Medial collateral ligament (MCL) is the most common injured ligaments in the knee accounting up to 40% of all knee injuries (Andrews et al., 2017). Its frequent in sports involving valgus knee loading such as football. Knee braces have been studied for their benefits as they can provide 20-30% greater resistance to lateral blows and ACL is further protected (Albright, Saterback and Stokes, 1995). However other studies have shown how it can decrease performance. Najibi and Albright (2005) showed knee braces can reduce straight-ahead sprint speed, cause early fatigue and increase oxygen consumption and heart rate. Big Ten Sports Medicine Committee conducted a 3-year analysis of MCL sprains amongst college football players. They found individuals who wore braces often increased injury to their fellow unbraced players and players were two times more vulnerable during practice. So, the use of bracing can prevent further injuries but also can restrict performance.
Classification of MCL injuries is based on the patient’s ability to relax and the clinician’s ability to find an end feel during knee examination. Grade 1 involves tears of few fibres and localised tenderness but no instability. Grade 2 involves localised tenderness and partially torn MCL and posterior oblique fibres and no instability. Grade 3 is a complete tear of the fibres with instability. Grade 3 is also considered as a chronic valgus instability because the MCL injury fails to heal. Avulsions (skin and tissues completely or partially torn) can lead to the MCL being trapped into the joint which can prevent healing (Chen et al., 2008).
This case study suggests the patient occurred left medial knee pain 2 days ago when they went for a tackle during football. They complained of Lock of control over knee with feeling it could away. Andrews et al., (2017) states one of the signs of MCL injury is the sensation of knee giving away. One of the positive findings are valgus stress and tenderness when palpating along the medial part of the knee. Pain, swelling and tenderness can show with 12 hours of injury (hemarthrosis- bleeding in the joints) (Phisitkul et al., (2006). Miyatomo, Bosco & Sherman, (2009) mention first-degree sprain showed tenderness over the MCL but no instability. Based on the information given it has been hypothesized that the patient has acute grade 1 MCL sprain.
Studies have shown grade 1 injuries can be treated non-operatively using exercise therapy for early range of motion (ROM), and Cryotherapy (cold therapy) during the first 24-48 hours. Phistikul et al., (2006) found ROM exercises and strength training showed high rate of return to play (RTP). Cold therapy decreases tissue blood flow and due to vasoconstriction reduces inflammation (Degrace & Thomas., 2013). The initial goal is to reduce pain and swelling.
Exercise therapy has been used for patients of all ages. It can increase function and reduce pain, improve walking, muscle strength and joint ROM (Holden et al., 2012). Phistikul et al., (2006) reviewed different treatments for MCL injuries and created a rehabilitation programme for athletes who have had collateral ligament sprains. It promoted weight bearing as tolerated using crutches as an initial treatment and active ROM exercises such as active knee flexion and extension as a subsequent treatment. Early ROM protocols improve healing and biomechanical properties of the MCL (Wijdicks et al., 2010). Chen et al., (2008) mentions a person can RTP in 20 days with grade 1 or 2 MCL injury with (Gelber & Oerelli 2018) showing earlier RTP at 11 days indicating exercise therapy is beneficial. Muller & O`Brien (2018) state PROM of 0-900 for 2 weeks and then full ROM has shown a safe ROM restriction for all ligamentous injuries. Some studies have discouraged using immobilization such as knee brace or cast because of stiffness and Miyamoto, Bosco & Sherman (2009) mentions immobilization as hinderance to ligament healing. Gelber & Pirelli (2018) mentioned immobilization techniques can be used for a short period such as crutches but doesn`t mention exactly for how long. Phusitkul et al., (2006) advices crutches can be discontinued when a person can start walking without a limp and Duffy & Miyamoto (2010) state it can be used acutely so basically its self-dependent. Chahla et al., (2017) have written a guide for RTP and state initial management should focus on improving gait abnormality and because our case study involves patient with a limp gait it`ll be beneficial to them for restoring ROM. Abnormal gait pattern occurs because of high tensile stress placed on the healing tissues which can interfere with the healing process (Paterno & Hewett, 2008). Another reason is lack of quadriceps muscle strength so the clinician should focus on strengthening this. Strength exercises can only be encouraged if knee motion is greater than 1150 and performed without any extension lag (Logan, O`Brien & LaPrade, 2016). Chahla et al., (2017) set up a 6-week programme divided into smaller phases (periodization) where reaching goals are manageable. For muscular strength single leg press and squat 12 reps, 3 sets with 90s rest in between for 3-4 sessions a week was set to improve early ROM and target quadriceps.
Hudes (2011) studied a case which was similar to our case study involving 16-year-old male football player with right medial knee pain of 2 days after been tackled during practice from left side. With similar PC (presenting condition) the patient was diagnosed with right MCL grade 1 sprain with possible meniscus tear. A 2-week rehab programme was given involving VMO (vastus medialis oblique) and wobble board exercises with progression to second week. VMO exercises involved sitting with knee bent and approximately 4 inches off the floor and then straighten leg without moving the thigh. Wobble board exercises included double and single leg balancing squats with instruction to perform 15 reps 3 times/day. After two weeks the patient reported no signs of pain unless running at full speed, but approaching third week even this was gone and the patient was able to play football with ease. Chahla et al., (2017) transitions from musclar strength to muscular power after 6-weeks using squat progression and calf raises.
Cryotherapy involves using any substance or physical medium to the body which can remove heat and decrease temperature. It’s mainly used for acute injuries, muscle spasms, inflammation, oedema and is part of R.I.C.E protocol (Malanga, Yan & Stark., 2014). Cryotherapy can reduce pain and control inflammation (Kim, Sung & Lee., 2017). Ice packs, gel packs, ice massage or ice bath are types of cryotherapy but they all have different physiological effects. Nadler, Weingand and Kruse., (2004) states ice massage cools faster than ice pack. They also found ice packs aren`t effective after 20 minutes of application whereas ice bath continuously dropped the temperature. They have stated ice packs and ice massage are effective for quick recovery such as immediate RTP whereas ice bath is effective for long-term cooling. Malanga, Yang & Stark., (2014) looked at intermittent cold therapy (10-minute ice, 10-minute room temperature) every 2 hours and suggested patients had less pain compared to standard 20-minute icing protocol. Kim, Sung & Lee., (2017) used this type of cryotherapy before patients underwent instrument-assisted mobilization.
Exercise therapy has shown to be very effective in restoring muscular strength and improving ROM but it’s worth mentioning these treatments aren`t effective on their own. Chahla et al., (2017) mentions the importance of patellar mobilization alongside exercise because hypermobility of the proximal end of patella can affect extensor mechanism which can reduce ROM and quadricep strength. Logan, O`Brien & LaPrade, (2016) stated deficits larger than 100 in knee flexion and extension can affect muscular strength and running speed. Therefore Chala et al., (2017) advises patellar mobilisation 3-4 times/day during first 6 weeks which is great for our patient as they lack 100 extension.
Some studies have used alternative approaches such as (Andrews et al., 2017) using NSAIDs and (Hudes.,2011) using TENs and laser therapy. NSAIDs are not bengin agemts so if taken incorrectly can result in harmful side effects (Warden., 2010). NICE guidelines recommend using Iboprufin (1200mg/day) and Paracetamol 0.5-1g/day 48 hours after injury. Having two or more NSAIDs at a time can increase risk of gastrointestinal problems (Atchhinson, Herndon & Ruise, 2013).
TENs and laser therapy have been used by (Hudes, 2011) however they seem to be non-effective and further research needs to done (Hanada,2003). Plus, laser treatment is scarce and expensive.
The effects of Cryotherapy are poor. Hawkins & Hawkins, (2016) state there isn`t any randomised clinical trials which mention decrease in temperature limits pain. The use of cryotherapy is based on a few papers and need further clarity. Use of cryotherapy instead of other treatments has been questioned because the effect on acute injuries have not been fully investigated. Therefore, it’s difficult to make any recommendations. Malanga et al., (2015) stated many studies were not blinded so were subject to bias and potential overestimation. But the guidelines remain that ice can be applied during initial 48-72 hours but after 72 hours there is little evidence for its benefit.
- Albright, J., Saterbak, A., Stokes, J. (1995). Use of Knee Braces in Sport. Journal of Sports Medicine. 20 (5), p281-301.
- Andrews, K., Lu A., Mckean L., Ebraheim, N.. (2017). Review: Medial collateral ligament injuries. Journal of Orthopaedics. 14 (4), p550-554.
- Arner, J., Jiang, K., Musahl, J., Fu, F. (2017). Pain and the unstable knee. Annals of Joint. 2 (82), p1-12.
- Atchison, J., Herndon, C., Rusie, E.. (2013). NSAIDs for Musculoskeletal Pain Management: Current Perspectives and Novel Strategies to Improve Safety. Journal of Managed Care Pharmacy. 19 (9), p3-15.
- Chahla, J., O’Brien, L., Godin, J. A.,. (2017). Return to Play After Multiple Knee Ligament Injuries. Return to Play in Football. 5 (47), p637-645.
- Chen, L., Kim, P., Ahmad, C., Levine W.. (2008). Medial collateral ligament injuries of the knee: current treatment concepts. Current Reviews in Musculoskeletal Medicine. 1 (2), p108-113.
- Cynthia R. (2007). Common Acute Sports-Related Lower Extremity Injuries in Children and Adolescents. Clinical Pediatric Emergency Medicine. 8 (1), p31-42.
- Degrace, D., Gill, T. III, Gill, T. VI. (2013). Analysis of Medial Collateral Ligament Injuries of the Knee. The Harvard Orthopaedic Journal. 15 (3), p13-22.
- Duffy, P., Miyamoto, R. (2010). Management of Medial Collateral Ligament injuries in the knee: an update review. International Journal of Physician & sports medicine. 38 (2), p48-54.
- Hanada, E. (2003). Efficacy of rehabilitative therapy in regional musculoskeletal conditions. Best Practice & Research Clinical Rheumatology. 17 (1), p151-166.
- Holden, M., Nicholls, E., Young, J., Hay, N Foster, E., . (2012). Role of exercise for knee pain: What do older adults in the community think? Arthritis Care & Research. 64 (10), p1554-1563.
- Gelber, P., Perelli, S.. (2018). Treatment of the medial collateral ligament injuries. Treatment of the medial collateral ligament injuries. 6 (78), p1-11.
- Hawkins, S., Hawkins, J. (2016). CLINICAL APPLICATIONS OF CRYOTHERAPY AMONG SPORTS PHYSICAL THERAPISTS. International Journal of Sports Physical Therapy. 11 (1), p141-148.
- Hubbard, T., Denegar, C. . (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. Journal of Athlethic Training. 39 (3), p278-279.
- Hudes, K. (2011). Two cases of medial knee pain involving the medial coronary ligament in adolescents treated with conservative rehabilitation therapy. Journal of the Canadian Chiropractic Association . 2 (55), p120-127.
- Kim, J., Sung, D., Lee, J. (2017). Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. J Exerc Rehabil. 13 (1), p12-22.
- Logan, C., O`Brien, L., LaParade, R. (2016). POST OPERATIVE REHABILITATION OF GRADE III MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY. International Journal of Sports Physical Therapy. 7 (11), p1177–1190.
- Malanga, G., Yan, N., Stark, J.. (2014). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Journal of Postgraduate Medicine . 127 (1), p1-9.
- Miyamoto, R., Bosco, J., Sherman, O. (2009). Treatment of Medial Collateral Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 17 (5), p152-159.
- Muller, B., O`Brien, L. . (2018). Multi ligament knee injuries in athletes, is it possible to return to play? —a rehabilitation perspective. Annals of Joint. 3 (92), p1-6.
- Nadler, S., Weingand, K., Kruse, R. (2004). The Physiologic Basis and Clinical Applications of Cryotherapy and Thermotherapy for the Pain Practitioner. Pain Physician. 7 (3), p395-399.
- Najibi, S., Albright, J.. (2005). The Use of Knee Braces, Part 1: Prophylactic Knee Braces in Contact Sports. The American Journal of Sports Medicine. 33 (4), p602-611.
- Paterno, M., Hewett, T. . (2008). Biomechanics of Multi-ligament Knee Injuries (MLKI) and Effects on Gait. North American Journal of Sports Physical Therapy. 3 (4), p234-241.
- Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J. 2006;26:77–90.
- Turner, T., Denegar, C.. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. Journal of athletic training. 39 (3), p278-279.
- Warden, S. (2010). Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment. THE PHYSICIAN AND SPORTSMEDICINE. 38 (1), p1-4.
- Wijdicks, C., Griffith, C., Johansen, S., Engebretsen, L.. (2010). Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee. The Journal of Bone and Joint Surgery. 92 (5), p1266-1280.