Collateral Ligament Injury Case Study

Male wrestler, from high school league, arrives at the PT clinic with an MD prescription for treatment. He was diagnosed with a grade II MCL knee sprain yesterday.
A medial collateral ligament (MCL) is known as common knee ligament injury, additional with low-grade sprains often going unreported. MCL sprain often occurs for an athletic population for both contact and non-contact sports athletes. There are two different parts to MCL; superficial MCL and deep MCL. There are no firm attachments or definable bursa between a superficial MCL and underlying deep MCL. A superficial MCL is the largest structure over medial aspect of the knee, which have one femoral and two tibial attachments. Femoral attachment of the superficial MCL is not located directly to the medial epicondyle, but is centered in a depression proximal and posterior. However, tibial attachments have two different attachment sites—distal and posterior. Tibial
attachment is located just anterior to the posteromedial crest of the tibia, which majority of the distal attachment is located within the pes anserine bursa. The posterior aspect of the tibial portion of the superficial MCL is attached primarily to soft tissues directly over the anterior arm of the semimembranosus. On the other hand, deep MCL consist of a thickening of the medial joint capsule with distinct meniscofemoral and meniscotibial components.7
The majority of the injuries to the MCL include lateral blow to the knee. For instance, in many contact sports would result in a valgus stress. Additionally, external rotation of the foot, with a flexed knee, can also result in injury to the MCL.11 Due to the location of the MCL on the knee, the MCL is the primary restraint against valgus stress. At 25o of flexion, the MCL provides 78% of the valgus restraining force. On the other hand, in extension position, the MCL only provides 57% of the restraining force against valgus stress.1 …….. For the first treatment, non-thermal ultrasound is applied to an athlete. Non-thermal ultrasound is the very first treatment because any kind of temperature cannot interferes with the treatment.10 Therefore, due to acute phase of an athlete, the temperature of the tissue cannot go above one degree Celsius during the whole treatment.10 The non-thermal ultrasound will be done with frequency of 3MHz, 0.5 W/cm2, 50% duty cycle for 6 minutes. Athlete will be lying on the involved side with the knee exposed. Thus, sound head of an ultrasound will be over athlete’s MCL. Many researches have been done to prove that non-thermal ultrasound helps the patient during patient’s acute phase of an injury.
Takakura et al5 done a study on thirteen male rats’ MCL to reveal benefits of ultrasound. The MCL of one knee was exposed to LIPUS (1.5MHz, 30mW/cm2) every day for twenty minutes after the MCL surgery, while other knee was left unexposed. The rats were divided into two groups; one group of rats got killed after 12 days and other after 21 days. After 12 or 21 days, the rats were killed after their surgery to test ultimate load, stiffness, and energy absorption level of both treated and untreated MCL. According to Takakura et al,5 the rats that were treated were significantly superior in ultimate load, stiffness, and energy absorption, unlike the untreated MCL specimens. Additionally, the mean diameter of the fibrils was significantly larger in treated ligaments than untreated ligaments. But, there were no signs of significant differences in specimens obtained 21 days after the surgery due to quick natural healing
process. Also, according to Starkey,10 non-thermal ultrasound enhances tissue healing process by phagocytosis, protein synthesis, collagen production, and production of healthy granulation tissues. It also increases production of collagen from stimulating fibroblasts by increasing fibroblastic activity, and increase pain threshold from the result of increasing cell membrane permeability. As a result, earlier onset of the proliferation stage will be promoted from using non-thermal ultrasound. After non-thermal ultrasound, athlete will be doing knee AROM. Athlete will be lying prone with knee hanging at the edge of the table. Athlete will be flexing and extending his knee to the furthest before athlete feels pain. However, it is important that athlete must stop his AROM when athlete is experiencing extreme pain while doing his AROM. There are numerous reasons why AROM is necessary for injured athlete. According to Starkey,10 active muscle contraction during the acute inflammatory response phase will facilitate healing by helping control inflammation, but it also limits excessive scar formation, increase revascularization, oxygen and nutrient delivery, facilitate muscle regeneration, and reorientate muscle and ligament fibers.10 After AROM, electrical stimulation therapy can be used for pain relief. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive therapy mainly used for pain relief for a variety of pain syndrome.12 According to Starkey,10 TENS activates the gate control theory to relieve the pain through stimulation of sensory nerves and to significantly relieve pain. The Gate control theory is a segmental pain inhibition process. By producing large amount of A fibers, which is mechanoreceptor, the synaptic transmissions in A and C fibers, which are nociceptor, are inhibited. Due to large number of A is transmitted to second order neurons, the substantia gelatinosa is closed at the dorsal horn of the spinal cord. Athlete will be treated with high frequency TENS (Transcutaneious Electrical Nerve Stimulation) with frequency of 100pps, pulse duration of 100sec. Intensity of the TENS will be added until patient feels strong stimulation. There must be a non-painful strong stimulation, but muscle contraction should be present. Athlete will be lying supine with electro pads on above and below the MCL for 20 minutes. High frequency TENS are proven to relief pain. Because according to Koke et al,12 180 patients were treated with TENS to see if their pain has reduced. 180 patient were divided into three groups: 1) High frequency conventional TENS, 2) Combination high frequency and high intensity TENS, 3) Combine of parameter of group 1 and 2 with control TENS. As a result, all the patients who got treated expressed significant pain relief. However, no differences in success rate or reduction in severity of pain per type of TENS were found. Therefore, even though there is no specific experiment was done on MCL with TENS, it is clear that TENS does help relieve pain.12