Rehabilitation of Medial Ligament Injuries

Third-Degree Injuries: Weeks 1 to 3

The treatment of third-degree medial ligament injuries involves short-term immobilization to allow the medial ligament structures time to heal, with the least elongation or laxity, by limiting medial joint opening and external tibial rotation. The lower limb is placed in a cylinder cast positioned in slight varus and internal rotation for 1 week to allow the disrupted medial soft tissues to “stick-down.” Fiberglass cast immobilization is required because a long-leg hinged brace, even if locked at 0 degrees, does not provide sufficient protection to maintain medial joint line closure to allow close approximation of the disrupted medial ligament and meniscus attachment soft tissues. The patient is instructed to maintain the leg in an elevated position with the limb supported to control lower extremity swelling. The patient is also instructed to stay off of the lower limb as much as possible. In addition, ankle-pumping exercises are performed to maintain lower extremity circulation, and quadriceps isometrics are done hourly. Electrical muscle stimulation (EMS) is used to augment the voluntary quadriceps contraction. Windows may be cut into the cast to observe the electrodes to ensure they do not irritate the skin or to determine whether or not they need to be replaced. EMS is used approximately six times per day for 15-minute sessions. A cocontraction should occur between the stimulator and the patient's voluntary contraction. Hamstring and gastrocnemius flexibility exercises are also encouraged to promote posterior muscle relaxation.

At 7 to 10 days, the cylinder cast is split into an anterior and posterior shell ( Fig. 20-2 ) to allow the patient to begin passive range of motion (ROM) exercises, which are initially assisted by the therapist. The cast is used for an additional 2 weeks to allow for early stick-down of the medial ligament structures. The patient is allowed to bear 25% of her or his body weight as long as the cast is in place. ROM exercises are initiated in a figure-four position from 0 to 90 degrees to avoid valgus and external rotation loads on the healing ligaments ( Fig. 20-3 ). A 4-inch tubular stocking is double-wrapped around the foot and ankle to allow the patient under her or his own power to flex the knee. This protected ROM program is performed three to four times a day for 10 to 15 minutes per session. Quadriceps strengthening exercises including isometrics and flexion straight-leg raises are emphasized. TheraBand resistance for plantar flexion is used to maintain gastrocnemius tone. Ice, compression, and elevation are used for pain and swelling control.

Third-Degree Injuries: Weeks 4 to 6

At the end of the first 3 to 4 weeks, the bivalved cast is discontinued and the patient is placed into a functional unloading brace depending on the extent of the knee effusion and residual tenderness to medial soft tissue pressure. Weight bearing is progressed approximately 25% each week to discontinue crutches by the sixth week. Gait retraining is encouraged to allow for return of the normal reciprocal gait pattern (sufficient push-off during toe-off, midstance quadriceps contraction, hip and knee flexion during swing, and an upright posture).

Cryotherapy and EMS are continued to maintain control of pain and swelling as well as quadriceps reeducation. Exercises include quadriceps isometrics and straight-leg raises in the flexion and prone positions through the fourth week. Abduction and adduction leg raises may then be initiated as long as there is sufficient quadriceps control to limit varus/valgus loading. Any resistance in a side-to-side fashion is kept above the knee through at least the sixth week. Closed-chain exercises such as standing calf raises and wall-sitting isometrics are encouraged. ROM is progressed with figure-four protection continued through the fourth to sixth week.

Emphasis during this time period focuses on ligament protection during gait and exercise. The progression of exercise allows knee motion to be restored within normal limits. Muscle strengthening includes both closed-chain and table exercises (straight-leg raises). Emphasis is placed on hip and core control, plus progression of quadriceps strengthening ( Table 20-3 ).

TABLE 20-3

Cincinnati Sports Medicine and Orthopaedic Center Rehabilitation Protocol for Medial Ligament Repair or Reconstruction

	POSTOPERATIVE WEEKS					POSTOPERATIVE MONTHS
	1-2	3-4	5-6	7-8	9-12	4	5	6	7-12
Brace:
Long-leg hinged postoperative	X	X	X
Functional unloader				X	X	X	X	X	X
ROM minimum goal (degrees):
0-90	X
0-110		X
0-120			X
0-130				X
Weight bearing:
None	X
Toe touch, 25% body weight		X
25%-50% body weight			X
100% body weight				X
Patellar mobilization	X	X	X	X	X
Modalities:
Electrical muscle stimulation	X	X	X	X
Pain/edema management (cryotherapy)	X	X	X	X	X	X	X	X	X
Stretching: hamstring, gastrocnemius-soleus, ITB, quadriceps	X	X	X	X	X	X	X	X	X
Strengthening:
Quadriceps isometrics, straight-leg raises	X	X	X	X	X
Active knee extension		X	X	X	X
Closed-chain: gait retraining, toe raises, wall-sits, minisquats	X	X	X	X	X	X	X	X
Knee flexion hamstring curls (90 degrees)					X	X	X	X	X
Knee extension quads (90-30 degrees)		X	X	X	X	X	X	X	X
Hip abduction-adduction, multihip					X	X	X	X	X
Leg press (70-10 degrees)				X	X	X	X	X	X
Balance/proprioceptive training:
Weight shifting, cup walking, BBS			X	X
BAPS, perturbation training, balance board, minitrampoline					X	X	X	X	X
Conditioning:
UBC		X	X	X
Bike (stationary)			X	X	X	X	X	X	X
Aquatic program					X	X	X	X	X
Elliptical machine					X	X	X	X	X
Swimming (kicking)					X	X	X	X	X
Walking					X	X	X	X	X
Stair machine					X	X	X	X	X
Ski machine						X	X	X	X
Running: straight *							X	X	X
Cutting: lateral carioca, figure-8s *							X	X	X
Plyometric training *								X	X
Full sports *								X	X

PHASE 1: WEEKS 1-2 (VISITS 2-4)
General Observation	Non–weight bearing, maximum protection Brace locked at 0 degrees (motion exercises 3-4 times/day) or cast Avoid valgus loads, abnormal external tibial rotation
Evaluation (Goals)	Pain (controlled) Hemarthrosis (mild) Patellar mobility (good) ROM minimum (0-90 degrees) Quadriceps contraction and patellar migration (good) Soft tissue contracture (none)
Goals	ROM 0-90 degrees Adequate quadriceps contraction Control of inflammation, effusion

	Frequency	Duration
ROM	3-4 ×/day, 10 min
Passive, 0-90 degrees, figure-four protection
Patellar mobilization
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	3 ×/day, 15 min
Straight-leg raises (flexion)		3 sets × 10 reps
Active quadriceps isometrics		1 set × 10 reps
Knee extension (active assisted, 90-30 degrees, per quad control)		3 sets × 10 reps
Modalities	As required
EMS		20 min
Cryotherapy		20 min

PHASE 2: WEEKS 3-4 (VISITS 2-4)
General Observation	Partial weight bearing: toe touch to 25% body weight Brace unlocked (motion exercises 3-4 times/day) or cast Avoid valgus loads, abnormal external tibial rotation
Evaluation (Goals)	Pain (controlled) Effusion (mild) Patellar mobility (good) ROM minimum (0-90 degrees) Quadriceps contraction and patellar migration (good) Soft tissue contracture (none)
Goals	ROM 0-110 degrees Control of inflammation, effusion Muscle control

	Frequency	Duration
ROM	3-4 ×/day, 10 min
Passive, 0-110 degrees, figure-four protection
Patellar mobilization
Ankle pumps (plantar flexion with resistance band)
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	2-3 ×/day, 20 min
Straight-leg raises (flexion)		3 sets × 10 reps
Isometric training: multiangle (0, 60 degrees)		1 set × 10 reps
Knee extension (active, 90-30 degrees, per quad control)		3 sets × 10 reps
Aerobic Conditioning	2 ×/day, 10 min
UBC
Modalities	As required
EMS		20 min
Cryotherapy		20 min

PHASE 3: WEEKS 5-6 (VISITS 1-2)
General Observation	Partial (25%-50%) weight bearing when: Pain controlled without narcotics Hemarthrosis is controlled Muscle control through ROM ROM 0-120 degrees Avoid valgus loads
Evaluation (Goals)	Pain (mild/no CRPS) Effusion (minimal) Patellar mobility (good) ROM (0-120 degrees) Muscle control (3/5) Inflammatory response (none)
Goals	ROM 0-120 degrees Control of inflammation, effusion Muscle control Early recognition of complications (motion, CRPS, patellofemoral changes) 50% weight bearing

	Frequency	Duration
ROM	3 ×/day, 10 min
Passive, 0-120 degrees
Patellar mobilization
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	2 ×/day, 20 min
Straight-leg raises (ankle weight, not to exceed 10% of body weight)		3 sets × 10 reps
Isometric training: multiangle (90, 60, 30 degrees)		2 sets × 10 reps
Closed-chain: minisquats		3 sets × 20 reps
Knee extension (active, 90-30 degrees)		3 sets × 10 reps
Aerobic Conditioning	2 ×/day, 10 min
UBC
Stationary bicycling
Gait Retraining
Muscle control of quadriceps and hamstrings
Walking with toe-in gait; avoid toe-out valgus position
Observe gait for any tendency for valgus thrust or external tibial rotation
Smooth stance phase flexion pattern
Modalities	As required
EMS		20 min
Cryotherapy		20 min

PHASE 4: WEEKS 7-8 (VISITS 1-2)
General Observation	Full weight bearing Functional unloading brace ROM 0-130 degrees
Evaluation (Goals)	Pain (mild/no CRPS) Effusion (minimal) Patellar mobility (good) ROM (0-130 degrees) Muscle control (4/5) Inflammatory response (none)
Goals	Full weight bearing Muscle control Control of inflammation, effusion ROM 0-130 degrees

	Frequency	Duration
ROM	2 ×/day, 10 min
0-130 degrees
Patellar mobilization
Hamstring, gastrocnemius-soleus stretches		5 reps × 30 sec
Strengthening	2 ×/day, 20 min
Straight-leg raises (flexion, extension, abduction, adduction)		3 sets × 10 reps
Straight-leg raises with rubber tubing		3 sets × 30 reps
Knee extension (active, 90-30 degrees)		3 sets × 10 reps
Closed-chain:
Wall-sits		To fatigue × 3
Minisquats (with rubber tubing, 0-45 degrees)		3 sets × 20 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Balance Training	3 ×/day, 5 min
Cup walking
BBS
Aerobic Conditioning	1-2 ×/day, 15 min
UBC
Stationary bicycling
Gait Retraining
Progress program
Continue to observe for valgus thrust, external tibial rotatin
Modalities	As required
EMS		20 min
Cryotherapy		20 min

PHASE 5: WEEKS 9-12 (VISITS 1-2)
General Observation	Full weight bearing Functional unloading brace ROM 0-130 degrees
Evaluation (Goals)	Pain (minimal) Manual muscle test (hamstrings, quadriceps, hip abductors/adductors/flexors/extensors) (4/5) Swelling (minimal) Patellar mobility (good) Crepitus (none/slight) Gait (symmetric)
Goals	Increase strength and endurance ROM 0-130 degrees Normal gait without valgus or external tibial rotation

	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Patellar mobilization
Strengthening	2 ×/day, 20 min
Straight-leg raises		3 sets × 10 reps
Straight-leg raises with rubber tubing		3 sets × 30 reps
Hamstring curls (week 12, active, 0-90 degrees)		3 sets × 10 reps
Knee extension (with resistance, 90-30 degrees)		3 sets × 10 reps
Closed-chain:
Wall-sits		To fatigue × 3
Minisquats (with rubber tubing, 0-45 degrees)		3 sets × 20 reps
Lateral step-ups (2- to 4-inch block)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Balance Training	3 ×/day, 5 min
Cup walking, BBS, BAPS, perturbation training
Aerobic Conditioning (Patellofemoral Precautions)	1 ×/day, 15-20 min
Water walking
Elliptical machine
Stationary bicycling
Stair-climbing machine (low resistance and stroke)
Swimming (kicking)
Walking
Modalities	As required
EMS		20 min
Cryotherapy		20 min

PHASE 6: WEEKS 13-26 (VISITS 2-3)
General Observation	No effusion, painless ROM, joint stability Performs activities of daily living, can walk 20 min without pain ROM 0-130 degrees Functional unloading brace
Evaluation (Goals)	Pain (minimal) Manual muscle test (4/5) Swelling (minimal) Patellar mobility (good) Crepitus (none/slight) Gait (symmetric)
Goals	Increase strength and endurance

	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	2 ×/day, 20 min
Straight-leg raises with rubber tubing (high speed)		3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension (with resistance, 90-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Closed-chain: minisquats (with rubber tubing, 0-45 degrees)		3 sets × 20 reps
Balance Training	1-3 ×/day, 5 min
Balance board, two legged
Single-leg stance
Aerobic Conditioning (Patellofemoral Precautions)	3 ×/wk, 20 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Elliptical machine
Stair-climbing machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Modalities	As required
Cryotherapy		20 min

PHASE 7: WEEKS 27-52 (VISITS 2-3)
General Observation	No effusion, painless ROM, joint stability Performs activities of daily living, can walk 20 min without pain Functional unloading brace
Evaluation (Goals)	Isokinetic test (% difference between quadriceps and hamstrings, 180 degrees/sec, 300 degrees/sec) (10-15) Swelling (none) Patellar mobility (good) Crepitus (none/slight)
Goals	Increase function Maintain strength and endurance Return to previous activity level

	Frequency	Duration
ROM	2 ×/day, 10 min
Hamstring, gastrocnemius-soleus, quadriceps, ITB stretches		5 reps × 30 sec
Strengthening	1 ×/day, 20-30 min
Straight-leg raises with rubber tubing (high speed)		3 sets × 30 reps
Hamstring curls (active, 0-90 degrees)		3 sets × 10 reps
Knee extension (with resistance, 90-30 degrees)		3 sets × 10 reps
Leg press (70-10 degrees)		3 sets × 10 reps
Multihip machine (flexion, extension, abduction, adduction)		3 sets × 10 reps
Closed-chain: minisquats (with rubber tubing, 0-45 degrees)		3 sets × 20 reps
Balance Training	1-3 ×/day, 5 min
Balance board, two legged
Single-leg stance
Aerobic Conditioning (Patellofemoral Precautions)	3 ×/wk, 20-30 min
Stationary bicycling
Water walking
Swimming (kicking)
Walking
Elliptical machine
Stair-climbing machine (low resistance and stroke)
Ski machine (short stride and level, low resistance)
Running Program (5 mo Minimum, <30% Deficit Isokinetic Test	3 ×/wk, 15-20 min
Jog		mile
Walk		mile
Backward run		20 yards
Cutting Program (5 mo Minimum, 20% Deficit Isokinetic Test)	3 ×/wk
Lateral, carioca, figure 8s		20 yards
Plyometric Training (6 mo Minimum, Completion of Running/Cutting Programs	3 ×/wk
Box hops, level, double leg		4-6 sets, 15 sec
Sport-Specific Drills	3 ×/wk
Modalities	As required
Cryotherapy		20 min

BAPS , Biomechanical Ankle Platform System (Patterson Medical); BBS , Biodex Balance System; CRPS , complex regional pain syndrome; EMS , electrical muscle stimulation; ITB , iliotibial band; ROM , range of motion; UBC , upper body cycle.

* Does not include combined anterior cruciate ligament/medial collateral ligament injuries; these require a longer period of protection and training. See text for criteria required to begin these activities.

Third-Degree Injuries: Weeks 7 to 9

The brace is continued for ambulation. Gait and ROM should be normal or nearly normal, with restoration to normal as soon as possible. Pain and swelling should be within normal limits. Emphasis during this phase of treatment is on returning lower extremity strength to normal and to begin cross-training for cardiovascular endurance. Balance and proprioception exercises are also important components of this phase (see Chapter 11 ).

Straight-leg raises in multiple planes with ankle weights are used for hip control. Ten pounds of resistance represents the target goal for these exercises. Progression of the closed-chain program includes performing calf raises off the edge of a step or with weight added for resistance. Isometric wall-sits are done with a gradual increase in hold time and then with handheld weights added. TheraBand resistance is used with minisquats and terminal knee extension. Gait retraining is done with a heavy elastic band positioned about the thighs. In addition, the patient is progressed to a machine-oriented program for leg press (80 to 10 degrees), knee extension (90-30 degrees), seated hamstring curls (0-90 degrees), hip abduction/adduction, and calf presses.

Endurance training includes a stationary bicycle, elliptical cross-trainer, and/or aquatics for 20 to 30 minutes at least three times per week. Activities such as cutting or twisting that place valgus and external rotation torques on the lower extremity are still limited. Proprioception and balance training includes unidirectional exercises balancing on a rocker board and multidirectional activities such as a wobble board or balance board. Balance activities at home progress from tandem balance positioning to single-leg stance. In select patients, isokinetic testing is performed to measure quadriceps and hamstrings muscle strength. The goals for initiating a running program are at least 70% on bilateral comparison for quadriceps and hamstrings at 180 degrees/sec and 300 degrees/sec, torque/body weight ratios (based on age and gender), and a hamstring-quadriceps ratio of 60%.

Third-Degree Injuries: Weeks 10 to 12

The focus of this final phase is on return to activity. By this time, gait, ROM, activities of daily living, and symptoms should be within normal limits. The exercise progression advocates return of isokinetic muscle strength parameters within 70% and 90% for straight-ahead running and more strenuous turning/cutting drills, respectively. The cross-training program is advanced to a full running program that then allows for sports-specific training. Distance and direction-specific running and agility drills are incorporated. Heavy strength training occurs on opposite days of the running program. Injury prevention and neuromuscular retraining programs include jump training activities with emphasis on technique, position, alignment, and repetition as discussed in detail in Chapter 14 . Isokinetic testing is performed, with the goal of achieving a 90% bilateral comparison for quadriceps and hamstrings at 180 degrees/sec and 300 degrees/sec, torque/body weight ratios (corrected for age and gender), and a hamstring/quadriceps ratio greater than 60%. Patients continue brace use for activity only. Follow-up treatment is based on either the need for symptom control and/or functional progression for unrestricted return to activity.

Concomitant Cruciate Ligament Injuries

Patients who have a concomitant ACL rupture and third-degree medial ligament rupture undergo the initial stick-down program and treatment described. According to the severity of the medial ligament injury, sufficient time is required to stick down the medial structures, allow for figure-four ROM, protect with partial weight bearing, and initiate early quadriceps exercises. Initial knee motion goals are 0 to 90 degrees. Normally, 3 to 6 weeks of conservative management is required before the patient undergoes ACL reconstruction. The progression of exercises and weight bearing is consistent with that described above.

Patients who have concomitant PCL and medial ligament ruptures also undergo the initial stick-down program with a posterior calf pad to prevent posterior tibial subluxation. The cast is bivalved at 2 to 4 weeks, allowing protected passive ROM exercises to be performed initially by the therapist and then by the patient. Figure-four ROM exercises with an anterior drawer support allow for protection of both ligaments. Two weeks later, the bivalved cast is replaced with a long-leg hinged brace with a posterior pad, which is used for another 4 weeks. Weight bearing, ROM, and quadriceps exercises are all progressed as tolerated. The initial knee motion goal is 0 to 90 degrees, which is then gradually progressed to a full 6 weeks after the cast is discontinued. Full weight bearing is permitted at this time, with emphasis on quadriceps control. Hamstring contractions are not allowed for the initial 6 weeks, and are then permitted in the active mode only for an additional 6 weeks. The patient's gait, knee motion, quadriceps control, and symptoms should be back to normal limits to consider surgical intervention. Knee injuries with combined third-degree medial ligament ruptures and PCL ruptures often require operative repair; the postoperative course is described in Chapter 18 .