MCL Reconstruction
Guideline
This rehabilitation program is designed to return the individual to their activities as quickly and safely as
possible. It is designed for rehabilitation following MCL reconstruction performed with an arthroscopic
approach. Modifications to the protocol may be necessary dependent on type of graft used, primary
reconstruction versus MCL revision, or concomitant injuries or procedures performed. This evidence-
based MCL rehabilitation protocol is criterion-based and time frames in each phase will vary depending
on many factors including patient demographics, goals, and individual progress. This protocol is designed
to progress the individual through rehabilitation to full sport participation. The therapist must modify the
program appropriately depending on the individual’s goals for activity following reconstruction.
This guideline is intended to provide the treating clinician with a guideline for rehabilitation. It is not
intended to substitute for making sound clinical decisions regarding the patient’s post-operative
care based on exam/treatment findings, individual progress, and/or the presence of post-operative
complications. If the clinician should have questions regarding post-operative progression, they should
contact the referring physician.
General Guidelines/Precautions:
• Therapist will monitor pain and swelling and adjust program appropriately.
• Neutral knee extension achieved by 2 weeks.
• Full flexion equal to other side in 6-8 weeks.
• Post-operative drop lock knee brace used for the first 6 weeks, unlocked for walking when
patient can complete a SLR with no extension lag.
• Non-weight bearing to toe-touch weight-bearing expected per MD preference.
• Caution against excessive resisted open-chained exercises for first 12 weeks post-op
• Closed chain strengthening limited to 70 degrees for first 16 weeks post-op
• If available, Blood Flow Restriction (BFR) training can begin after suture removal and progress
along with recommendations per physician approval.
• Level 1 testing (see Lower Extremity Testing Guideline) at or near 5 months post operatively.
• No impact activities until full ROM, no swelling, adequate strength and biomechanics are
demonstrated.
• Progression to running program at 16-20 weeks based on Level 1 Return to Play testing,
physician preference, when able to demonstrate sufficient symmetry and shock absorption
with running mechanics and plyometrics.
• Level 2 testing (see Lower Extremity Testing Guideline) at 7+ months post-op
• Return to full sport activities when able to complete Level 2 Return to Play testing with
sufficient biomechanics, strength, balance and confidence. (See guideline and appendix for
more specific information).
MCL Rehabilitation Guideline (6-12 months depending on
patient goals and progress)
GOALS/MILESTONES
PHASE SUGGESTED INTERVENTIONS
FOR PROGRESSION
Phase 0 Discuss: Goals of Phase:
Patient Education Anatomy, existing pathology, post-op rehab schedule, 1. Regain near normal joint and
Phase bracing, and expected progressions. gait mechanics
Pre-operative Phase Pre-Operative Testing: Test contralateral isokinetics at 2. Reduce fear or anxiety prior to
60/180/300o/sec, introduce to blood flow restriction surgery
training.
Instructions on Pre-Operative Exercises: Criteria to Advance to Next Phase:
• Quad setting 1. No pain or swelling
• Straight leg raises 2. Normal gait and motion
• Heel slides 3. Excellent quad activation
• Towel calf stretching
• Immediate Post-Operative instructions:
• Use ice and medication as instructed
• Quad setting every hour
• Heel propped to tolerance every 3 hours
Phase I Specific instructions: Goals of Phase:
Maximum Protection • Non-weight bearing to toe touch weight bearing in 1. P1. Prevention of post-
Phase locked brace per MD preference, unlocked with home operative complications
program exercises 2. Reducing fear with regaining
Weeks 0-6 • Crutches for the first 6 weeks ROM.
3. Prevention of arthrofibrosis
Expected visits: 6-12
Suggested Treatments: through ROM program
4. Reduction of post-operative
Modalities as Indicated: swelling and inflammation (zero
• Edema controlling treatments to trace effusion)
• NMES for quad activation
Criteria to Advance to Next Phase:
Range of Motion: 1. Control of post-operative pain
• Full extension to neutral at 2 weeks (0-2/10 with ADL’s in brace)
• Flexion ROM to 90o at 2 weeks, 130o by 6 weeks 2. Restoration of full extension
3. PROM 0-130o
Manual Therapy: Patellar mobilizations, focused on 4. Independent SLR without brace
superior glide with no extension lag
Exercise Examples:
• Quad set, straight leg raise, isometric quad set at 60o
with strap
• Towel calf stretch, static knee extension stretch
• Seated PROM knee flexion, wall slide, towel heel slide
• Clamshells, SL hip abduction, calf raises
• Initiation of blood flow restriction training if applicable
Other Activities:
• Recumbent bike, upright bike when ROM allows or
week 4; no resistance, using strobe glasses, or other
vision challenges with balance exercises
(continued on next page)
MCL Rehabilitation Guideline (6-12 months depending on
patient goals and progress)
Phase II Specific Instructions: Goals of Phase:
Early Rehabilitation • Continue with previous exercise program 1. Re-education and initiation of
Phase • Progress to light CKC program with good knee control; quad control with easy CKC
limited to 70 degrees program
Weeks 6-12 2. Protect the graft
• Progress out of drop-lock brace with good quad
control 3. Normalize gait
Expected visits: 6-9
• No pivoting on planted foot; full OKC exercises
Criteria to Advance to Next Phase:
Suggested Treatments: 1. Symmetrical hyperextension to
130o+ flexion
Modalities:
• Edema controlling treatments 2. Normal walking
• NMES for quad activation 3. Good knee control and
symmetry with CKC exercises
ROM:
• Continue to reinforce full extension
• Progressive flexion as tolerated
Manual Therapy: Continue with patellar mobilizations as
indicated
Exercise Examples:
• HS stretching
• Leg extensions 90-45 (see general guidelines above)
• 4-8 inch eccentric step ups
• Mini squats to table, wall sits, band walks
• HS isometrics, AROM hamstring at 6 weeks
• DL or SL leg press to tolerance, eccentrics
• Proprioceptive progressions
Other Activities:
• Recumbent bike, upright bike for light cardiovascular
exercise
(continued on next page)
MCL Rehabilitation Guideline (6-12 months depending on
patient goals and progress)
Phase III Specific Instructions: Goals of Phase:
Controlled • Weight training program on their own 1-2 times per 1. Improve muscular strength and
Ambulation and week endurance
Strengthening Phase 2. Improve cardiovascular
Suggested Treatments: endurance and conditioning
Weeks 12-20
3. Reduce fear and improve
ROM: Progress to full flexion ROM (kneeling), progress
confidence in the limb
Expected visits: 10-20 strength training
Criteria to Advance to Next Phase:
Exercise Examples:
1. Full pain free active and passive
Week 12: ROM
• Initiation of resisted hamstring curls, progressing as 2. Quad and HS deficit <25% 60o/
tolerated sec
• Single leg calf raises 3. Single leg step down with good
• Leg extensions 90-45 with gradual increase in ROM form with no compensatory
(see general guidelines above) movements
• Plank progressions 4. Back squat 70% body weight
with no compensatory
• Leg press progressions
movements
• Eccentric focused program
• Goblet squat
• Offset squats (biased for surgical side)
• DB eccentric step ups (forward and lateral)
• Lateral step downs
• Standing fire hydrant holds
• Single leg squats
• Higher level proprioceptive progressions
Week 14:
• Reorganize home program to address current
deficiencies
• Front/back squat
• Lunge progressions (all directions)
• Progress weight with previous exercises
• Leg extensions 90-0 at week 12 (see general
guidelines above)
Week 19: To prepare for Level 1 testing
• Initiate jumping progressions (see appendix)
• Initiate functional movement progressions (see
appendix)
Week 20: Level 1 Return to Play testing (see appendix)
Other Activities:
• Aquatic program, resisted bike/elliptical intervals
(continued on next page)
MCL Rehabilitation Guideline (6-12 months depending on
patient goals and progress)
Phase IV Specific Instructions: Goals of Phase:
Advanced • Reorganize home program to address current 1. Improve muscular strength,
Strengthening and deficiencies power, and endurance
Power Phase 2. Improve cardiovascular
Suggested Treatments: endurance and conditioning
Weeks 20-24+
• Depending on specific demands of the patient’s goal 3. Reduce fear and improve
for an activity level confidence in the limb
Expected visits: 8-16
• Continued single leg strengthening as needed 4. Improved quad strength (80%
• More advanced strength and power lifts of contralateral limb)
• 3-4 sets of 2-8 reps for strength (heavy weight, 2-3 5. Normalized gluteal strength
min rest)
• 3-4 sets of 8-15 reps for hypertrophy (moderate Criteria to Advance to Next Phase:
weight, 45-60 sec rest) 1. Quad and HS deficit < 30% at
• 3-4 sets of 1-5 reps for power (lighter weight, 5-10 60 deg/sec
min rest) 2. Back squat to 80% body
weight with no compensatory
Exercise Examples: movements
• Continue progression of strength training 3. Excellent form with RTP
• Dead lift, RDL movements
• Progress into power development (pulling derivatives)
• Clean pull, snatch pull, high pull, jump shrug
Phase V Specific Instructions: Criteria for Beginning Phase V
Advanced Movement • Reorganize home program to address current Activities:
Phase deficiencies 1. <25% strength deficit in quad,
HS, gluteals
Weeks: 20+ Suggested Treatments: Selected Criteria for Discharge:
• Depending on specific demands of the patient’s 1. <10% strength deficit in quads
Expected Visits: 8-24
goal for an activity level: Return to Run program and gluteals
(see Guideline); Interval Intensity Running Program 2. Limb symmetry index of 90%
(see appendix), Plyometric Progressions, Movement or greater on functional hop
Retraining Progressions tests and Y balance tests
3. 40/50 on biomechanical
Exercise Examples: functional assessment tests (if
• Initiate double limb jump training performed)
• Initiate running program (sport specific) 4. No pain or complaints of
instability with functional
• Initiate deceleration and single leg hopping
progression of sport specific
• Initiate cutting activities skills
• Initiate agility (floor ladder and cone drills) 5. >90% on outcome measures
(continued on next page)
**NOTE: Progression of functional activities should be performed only as pain and proper biomechanics allow. Emphasis should be on proper shock
absorption and control of dynamic valgus stress at knee (hip medial rotation with knee valgus) with each task performed. Progression to single
limb based tasks (deceleration, hopping, and cutting) should not be performed until double limb activities have been mastered. Activities
requiring dynamic control of rotational stress at the knee (cutting, multiple plane lunges/jumps/hops) are initiated only after sagittal and frontal
plane control is achieved. Return to sport may occur at any time during this stage per physician clearance and goal achievement. Return to sport
may occur at any time during this stage as cleared by physician and as progress and goal achievement occurs.
REFERENCES:
1. Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther. 2012;42(3):221-233.
2. 2. Logan CA, O’Brien LT, Laprade RF. Post-operative rehabilitation of grade III medial collateral ligament injuries: evidence based rehabilitation and
return to play. Int J Sport Phys Ther. 2016;11(7):1177-1190.
3. 3. Bakshi NK, Khan M, et al. Return to play after multiligament knee injuries in national football league athletes. Sport Health. 2018;10(6):495-499.
4. 4. Lynch AD, Chmielewski T, Bailey L, at el. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr
Rev Musculoskeletal Med. 2017;10:328-345.
Revision Dates: 12/20
Interval Sprinting/Running Program
Guidelines
• Increase total distance by 10% per workout
• To be complete with no pain and or swelling
• Repeat 3 times at same distance with no swelling or pain prior to 10% increase
Stage I: Purpose: build up work capacity and improve technique
1. 5 x 20 yds or 5 x ¾ court
2. 4 x 50 yds or 4 x 2 full court
3. 5 x 40 yds or 5 x 1 ½ court
4. 2 x 50 yds or 2 x full court
5. 1 x 100 yds or 1 x 3 courts
Stage II: Purpose: work on increased speed and build intensity
1. 5 x 20 yds or 5 x ¾ court (63 feet)
2. 4 x 50 yds or 4 x 2 full court (168 feet)
3. 5 x 40 yds or 5 x ¾ court (63 feet)
4. 2 x 50 yds or 2 x full court (168 feet)
5. 1 x 100 yds or 1 x 3 courts (252 feet)
Stage III: Purpose is to build into max speed with bias towards sports specific speed/
distance and metabolic demands.
*These sprint intervals should be developed based on the needs of the individual patient and the demands
of the sport they are planning to return to, the program does not need to be 5 different levels, but intensity
should be high.
1.
2.
3.
4.
5.
Work:Rest Ratio or based on sports specific demands: ____:____
INTENSITY 90-100%
Plyometric Progressions
Guidelines
• Must be able to perform full, free-weight squat 1.5-2.5 times body weight or squat 60%
of body weight five times in five seconds.3
• Add to sessions 1-2x/wk – 3 days between sessions.
• Begin with 30-40 foot contacts per session and increase as able.
• No more than 80-120 foot contacts per session.
Step 1
• Jumping TO box (decreased landing forces)
• 2 legs to 2 legs
• 2 legs to 1 leg
• 1 leg to opposite leg
• 1 leg to same leg
Step 2
• Jumping FROM box
• Landing on 2
Step 3
• Squat jumps
• 1 leg jump -> 2 leg land
• 2 leg jump -> 1 leg land
• Split squat jumps -> scissor jumps
• 1 leg jump -> opposite leg land
• 1 leg jump -> same leg land
Step 4
• Progress to various planes of movement as able.
ie: Double leg broad jumps, single leg lateral hops, skater lateral jumps, bounding,
drop jumps to jumps over hurdles forward or lateral, etc.
REFERENCES:
1. Bedoya AA, Milltenberger MR, Lopez RM. Plyometric training effects on athletic performance in youth soccer athletes: a systematic review. JSCR 2015.
2. Performance Enhancement in Rehabilitation: “Bridging the Gap”, Dan Lorenz DPT,PT,LAT,CSCS,USAW: March 5-6, 2016.
3. Davies G, Riemann BL, Manske R. Current concepts of plyometric exercise. Int J Sports Phys Ther. 2015;10(6):760-86.
4. Chmielewski TL, George SZ, Tillman SM, et al. Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior Cruciate Ligament
Reconstruction. Am J Sports Med. 2016;44(3):609-17.
Movement Retraining Progressions
Guidelines
• Single skill blocked practice
• Single skill variable practice
• Combination of multiple skills in blocked practice
• Combination of multiple skills in variable practice
• Combination of multiple skills with reactive cueing
• Use sport specific work:rest ratios
Excellent lateral lunge at multiple speeds -> lateral shuffle cone drills
• Progressing to reactive drills
Excellent forward and reverse lunge at multiple speeds -> decelerations
• 3 step walking deceleration cone drill
• Jogging deceleration drills, increasing speed as able
• Reactive deceleration drills
Excellent lateral shuffle and deceleration at multiple speeds -> cutting
• Shallow cuts jogging (45 degrees)
• Deceleration to lateral shuffle cone drills, increasing speed as able
• Deceleration to 90 degrees cuts, increasing speed as able
• Reactive cutting drills
Excellent lateral shuffle, deceleration, cutting, and jumping
• Reactive, variable, combined drills
• Utilize strobe glasses, resistance cords, cones, sport specifics, varied surfaces,
perturbations
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