Intended for licensed physical therapists coordinating care with Dr. Vasileff. Defer to the operative note and the surgeon’s office for patient-specific direction.

Knee · Ligament

MCL Sprain (Non-Operative)

Non-operative protocol · Dr. Chris Vasileff, MD

For the treating physical therapist. This protocol is a guideline; progression is criteria-based and individualized. Defer to the operative note and the surgeon’s office for patient-specific direction.

Non-Operative Treatment of MCL Sprain

Rehabilitation Protocol

These are guidelines for the non-operative management of medial collateral ligament (MCL) sprains of the knee. They are divided into four phases dependent on patient presentation and grade of the sprain (grade 1-3). Progression is both criteria based and patient specific. The rehabilitation program initially emphasizes reduction of pain and swelling while not overstressing the involved tissue and progresses to restoration of stability and functional activity in later phases. Timing for advancement through the phases varies depending on the severity of the sprain and concomitant injuries, if present. Additionally, progression through the phases should be in alignment with patient goals.

Grades of Sprain

Grade 1 sprains involve a minimal number of fibers torn with localized tenderness and no laxity. These sprains typically present with full or near full range of motion (ROM), with little or no swelling or accompanying quadriceps inhibition. Athletes with grade 1 sprains usually progress quickly and return to contact sports in 1-2 weeks with physician clearance.
Grade 2 sprains involve a greater degree of ligamentous disruption with slight to moderate laxity and require an element of protection (weight bearing precautions). Grade 2 sprains in athletes typically result in 2-4 weeks of rehabilitation and return to contact sports wearing a brace if the sport allows.
Grade 3 sprains involve a complete tear of the ligament with disruption of fibers and demonstrable laxity. Grade 3 sprains require protection and are usually season ending with a 8+ week course of rehabilitation required.

KNEE MCL SPRAIN NON-OPERATIVE GUIDELINES

Phase 1: Weeks 0-2 (up to 4 weeks if grade 3 sprain)

PRECAUTIONS

Screen for fractures with Ottawa Knee Rules
Assess for injury to supporting structures o Anterior cruciate ligament
- Posterior cruciate ligament
- Medial and lateral meniscus
- Patella instability in grade 2-3 sprains
CONSIDERATIONS
- Know grade of sprain and tissues involved
- Grade 1 sprains typically progress more quickly than time frames noted in guideline
ASSESSMENT
- Lower Extremity Functional Scale (LEFS)
- Pediatric International Knee Documentation Committee Subjective Knee Evaluation Form (Pedi-IKDC) validated for ages 10 -18 years
- Numeric Pain Rating Scale (NPRS)
- Edema measurements
- Neurovascular assessment
- Palpation of pain generators
- Lower extremity (LE) active range of motion (AROM) and passive range of motion (PROM)
- LE flexibility, where appropriate
- LE strength, where appropriate
- Patellar mobility and apprehension
- Special tests for ligamentous laxity and irritability
- Quality of quadriceps contraction: good, fair, poor
- Straight leg raise (SLR) in supine: with or without lag
- Gait: with/without assistive device
- Prior/current level of function
TREATMENT RECOMMENDATIONS
- Patient education
  - Understanding valgus stress on the knee
  - Activity modifications to decrease or eliminate pain and swelling
  - Understanding the importance of compliance with the home exercise program (HEP)
  - Management of pain and effusion
  - Gait
    - Follow referring provider’s prescribed brace and WB instructions, typically:
      - Grade 1: weight bearing as tolerated (WBAT)
      - Grade 2-3: protected WB as per referring provider’s instructions
      - Progress from non-reciprocal to reciprocal stair negotiation as tolerated and per referring provider’s instructions
      - Flat, static surface
      - Progress to uneven surfaces
      - Protect, optimal loading, ice, compression, elevation (POLICE)
      - Modalities
      - Joint mobilizations
        Patella mobilizations in all planes if appropriate
        
        Active assisted range of motion (AAROM) and AROM exercises (if braced, may remove or unlock unless not permitted by referring provider)
        Stretching
        Foam rolling
        Stationary bike
        Aquatic therapy if available
        
        Progressive resistance exercises (PREs)
        Consider blood flow restriction (BFR) with low demand exercises with FDA approved device and qualified therapist
        Quadriceps sets
        SLR – all planes
        Lock brace at 0* if there is a quad lag
        Grade 1: hip adductors when no pain (delay for grade 2-3)
        
        Consider weight bearing status
        If no pain at end range extension
        
        No limits on UE or core workouts that do not affect the injured knee
        
        CRITERIA FOR ADVANCEMENT
        
        Minimal to no swelling present
        Improved knee ROM
        Full knee extension
        110° knee flexion
        
        EMPHASIZE
        
        Pain-free exercises
        Edema management
        Limit activities that stress healing tissues
        Avoid valgus stress
        Normalize gait
        
        KNEE MCL SPRAIN NON-OPERATIVE GUIDELINES
        
        Phase 2: Weeks 3-6 (up to 8 weeks if grade 3 sprain)
        
        PRECAUTIONS
        
        Avoid premature return to activity
        Avoid stretching or overloading the injured ligament
        
        ASSESSMENT
        
        LEFS
        Pedi-IKDC
        NPRS
        Edema measurements
        Patellar mobility
        Quality of quadriceps contraction: good, fair, poor
        LE AROM and PROM
        LE flexibility
        LE strength, handheld dynamometry preferred (HHD)
        Gait without assistive device (if cleared by referring provider)
        Functional assessment
        Squat: bilateral
        Single leg balance
        Forward step up
        
        TREATMENT RECOMMENDATIONS
        
        Patient education
        Progressive activity modification based on pain
        Reinforce compliance with HEP
        Movement strategies (importance of hip strategy versus knee strategy)
        Edema management: POLICE, modalities
        
        Joint mobility
        Patella all planes
        
        Achieve full and painless knee AROM
        Stretching
        Foam rolling
        
        PRE for quadriceps, hamstrings, hip abductors/adductors (Grade 3: hold isolated adductor strengthening until weeks 4-6)
        Emphasize closed kinetic chain exercises </= 90° knee flexion
        TKE
        Wall Sits
        Static lunges
        Leg press: double leg → eccentric → single leg
        Avoid hyperextension
        
        No limits on UE or core workouts that do not affect the injured knee
        
        Progress from double limb to single leg balance
        Stable surfaces → unstable surfaces → eyes closed
        Add opposite LE movement
        
        Gait: retrograde treadmill, antigravity treadmill
        Squat emphasizing hip strategy
        Bilateral to chair, progress depth as tolerated to 90°
        
        Progress from 4-6-8 inch (“) step
        
        Progress from 4-6” step
        
        Stationary bicycle
        Elliptical
        
        CRITERIA FOR ADVANCEMENT
        
        Full knee ROM
        Pain and edema managed as activity increases
        80% or greater quadriceps strength compared to contralateral leg with HHD
        Able to perform symmetrical squat with proper alignment and control
        Able to perform single leg balance without compensation
        Able to perform pain-free FSU 8” and FSD 6” with proper alignment and control
        
        EMPHASIZE
        
        Importance of adherence to HEP
        Pain-free exercise
        Edema management
        Quadriceps strength
        Activity modification that is age appropriate
        
        KNEE MCL SPRAIN NON-OPERATIVE GUIDELINES
        
        Phase 3: Weeks 7-10 (up to 12 weeks if grade 3 sprain)
        
        PRECAUTIONS
        
        Avoid overloading and premature return to activity
        Avoid compensatory movement strategies
        
        ASSESSMENT
        
        LEFS
        Pedi-IKDC
        NPRS
        LE flexibility
        LE strength (HHD)
        Functional assessment
        Squat: bilateral, unilateral
        Dynamic single leg balance
        Step up and step down
        
        TREATMENT RECOMMENDATIONS
        
        Patient education
        Functional progression
        Importance of adequate rest and recovery
        
        STM to musculature, as needed
        
        Stretching, as needed
        Foam roller, as needed
        
        Progression of isotonic exercises
        Double leg single leg exercises
        Body weight external resistance
        
        Dynamic proprioceptive exercises and perturbation training
        
        FSD 8”
        Single leg squat
        Double leg drop squat
        Jumping
        Bilateral vertical forward lateral
        
        Single alternating single unilateral
        Vertical forward lateral
        
        Use antigravity treadmill or aquatic therapy if available to introduce running
        
        Elliptical
        Stationary bike – progressively increase resistance
        
        CRITERIA FOR DISCHARGE OR ADVANCEMENT TO PHASE 4 (IF RETURNING TO SPORT)
        
        Demonstrate FSD 8” with proper form and control
        Demonstrate unilateral squat with proper alignment and control
        Proper utilization of full kinetic chain during exercise
        Complete running program without limitations, if applicable
        
        EMPHASIZE
        
        Importance of adherence to HEP
        Pain-free exercise
        Quality of functional activities
        Proper knee alignment with functional strengthening
        Avoid dynamic valgus
        
        KNEE MCL SPRAIN NON-OPERATIVE GUIDELINES
        
        Phase 4: Return to Play
        
        PRECAUTIONS
        
        Avoid premature return to play
        Ensure adequate rest and recovery with increasing activity
        Avoid dynamic valgus alignment during sport specific training
        
        CONSIDERATIONS
        
        Sport and position
        Need for functional athletic brace
        
        ASSESSMENT
        
        LEFS
        Pedi-IKDC
        NPRS
        Functional movement screen
        Quality of movement, e.g., symmetry, pain
        
        Star excursion test
        Hop tests, e.g.
        Single hop for distance
        Crossover hop
        Triple hop for distance
        6-meter timed hop
        
        TREATMENT RECOMMENDATIONS
        
        Running
        Progress to shuttle runs, sprinting
        Distances required by sport
        
        Progress resistance and endurance, sport specific
        
        Ladder, hurdles, cutting drills
        
        CRITERIA FOR DISCHARGE
        
        **HHD Testing: >90% strength of contralateral limb**
        
        Demonstrate good quality of movement on functional movement screen
        > 90% of contralateral limb on hop tests
        > 90% of contralateral limb on star excursion test
        No symptoms with sprinting, sport-specific multidirectional movements and plyometrics
        Achieved established performance levels for their sport and position
        
        EMPHASIZE
        
        Sport specific drills without valgus
        Importance of recognizing fatigue
        Collaboration with performance trainer or coach, as needed
        
        RETURN TO ACTIVITIES
        
        Running: 4-5 months when functional criteria are met
        
        Golf: Short irons at 4 months, full swing with long irons at 5 months.
        
        Delay 4-6 weeks if lead leg.
        
        Pivoting/cutting sport: When functional criteria are met and cleared by surgeon, typically
        
        6+ months at earliest

Questions about a protocol? Contact Dr. Vasileff’s office at (704) 865-0077.