LCL Sprain Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for Lateral Collateral Ligament (LCL) sprains. It is intended as a guideline and should be modified based on the individual patient's presentation, pain levels, functional limitations, and healing progress. Consistent communication between the physical therapist, physician, and patient is essential.

Pathophysiology

The Lateral Collateral Ligament (LCL) is a strong cord-like ligament that provides lateral stability to the knee joint. It resists varus stress (force applied to the medial aspect of the knee causing lateral opening). LCL sprains occur when this ligament is stretched or torn due to excessive varus force, often combined with tibial external rotation. The severity of the sprain is graded from I to III:

• Grade I: Mild sprain; ligament is stretched, but no significant tearing. Minimal pain and swelling. No laxity on varus stress testing.
• Grade II: Moderate sprain; partial tear of the ligament. Moderate pain, swelling, and some laxity on varus stress testing (endpoint felt).
• Grade III: Severe sprain; complete rupture of the ligament. Significant pain, swelling, and gross laxity on varus stress testing (no endpoint felt).

Associated injuries, such as fibular head fractures or peroneal nerve injuries, should be ruled out during the initial assessment.

Phase I: Protection (0-2 weeks)

Goals: Control pain and inflammation, protect the injured ligament, and initiate early range of motion (ROM) exercises.

• Pain and Swelling Management:
• RICE (Rest, Ice, Compression, Elevation) protocol. Apply ice packs for 15-20 minutes every 2-3 hours.
• Compression bandage to minimize swelling.
• Elevation of the leg above heart level.
• Pain medication as prescribed by the physician.
• Immobilization:
• Hinged knee brace locked in full extension or limited ROM (depending on the grade of sprain).
• Grade I: Brace may not be required.
• Grade II: Brace locked in extension, then gradually unlocked as pain and swelling subside.
• Grade III: Brace locked in extension for a longer period, with gradual progression based on physician recommendations. Non-weight bearing or toe-touch weight bearing may be required initially.
• Range of Motion (ROM) Exercises:
• Ankle pumps and circles to promote circulation.
• Heel slides within a pain-free range (if tolerated). Focus on achieving full extension.
• Patellar mobilizations (superior/inferior, medial/lateral) to prevent stiffness.
• Muscle Activation:
• Quadriceps sets (isometric contractions).
• Hamstring sets (isometric contractions).
• Gluteal sets (isometric contractions).
• Adductor squeezes (isometric contractions).
• Weight Bearing:
• Non-weight bearing (NWB) or toe-touch weight bearing (TTWB) with crutches as prescribed by the physician (especially for Grade III sprains).
• Progress to partial weight bearing (PWB) as tolerated, using crutches for support.

Phase II: Loading (2-6 weeks)

Goals: Improve ROM, restore strength and endurance, and normalize gait.

• ROM Progression:
• Continue heel slides, gradually increasing the range of motion.
• Stationary bike with minimal resistance (begin with rocking motion only).
• Standing knee flexion exercises.
• Strength Training:
• Resistance band exercises:
• Knee extensions.
• Hamstring curls.
• Hip abduction and adduction.
• Weight training (low weight, high repetitions):
• Leg press.
• Hamstring curls (machine).
• Calf raises.
• Closed kinetic chain exercises:
• Mini squats (pain-free range).
• Step-ups (low step).
• Balance exercises (single-leg stance with support).
• Gait Training:
• Progress weight bearing as tolerated, weaning off crutches.
• Focus on normal gait mechanics: heel strike, midstance, toe-off.
• Practice walking on even and uneven surfaces.
• Proprioception:
• Single-leg balance exercises (progress from stable to unstable surfaces).
• Balance board or wobble board exercises.
• Tandem stance.
• Brace Weaning:
• Gradually reduce brace use as strength and stability improve. Start by unlocking the brace for ambulation and functional activities. Remove the brace completely when the patient demonstrates adequate control and stability.

Phase III: Return to Function (6+ weeks)

Goals: Restore full strength, power, endurance, and functional abilities. Prepare for return to sport or activity.

• Advanced Strengthening:
• Increase weight and resistance in previous exercises.
• Plyometric exercises:
• Box jumps.
• Lateral hops.
• Jump rope.
• Agility drills:
• Shuttle runs.
• Figure-of-eight runs.
• Ladder drills.
• Sport-Specific Training:
• Begin sport-specific drills at a low intensity.
• Gradually increase the intensity and duration of drills.
• Focus on proper technique and body mechanics.
• Functional Testing:
• Single-leg hop test.
• Triple hop test.
• Crossover hop test.
• Agility T-test.
• Criteria for Return to Activity:
• Full pain-free ROM.
• Strength at least 80-90% of the uninvolved limb.
• Successful completion of functional testing.
• Physician clearance.

Common Special Tests

• Varus Stress Test: Performed at 0 and 30 degrees of knee flexion. Tests the integrity of the LCL. Increased laxity compared to the uninvolved side indicates LCL injury.
• Posterolateral Corner (PLC) Testing: Evaluate for injuries to the PLC, which often occur with LCL injuries. Dial test, reverse pivot shift test, and external rotation recurvatum test.
• Fibular Head Palpation: Palpate for tenderness, displacement or fracture of the fibular head.
• Peroneal Nerve Assessment: Check sensation and motor function of the peroneal nerve, which can be injured with LCL injuries. Assess for foot drop.

Note: This protocol is a general guideline and should be individualized based on the patient's needs and progress. Regular reassessment and communication with the physician are crucial.