tolerated (WBAT) ambulation. Early ambulation is recommended.
-
Grade II - A short-hinged brace that blocks 20º of terminal extension but allows full flexion should be used. The patient may ambulate, WBAT. Closed-chain exercises allow for strengthening of knee musculature without putting stress on the ligaments.
-
Grade III - The patient initially should be non–weight-bearing (NWB) on the affected lower extremity. A hinged braced should be used, with gradual progression to full weight-bearing (FWB) over 4 weeks. Grade III injuries may require 8-12 weeks to heal.
All MCL injuries should be treated with early range of motion (ROM) and strengthening of musculature that stabilizes the knee joint. Conservative measures usually are adequate, but, if the patient fails to progress with treatment, a meniscal or cruciate ligament tear is suggested.
Lateral collateral ligament (LCL) injuries heal more slowly than do MCL injuries, due to the difference in collagen density. Recommendations for the treatment of LCL injuries include the following:
-
Grades I and II - These injuries are treated according to a regimen similar to that for MCL injuries of the same severity. A hinged brace is used for 4-6 weeks.
-
Grade III - Severe LCL injuries typically are treated surgically due to rotational instability, because they usually involve the posterolateral corner of the knee. Patients may require bracing and physical therapy for up to 3 months in order to prevent later instability.
Surgical Intervention
Most patients with a collateral ligament injury can be treated effectively with conservative measures. Grade III lateral collateral ligament (LCL) tears usually involve the posterolateral complex and are associated with instability. These patients do require surgical repair. [17, 18, 19, 20, 21] Surgical treatment for isolated injuries of the medial collateral ligament (MCL) or LCL is a controversial topic. The treatment plan should be based partially on the patient's pre-injury level of activity and on motivational factors. For example, a young competitive swimmer may want surgery, followed by a comprehensive rehabilitation program to accelerate the time needed for adequate functional recovery. [22] A technique for repairing severe MCL injuries using autogenous hamstring tendons has been proposed. [23]
A study by Dong et al indicated that both anatomic ligament repair and triangular ligament reconstruction are about equally effective in the treatment of acute grade III MCL tear combined with anterior cruciate ligament (ACL) tear. The study, which involved 64 patients, had a mean 34-month follow-up period. Although International Knee Documentation Committee (IKDC) scores and evaluation of the medial opening of the knee showed no significant differences between the techniques, the investigators did find that patients who underwent triangular ligament reconstruction had a significantly lower incidence of anteromedial rotatory instability than did the anatomic ligament repair patients at final follow-up. [24]
A retrospective study by King et al looking at multiligament repair/reconstruction for medial (ACL, posterior cruciate ligament [PCL], MCL) and lateral (ACL, PCL, LCL) knee dislocations indicated that compared with medial repair, medial reconstruction and lateral repair/reconstruction are more likely to produce positive results; medial repair was associated with worse Lysholm Knee and IKDC scores. [25]
Consultations
An orthopedic surgery consultation is advised for individuals with severe ligament injury.
-
The medial and lateral collateral ligaments of the knee. Courtesy of Randale Sechrest, MD, CEO, Medical Multimedia Group.
