Physical therapy treatment for PCL tears depends on primary treatment. Conservative care generally calls for immediate physical therapy, whereas post-op care is dictated by the operating surgeon. The immediate goal for non-operative PCL tears is to reduce pain and inflammation and restore range of motion, similar to ACL rehabilitation. Early progression of weight bearing and quadriceps strengthening is pertinent to ensure stability of the tibia on the femur (Peterson, 2017). Medial collateral ligament The MCL is the prime static stabilizer of the medial side of the knee joint, and is important for providing support against valgus stress, rotational forces, and anterior translational forces on the tibia (Andrews, 2017). The medial collateral ligament is also the most injured ligament of the knee. Injury is generally sustained in the athletic population as a result of valgus contact with or without tibial external rotation. The capacity of the medial collateral ligament to heal has been demonstrated, however it is noted that complete ruptures heal less consistently and may result in persistent instability of the knee joint (Logan, 2016). Signs and symptoms of MCL injury include a history of the above-described mechanism of injury, coupled with a positive valgus test with the knee tested in 30° of flexion to isolate the MCL. Additionally, reported knee joint line pain and pain with resisted knee flexion suggest an MCL tear. Following a valgus test with the knee flexed to 30°, the test should be repeated in 0° of flexion (full extension). An increase in medial joint space during this valgus test indicates additional posterior oblique ligament injury, and possible PCL or ACL involvement (Logan, 2016). Standard radiograph films may be ordered when there is high suspicion of an MCL tear due to the possibility of bony avulsion with tearing, as the presence of these or osteochondral fragment will significantly change the treatment plan. Furthermore, medial tibial plateau fractures can result from valgus force to the knee, and can imitate medial joint instability on physical exams. Stress views may help rule out physeal damage in skeletally immature patients. Tears of the MCL are classified into three grades. Grades I and II are partial tears and most often medically managed conservatively with physical therapy, and most athletic patients with MCL tears across all grades can return to their pre-injury performance level without surgical intervention (Andrews, 2017). However, if the MCL is compromised in combination with other ligaments in the knee, especially the ACL, then surgical intervention may be warranted (Logan 2016). The emphasis for rehabilitation of Grades I and II tears is protecting the knee from excessive valgus forces and loading. Early rehabilitation and ROM exercises with progressive strength training is advised (Andrews, 2017). Graded exposure to balance and proprioceptive activities is also pertinent. Grade III rupture of the MCL ligament in isolation can be treated either conservatively or surgically. Rehabilitation will depend on the course of treatment taken, and will include promotion of range of motion, lower-extremity progressive resistive strengthening, proprioceptive training, and functional activity training. When operative intervention is deemed necessary, anatomical medial knee reconstruction may be recommended (Logan, 2016). Post-operative rehabilitation focuses on early motion and the return of normal neuromuscular control and coordination with progression based on attainment of specific phase criteria and goals that may vary according to the surgeon. Lateral collateral ligament The lateral collateral ligament (LCL), also known as the f ibular ligament serves as one of the key stabilizers of the knee joint. Originating on the lateral epicondyle of the femur and inserting on the fibular head, the lateral collateral ligament’s primary purpose is to prevent varus stress and posterior-lateral rotation of the knee. Lateral collateral ligament injury is less common than other ligamentous injury due to mechanism of injury required
to impair the ligament—a varus force occurring from inside the medial aspect of the leg is required to sustain this injury. The most common mechanism of injury is seen via a high impact blow to the anteromedial knee, combining hyperextension and extreme varus force. Noncontact hyperextension and noncontact varus stressors have also been reported to cause LCL injuries, though they are rare (Yaras, 2020). LCL injury commonly occurs in tandem with injury to other structures including the PCL, ACL, or the knee capsule. Lateral capsular ligaments and fibular collateral ligaments may also be injured. More severe injury to the lateral aspect of the knee may involve the biceps femoris tendon and iliotibial band disruption at the attachment at the head of the fibula and Gerdy’s tubercle. Due to proximity anatomically, the peroneal nerve and popliteal tendon may also be involved, as well as the knee menisci. Signs and symptoms include a report of varus knee contact in a sport, with acute lateral knee pain and knee point swelling. Evaluation should include varus knee joint testing, and assessment of knee swelling. A comprehensive full range of motion knee exam is imperative for all patients. Palpation of the lateral knee should be performed with the most common exam finding being pain at palpation. This may also be evident along the infrapatellar bursa, Gerdy’s tubercle, and the patellar tendon attachment (Yaras, 2020). As it is rare for injury to occur to the LCL in isolation, treatment is heavily dependent upon what other structures were damaged. In more mild cases, the patient may be placed in a hinged brace and prescribed crutches with orders to weight bear as tolerated. Rest, ice, and compression are warranted in the acute phases. Physical therapy 3 to 5 days after injury to promote range of motion, decrease pain, and slowly implement progressive resistive training is beneficial. If the patient undergoes surgery, rehabilitation will be dependent on procedures provided and post-op protocol, which will vary by surgeon. Rehabilitation for Grade I and II strains generally may include passive and active prone knee flexion, initiated in the immediate weeks following injury to help prevent stiffness or contracture. Around 6 weeks post-injury, a hinged knee brace is removed, and the patient may begin physical therapy with focus on quadriceps strengthening, proprioceptive capabilities, and strengthening of the muscles of knee and hip. Patients may return to sports only when meeting the following criteria: full, painless knee motion, complete reduction of lateral knee tenderness, and complete resolution of ligamentous laxity. In general, return to sports is approximately 4 weeks for Grade I injuries, and 10 weeks for Grade II (Yaras, 2020). For Grade III injury rehabilitation, patients should be non- weight bearing in a knee immobilizer for 6 weeks after surgical interventions if they are performed. As in Grades I and II injuries, quadriceps strengthening is imperative throughout recovery. Hamstring strengthening should be avoided for at least 4 months to prevent damage to the reconstruction. Sport-specific therapy may commence four months postoperatively (Yaras, 2020). In 2013, a new lateral knee ligament was discovered: the anterolateral ligament (ALL). There had been controversy surrounding its true anatomical parameters and existence until the cadaveric study conducted by Claes et al. (2013) identified its true anatomic nature. The ALL bony attachments are the femur and tibia, and it is distinguished from the anterolateral joint capsule. The origination is the lateral aspect of the femoral epicondyle, anterior to the origin of the LCL. It takes an oblique course and inserts onto the anterolateral aspect of the proximal tibia and the lateral meniscus (Claes et al., 2013). Meniscal tears Menisci are critical for maintaining stability and force-absorption capabilities of the knee. It is estimated that menisci are responsible for 60% to 90% of loads transmitted across the joint space between the femoral condyles and tibial plateau,
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