Physiotherapy and rehabilitation after multiligament reconstruction- Henry Atkinson August 2009

Physiotherapy and rehabilitation following multi-ligament reconstruction
Henry Dushan Edward Atkinson,  Jennifer Michelle Laver,  Elizabeth Sharp

Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth
Consultant Trauma and Orthopaedic Surgeon
North Middlesex University Hospital, Sterling Way, London N18 1QX
North London Sports Orthopaedics

Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons)
Senior Lower Limb Sports Physiotherapist
SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia

Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys
Clinical Director ESPH
ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD
ESPH, 22 Harley Street, London W1G 9PL

Multi-ligament reconstructions are not commonly performed and thus there are no set protocols. As combinations, ACL and PCL have a high risk of long-term knee stiffness if repaired at the same time (Jari and Shelbourne (2001). The MCL and PCL have the capacity to heal without surgery (Jari and Shelbourne 2001). Combined LCL and ACL are very rare. MCL and ACL are the most commonly seen of the multi-ligament reconstructions.

When an MCL (usually grade III injury) is repaired concurrently with an ACLR, then treat the patient as an ACLR. However, the early rehabilitation timeframes are longer than with isolated ACLR and the knee should be braced for 6 weeks in a limited ROM brace (allowing full range motion but blocking 10 degrees of terminal extension). Non-operative MCL injuries (eg Grade II) may also be braced.
The first 6 weeks are a maximum protection phase (Edson 2003). Weeks 7-16 are a moderate protection phase where patients increasingly weightbear with increased ROM, and low intensity strengthening exercises (Edson 2003). The final phase involves regaining full mobility, strength and a return to full function (Edson 2003)

    Noyes et al braced their patients limiting the last 10-20 degrees of extension for 2-3 weeks following MCL repair with ACLR to protect medial ligament and posteromedial capsular repairs, but also limited their active flexion to 90 degrees while in the brace (Noyes and Barber-Westin (1995). Robins et al also restricted their extension range in the early post-op phase (ACLR with MCL Repair) by placing their patients in a controlled motion brace, with a limit to extension at 20 degrees for the first 2 weeks post-op, a limit to extension at 10 degrees during weeks 3-4, and full extension from weeks 5-6 (Robins et al (1993). They also had restrictions to flexion range to 90 degrees until 6 weeks post-op (Robins et al 1993). Hastings et al suggested that immobilization in extension and early range of motion into full extension may cause a collateral ligament to heal at its maximum length, rather than in a shortened position that assumes tension when the knee moves into extension (Hastings (1980).

Healing of the MCL was demonstrated in both the surgically repaired complete MCL rupture and non-operatively treated superficial tear of the MCL when occurring in conjunction with a ACLR (both were braced post-op ACLR) (Noyes and Barber-Westin 1995)

Restrict movement to the sagittal plane to avoid stressing the MCL (Manal and Snyder-Mackler 1996). Brace with unrestricted flexion and extension range to control valgus and varus laxity for 8 weeks post-op ACLR with non-operative treatment of the valgus laxity (Hara et al 2008). Benjamin et al (2000) found that in goat models, when a valgus stress was applied to the knee, the insitu forces in the ACL graft increased by nearly 2.5 times in a MCL deficient knee compared with an intact MCL, concluding that an ACLR MCL deficient knee should be protected from high valgus forces during the early healing phase to avoid excess loading of the ACL graft. In view of this, Halinen et al (2006) recommended the use of a hinged brace post-operatively to protect both of the healing ligaments (MCL and ACL), used for 6 weeks and then 2 weeks during ADL only.

In a RCT comparing operative and non-operative treatment of grade III MCL injuries with ACLR, the post-op protocol allowed full ROM and weightbearing in a hinged knee brace for 6 weeks immediately, with the brace locked at 0 degrees and not allowing hyperextension and allowing full flexion, and crutches used for 2-3 weeks to normalize gait (Halinen et al 2009). Halinen et al (2006) allowed the same post-op protocol in a hinged knee brace, but did not mention any lock at 0 degrees extension

Battaglia et al (2009) did a cadaveric study on ACL stress with MCL injury, and found that there was a significant increase in ACL load at 30 degrees knee flexion during the application of valgus load and internal rotation torque to specimens with a partial of complete MCL injury, and at 0 degrees with the application of internal rotation torque only (Battaglia et al 2009). This supports the potential need to support a knee in the post-op period after ACLR with a concurrent partial or complete MCL injury to protect the healing ACL from valgus and rotatory forces (Battaglia et al 2009)

Early rehab aims are to normalize gait and restore ROM (Halinen et al 2006)

Aggressive muscle strengthening delayed, and commenced with CKC exercises (Halinen et al 2006, Halinen et al 2009)

Multi-ligament reconstructions are progressed at a slower rate early during the ACLR program (Eckersley et al 1995). The rehab program used by Hara et al (2008) was the same for isolated ACLR and grade II MCL treated non-operatively combined with ACLR. Generally followed ACLR rehab program (Noyes and Barber-Westin 1995).

RTS at 9-12 months if 90% muscle strength compared with the other knee achieved (Halinen et al 2009)

RCT showed that nonoperative treatment of the MCL, with post-op bracing, allowed for the faster return of knee flexion range (statistically significant at 6, 12 and 36 weeks post-op, but not beyond that) and quads power (statistically significant difference at 1 year post-op but not 2 years) (Halinen et al 2009)


Battaglia MJ, Lenhoff MW, Ehteshami JR, Lyman S, Provencher MT, Wickiewicz TL and Warren RF (2009): Medial Collateral Ligament Injuries and Subsequent Load on the Anterior Cruciate Ligament: A Biomechanical Model in a Cadaveric Model. American Journal of Sports Medicine 37 (2): 305-311

Benjamin C, Papageogiou CD, Debski RE and Woo SL-Y (2000): Interaction between the ACL graft and MCL in a combined ACL+MCL knee injury using a goat model. Acta Orthopaedica 71 (4): 387-393

Eckersley EA, Fritz JM and Irrgang JJ (1995): Criterion-Based Rehabilitation Program After Anterior Cruciate Ligament Reconstruction. Operative Techniques in Orthopaedics 5 (3): 266-269

Edson C (2003): Postoperative rehabilitation of the multi-ligament reconstructed knee. Operative Techniques in Sports Medicine 11 (4): 294-301

Halinen J, Lindahl J, Hirvensalo E and Santavirta S (2006): Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture With Early Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study. American Journal of Sports Medicine 34 (7): 1134-1140
Halinen J, Lindahl J and Hirvensalo E (2009): Range of Motion and Quadriceps Muscle Power After Early Surgical Treatment of Acute Anterior Cruciate and Grade-III Medial Collateral Ligament Injuries: A Prospective Randomized Study. Journal of Bone and Joint Surgery (American) 91-A (6): 1305-1312

Hara K, Niga S, Ikeda H, Cho S and Muneta T (2008): Isolated Anterior Cruciate Ligament Reconstruction in Patients With Chronic Anterior Cruciate Ligament Insufficiency Combined With Grade II Valgus Laxity. American Journal of Sports Medicine 36 (2): 333-339

Hastings DE (1980): The Non-Operative Management of Collateral Ligament Injuries of the Knee Joint. Clinical Orthopaedics and Related Research 147: 22-28

Jari S and Shelbourne KD (2001): Nonoperative or Delayed Surgical Treatment of Combined Cruciate Ligaments and Medial Side Knee Injuries. Sports Medicine and Arthroscopy Review 9 (3): 185-192

Manal TJ and Snyder-Mackler L (1996): Practice guidelines for anterior cruciate ligament rehabilitation: a criterion-based rehabilitation progression. Operative Techniques in Sports Medicine 6 (3): 190-196

Noyes FR and Barber-Westin SD (1995): The Treatment of Acute Combined Ruptures of the Anterior Cruciate and Medial Ligaments of the Knee. American Journal of Sports Medicine 23 (4): 380-391

Robins AJ, Newman AP and Burks RT (1993): Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries: The effect of medial collateral ligament rupture location. American Journal of Sports Medicine 21 (1): 20-25

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