Medial Collateral Ligament Injuries
The Medial Collateral Ligament (MCL) is located on the inside of the knee. It is unfortunately one of the most common knee ligament injuries. The primary role of the MCL is to help limit any valgus movements. This means stopping the knee from becoming unstable and collapsing inwards. When the knee is slightly bent at around 25 degrees, this is when the greatest load and stress is put through the MCL. There is obviously a significant increase in stain/ stresses when playing sports that incorporate changes of direction and rotation. Injuries to the MCL can occur in many different ways. Non-contact injuries occur in sports such as downhill skiing. While contact injuries often occur in team sports such as soccer, and other football codes (rugby union, NRL, AFL). These contact injuries can occur when there is significant force applied to the lateral aspect of the knee (outside of the knee), causing the knee to collapse inwards/ medially. Alternatively contact can occur at the foot when kicking, this is more common in soccer. When the foot is stopped mid kick, the momentum of the knee continues, causing a valgus movement to occur at the knee, straining the MCL. Degrees of injury
Grade 1 = mild stretch or a strain, only a few fibers of the ligament is tear. This results in no instability but localized tenderness.
Grade 2 = moderate, with more fibers torn, still localized tenderness. Some swelling can occur. With limited to no instability still.
Grade 3 = complete rupture of the fibers which involved swelling and resulting in instability.
There is great research out that suggests surgical repair of the MCL isn’t required in most occasions. The MCL is fairly unique, as it has been found to heal by itself fairly comfortably with conservative measures, meaning when coupled with exercise programs to help with the rehabilitation process. Usually the MCL is surgically repaired when there is an associated ACL tear, but not often when it is just the MCL injured. Treatment approach MCL injuries can vary with length of time away from sport and exercise. However, our aim her at START Training is to return you to sport as soon as possible, whilst also limiting the losses in strength and fitness that may be associated with injury. A rough outline of a treatment protocol for an MCL injury: Our focus upon first coming into clinic is:
Pain relief = Can be done in several ways, however hands on therapy is often used to help with pain relief. Depending on the severity of the injury, support for the knee may be used, like tape or bracing. Exercise is brought in early to help with pain relief, as the better the knee is functioning, the less reoccurrence of pain.
Exercises are introduced early. Often our aim is to maintain movement and strength as best possible. Stability of the knee is extremely important when rehabilitating an MCL injury. One of the main muscles we focus on is the vastus medialis (VM). The VM is involved in knee stability. It works in conjunction with the glute muscles (glut med) to help maintain femoral alignment through movement. The VM also helps with patella stability, it needs to be trained in both isolation making sure it is active and strong, but also in gross compound movements. VM works with the vastus lateralis (VL) through the whole range of knee flexion. Therefore, it is important to work through ranges of depth when able (pain free).
Another important reason to make sure VM is working well is to deter the adductors from tightening and adding to the pain. Some of the adductors cross the knee joint medially, in a similar position to the MCL, therefore the body often recruits them to help stabilize the knee when an injury has occurred. If we can make sure VM is active and working well the body doesn’t feel the need to recruit the adductors. This then limits tightness and pain which can be associated with an MCL injury. Once the pain has subsided and good range of movement (ROM) is present, we are able to focus on building linear strength throughout the knee. Exercises like squats, lunges, assisted pistols can be used during this phase. Exercise selection is specific to the persons needs for their chosen sport. We focus on making sure the correct muscles are working throughout the movements, and there is no further pain being developed from the exercises. Once stability in the knee is present with movement, straight line running can be introduced. This can be done individually or training with the team. As strength and improved function continues, we progress through big figure of 8’s, gradually decreasing the size of the turns and increasing the sharpness of turns, until cutting and sharp change of direction can be introduced. This is dependent on the individual and their ability. Introducing this too early can cause reinjury or a prolonged rehab process. Lateral movements during strength-based sessions can be introduced when pain is no longer present. These are performed under control and within limits of the individual. This is the same principle for when dynamic movements, such as plyometrics can be introduced. When the knee is stable, more explosive movements and sports specific movements can be performed. Before the client is discharged to return to sport or their chosen exercise, they undergo some extensive testing/ sessions to make sure the knee will remain stable throughout their return. These sessions are designed to test the knee and it’s ability to perform under fatigue. An MCL injury can take anywhere between 4-6 weeks on average to heal. Our aim with early exercise interventions for MCL injuries are for a few different reasons.
Limit any secondary issues.
Specifically compensatory movements that can cause further injury; such as the adductors becoming overactive or overcompensating with the other knee developing more problems;
Help support the joint with muscles taking the load off the ligament itself, to help healing;
Keep as much strength in knee as possible
As with injuries and rest, loss of strength and fitness is often associated. If we are able to maintain strength and fitness at higher levels, then the return to training process, is performed much easier.
Keep the athlete in as much of a sport/ exercise environment as possible
This can be very important for mental health. Injuries suck, we can all agree. When injured there can be negative affects on ones mental health. If we are able to make it seem like the injury isn’t bad and you are able to continue to train as much as possible whilst recovering, then there is less impact on the mental health of the athlete.
The mental effect of injury can include general depression from injury, fear of returning to sport, apathy when returning to sport.
Team sport environments are often the reason why people continue to play sport. The environment and friendship associated with them is massive. If you are able to keep the athlete in and around that environment it can be greatly beneficial.
The same goes for Individual sport, being able to maintain their training load as best possible can help mitigate the effects of injuries on not just the injury, but mental health. As many individual sports have deadlines for competitions, the more one is able to train the better prepared they are for future competitions.
By William Holland – Exercise Physiologist