Rehabilitation of uncomplicated grade I and II MCL strains^[1-5]

Time required for MCL rehabilitation and return to sport varies with grade of strain and pain-free weight-bearing. Duration can range from approximately 3 to 12 weeks.
Goals	Protection	Exercises	Sets and repetitions	Frequency	Criteria for progression
Acute phase (0 to 2 weeks)*
Reduce pain. Improve hip and knee mobility as necessary. Prevent muscle atrophy.	Wear hinged knee brace with restricted lateral movement when out of bed. If weight-bearing is painful, use brace and crutches to prevent stressing ligament. May bear full weight once weight-bearing is pain free. During acute phase, perform an exercise only if pain level is 2/10 or less.	After exercise, apply ice with compressive wrap to knee.	Apply for 20 minutes or longer.		Performs ADLs and walks 150 meters (500 feet) without crutches or brace and with knee pain no more than 0 to 1/10.
		Perform all exercises with both injured and uninjured legs.
		Perform gradual knee flexion and extension (in pool if possible). If pool unavailable, may use stationary bicycle with zero resistance and maximal knee motion of 45 degrees flexion and near-full extension.		1 to 2 times per day.
		Straight leg raises.	3 sets × 10 reps; 45- to 60-second hold per rep at 7/10^¶ effort; 2-minute rest between sets.	1 to 2 times per day.
		Isometric quadriceps contractions with 30 to 60 degrees knee flexion (use pillow under knee).	3 sets × 5 reps; 45- to 60-second hold per rep at 7/10^¶ effort; 2-minute rest between sets.	1 to 2 times per day.
		May use upper extremity ergometer or swim to maintain fitness. If swimming, only flutter kick (knee flexion-extension) permitted; breast stroke-style kicks prohibited. May use upper body resistance machines. Avoid any exercise or movement that causes knee pain.	Duration of cardiovascular conditioning depends upon baseline fitness. Can begin with 10 to 15 minutes and increase by 3 to 5 minutes daily, with goal of 30 to 45 minutes.	May perform conditioning work daily. Upper body strength workouts should not be performed on consecutive days.
Subacute phase (1 to 4 weeks total)^Δ – Early stage
Increase pain-free knee flexion to 90 degrees. Increase strength. Improve cardiovascular fitness.	Continue wearing knee brace during activity. Gradually increase knee flexion during exercises to 90 degrees. Unless otherwise noted, perform an exercise only if pain level is 3/10 or less.	Perform exercises 1 through 3 with injured leg only for grade 1 injury; perform bilaterally for grade 2 injury.			Walks 300 meters (1000 feet) with pain no greater than 1/10. Achieves knee flexion beyond 90 degrees without pain.
		Seated heel slides from knee extended to knee flexed (may use isokinetic variation of this exercise if available).	2 sets × 10 reps; knee flexion should not exceed 90 degrees.	Early subacute phase exercises are performed 1 to 2 times per day; 2 times preferred.
		Short-arc quadriceps extension (may use isokinetic variations of this exercise if available).	3 sets × 10 reps; knee flexion should not exceed 45 degrees.
		Standing hip abduction.	3 sets × 10 reps; no added resistance.
		Continue range-of-motion exercises. May continue upper extremity ergometer or swimming for conditioning.
		Begin stationary bicycle ergometer; begin with seat high to prevent excessive knee flexion; gradually lower seat until knee reaches 90 degrees of flexion; pain should not exceed 2/10.	Start with 10 to 15 minutes of cycling; increase by 3 to 5 minutes per day, with a goal of 30 minutes.
Subacute phase – Progressive stage
Increase pain-free knee flexion to 90 degrees. Increase strength. Improve cardiovascular fitness.	Continue wearing knee brace during activity. Gradually increase knee flexion during exercises to 90 degrees. Unless otherwise noted, perform an exercise only if pain level is 3/10 or less.	Quarter squats (knee flexion ≤45 degrees); dumbbell or goblet squats may be used.	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶	Progressive subacute phase exercises are performed once per day.	Able to perform all exercises with pain no greater than 3/10.
		Knee extension on weight machine; knee moves from 90 degrees flexion to full extension.	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶
		Hamstring (knee flexion) weight machine; knee moves from full extension to 90 degrees flexion.	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶
		Standing exercises with resistance bands:	3 sets × 10 reps for each exercise. Perform with injured leg only for grade 1 injury; perform bilaterally for grade 2 injury.
		Hip abduction.
		Hip internal rotation.
		Hip external rotation.
		Hip extension to 45 degrees.
Functional phase*
Improve knee strength. Improve balance. Improve cardiovascular fitness.		Core stability and balance exercises:		Functional phase exercises are performed once per day.	Able to perform all exercises with pain no greater than 3/10. Knee without valgus laxity.
		Plank.	Hold position for 30 seconds × 3 sets; build to 60-second hold.
		Bird-dog.	Hold position for about 8 seconds per repetition; perform 3 sets × 10 reps per side.
		Single-leg standing balance.	For standing balance exercise, start by performing it in shoes, then without shoes, and finally with a towel roll underfoot.
		Supine butt lift.	3 sets × 10 reps; hold bridge at the top for 5 seconds during each repetition, then return to start position.
		Single-leg half-squats on affected leg.	3 sets × 5 reps.
		Side step-ups on affected leg.	3 sets × 5 reps; use approximately 10 cm step.
		Two-leg squats (keep knee flexion ≤75 degrees).	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶
		Walking lunge.	3 sets × 10 reps/leg; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶
		Stair walk.	Begin by walking up and down 5 stairs. Increase the number of steps by 2 each day, provided pain is no greater than 3/10. Goal is 20 stairs. Complete 1 set daily.
		Continue mobility, conditioning, and upper body strength exercises.	Reasonable conditioning goal is 30 to 60 minutes on stationary bicycle using light resistance.
Sport-specific phase
Prepare for return to full sport.	Completes all exercises with pain no greater than 3/10. Athletes continue to wear brace during practice and games for remainder of current season (applies to both grade 1 and 2 injuries). Heavy laborers continue to wear brace until completely comfortable with strength and stability of knee.	Exercises vary by type of sport.			Approximately equal strength of hamstring and quadriceps in each lower extremity. Approximately symmetric strength of lower extremities. Able to perform full-speed, sport-specific movements without difficulty or pain. Able to complete dynamic exercise program or sport-specific equivalent. Sample dynamic exercise program: Jog 1 km. 5 × 50-m sprint at half speed. 5 × 50-m sprint at three-quarter speed. 5 × 50-m sprint at full speed. 5 × 25-m direction-change (cutting or "zig-zag") sprints at half speed. 5 × 25-m direction-change sprints at full speed. Agility drills.
		Generally includes ballistic movements (eg, skipping, jumping) and sport-specific movements (eg, cutting); gradually increase movement intensity.		Sport-specific training performed once per day.
		Squat (progress to 90 degrees knee flexion).	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^¶	2 to 3 times per week on nonconsecutive days.

MCL: medial collateral ligament; ADL: activity of daily living.
* Timeframes are estimates, and patients can proceed to the next phase as soon as they meet the criteria for advancing.
¶ Resistance for weighted exercises should be challenging but not overwhelming (about 7/10 effort). Weight should be increased judiciously but steadily once all repetitions can be completed without difficulty. Increased resistance stimulates additional strength gains. Depending on the present weight being used and patient fitness, an increase of 10 to 20% weekly is a reasonable estimate. If pain >3/10 recurs, the weight should be reduced to that used the prior week.
Δ Clinicians can use a scale of 1 to 10 to judge pain and exertion. During exercise, pain should not exceed 3 out of a maximum of 10 (ie, 3/10).

References:

Logerstedt DS, Scalzitti D, Risberg MA, et al. Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain Revision 2017. J Orthop Sports Phys Ther 2017; 47:A1.
Phisitkul P, James SL, Wolf BR, Amendola A. MCL Injuries of the Knee: Current Concepts Review. Iowa Orthop Journal 2006; 26:77.
Soheil N, Albright JP. The use of knee braces, part 1: Prophylactic knee braces in contact sports. Am J Sports Med 2005; 33:602.
Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee 2006; 13:184.
Duffy PS, Miyamoto RG. Management of medial collateral ligament injuries in the knee: An update and review. Phys Sportsmed 2010; 38:48.

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Rehabilitation of uncomplicated grade I and II MCL strains[1-5]

Rehabilitation of uncomplicated grade I and II MCL strains^[1-5]