Physiotherapy & Rehabilitation Protocol

Right Knee Grade II Proximal MCL Injury

(dMCL Meniscofemoral) · 6-week rehab.

Target RTPDay 35–42
Return to RunDay 14–21
HSR/SprintDay 21–28
RTT partialDay 28–35
ContactDay 32–38
OptimisationWeeks 7–9

Protocol identity

SideRight lower limb
MechanismAcute valgus contact trauma during competitive match
Injury dateDay 0
MRI dateDay 1
Target RTPDay 35–42 (6 weeks rehab) criteria-based
Diagnosis : Acute valgus sprain of the right knee, with isolated discrete/moderate partial tear of the proximal segment of the MCL (Grade II)

1. Clinical summary of the injury

FAVOURABLE PROGNOSTIC FACTORS
  • Proximal / femoral-sided location: the most favourable healing site for MCL injuries (Vosoughi 2021 proximal MCL lesions cicatrise better than mid-substance or distal Stener-like avulsions).

2. Estimated prognosis

6-week + 3-week window
Phase IDays 0–7
 Phase IIDays 7–21
 Phase IIIDays 21–35
 Phase IVDays 35–42+

PROPOSED 6-WEEK + 3-WEEK WINDOW

  • Return to Run (controlled tempo): Day 14–21 (Phase II → III gate)
  • Return to HSR / Sprint build: Day 21–28 (Phase III)
  • Return to Train (partial): Day 28–35 (Phase IV start)
  • Return to Contact (graduated): Day 32–38
  • Return to Trainig (full): Day 35–42 (Day ~35 best case, Day 42 conservative.

PHASE I PROTECTION & EARLY ACTIVATION

Inflammatory phase control pain and effusion, protect medial complex, maintain extension, initiate quadriceps and hip activation

Days 0–7
GOALS
  • Pain control (NRS ≤ 2/10 in ADLs, 0/10 at rest)
  • Resolution of minimal effusion (already minimal per MRI trace or less expected by day 5)
  • Full passive knee extension (0°), symmetrical to contralateral
  • Passive knee flexion ≥ 100° by end of phase
  • Pain-free isometric quadriceps activation, VMO visible, NO extension lag on SLR
  • Painless valgus stress at 30° at light pressure FIRM end-point maintained
  • Brace 0–90° → progressively opened to full ROM by end of phase
  • Establish daily clinical-testing baseline (including patellar tendon NRS)
INTERVENTIONS
  • Hinged knee brace (flexible Donjoy Playmaker / Bauerfeind GenuTrain): 0–90° ROM for first 5–7 days then opened to 0–110° by day 7.
  • Cryotherapy + compression: 15–20 min × 4/day for first 48–72 h,
  • Crutches with WBAT → FWB by day 4–7: brace remains for normalised gait pattern (no antalgic limp)
  • Patellar mobilisations: 4 directions
  • Active ROM within brace settings: heel slides, supine knee flexion-extension, prone hangs for terminal extension.
  • Quad sets + NMES (VMO emphasis
  • Straight leg raise (multi-plane): flexion, abduction, extension, adduction.
  • Hamstring isometrics: supine, knee 60° flexion
  • Hip activation (uninvolved planes NO valgus stress): clamshells, side-lying abduction, 3 × 10–12 reps.
  • Patellar tendon isometric loading (from Day 3): NRS ≤ 3 at patellar tendon. Maintains tendon capacity through the early-phase deload.
  • Core / lumbo-pelvic: dead-bug, bird-dog, supine draw-in
  • UB / uninvolved-limb conditioning: UBE 20–30 min RPE 5–6
  • Manual therapy (NO direct MCL provocation): soft tissue around quad, calf
DAILY TESTING
  • NRS at rest
  • Patellar tendon NRS
  • Knee circumference (effusion)
  • Active and passive ROM
  • Valgus stress at 30° flexion + at 0° extension not everyday
  • SLR NO lag for Phase II progression
  • Effusion grading (stroke test)
PROGRESSION CRITERIA (→ Phase II)
  • Pain at rest 0/10; pain walking ≤ 1/10
  • Effusion ≤ trace
  • Full passive extension (0°), symmetrical
  • Passive flexion ≥ 100°
  • Pain-free valgus stress at 30° at moderate pressure (NRS ≤ 2), FIRM end-point
  • Painless valgus stress at 0° extension
  • No reactive symptoms 24 h post-session
REGRESSION / RED FLAGS
  • Regression: pain > 3/10 with isometric or active ROM; new effusion; valgus stress
  • Red flags (refer / re-image): new instability sensation; valgus opening at 0°

PHASE II EARLY LOADING & GAIT NORMALISATION

Proliferative phase wean brace, restore full ROM, build bilateral CKC strength, introduce single-leg progressions, prepare for Return to Run

Days 7–21
GOALS
  • Full pain-free ROM (0–135°+)
  • Effusion = 0
  • Normal gait pattern without brace by end of phase
  • Quadriceps LSI ≥ 70% (HHD)
  • Hamstring LSI ≥ 70%
  • Painless valgus stress at 30° at firm pressure
  • Return to Run achieved at end of phase if criteria met
INTERVENTIONS Days 7–14
  • Stationary bike: introduce day 7–8 at low resistance, 15 min building to 30 min. RPE 5–6.
  • Bilateral CKC: mini-squats 0–45°, leg press 0–60°, wall sit at 60° flexion + NMES
  • Step-ups 10 cm
  • Quadriceps isometric multi-angle: 0°, 30°, 60°
  • Patellar tendon isometric (CONTINUED from Phase I): Spanish squat at 60° knee flex
  • Hamstring concentric: seated curl light-moderate.
  • Hip abduction (side-lying with band or weight)
  • Hip adduction (Copenhagen modified, side plank with hip ABD):
  • Lateral band walks (frontal plane only, brace ON):
  • Single-leg balance (stable surface)
  • Aquatic therapy (if available)
INTERVENTIONS Days 14–21
  • Bilateral CKC progression: leg press 0–90° at 60–70%
  • Single-leg press 0–60°:.
  • Step-ups 15 cm + light DBs
  • Romanian deadlift (light
  • Single-leg RDL (no DB initially): trunk and pelvis control.
  • Hip thrust (bilateral):
  • Slider hamstring curl bilateral (eccentric emphasis 3-s descent)
  • Single-leg squat to 45° depth:
  • Single-leg stance + ball toss (frontal plane perturbation
  • BOSU bilateral squat dome-up
  • Patellar tendon iso heavier: Spanish squat
  • Aerobic: bike RPE 6 (HIGH saddle), elliptical, AlterG.
RETURN TO RUN PROGRESSION (Days 17–21)
  • Day 17–18 AlterG / pool jogging
  • Day 18–19 Linear walk-jog (grass / treadmill)
  • Day 19–20 Continuous jog
  • Day 20–21 Tempo run
  • Footwear / surface: supportive boots/shoes, flat firm grass or treadmill; avoid uneven ground in this phase.
DAILY TESTING
  • Pre-session: NRS (knee + patellar tendon), knee circumference, ROM, valgus stress at 30°
  • HHD knee extension and flexion
  • ForceFrame hip ABD/ADD mid-week (if available)
  • Single-leg squat video
  • Patellar tendon palpation + isometric loading NRS daily
PROGRESSION CRITERIA (→ Phase III)
  • Pain = 0 during all activities including running
  • Effusion = 0 (no reactive effusion 24 h post-session)
  • Full ROM 0–135°+ symmetrical
  • Painless valgus stress at 30° at firm pressure
  • Painless valgus stress at 0°
  • Quad LSI ≥ 70% (HHD)
  • Hamstring LSI ≥ 70%
  • Hip ABD / ADD symmetry ≥ 75% (ForceFrame)
  • Single-leg squat 8 reps with good alignment (no valgus)
  • Patellar tendon NRS ≤ 2 during Spanish squat at 80% effort
REGRESSION / RED FLAGS
  • Regression: pain > 2 during running or stiffness 24 h post-session; strength drop > 10%; effusion recurrence; loss of firm end-point on valgus stress
  • Red flags: sharp medial pain during single-leg loading

PHASE III STRENGTH, HSR & DECELERATION

Strength rebuild + high-speed running + deceleration introduction preparing for cutting and COD

Days 21–35
GOALS
  • Quad LSI ≥ 85% (HHD and 90:20 IPCT)
  • Hamstring LSI ≥ 85%
  • Hip ABD/ADD symmetry ≥ 85%
  • Tolerance to HSR
  • Tolerance to linear acceleration / deceleration
  • Hop test introduction (bilateral → unilateral)
  • CMJ within < 15% of contralateral
  • Single-leg squat 10 reps clean
  • Begin controlled COD work (large radius)
  • Patellar tendon NRS ≤ 2 with heavy CKC + plyometric introduction
STRENGTH SESSION A (heavy bilateral CKC + posterior chain)
  • Back / front squat 0–90°: 70–80% 1RM
  • Leg press 0–90°: 80% 1RM
  • Romanian deadlift: 70% 1RM
  • Hip thrust (barbell): 70–80% 1RM
  • Calf raise slow eccentric:
  • Patellar tendon isometric (post-strength): Spanish squat
STRENGTH SESSION B (single-leg + eccentric)
  • Single-leg press 0–60°:
  • Bulgarian split squat with DBs:
  • Single-leg RDL with DB:
  • Nordic hamstring (assisted → full range)
  • Lateral lunge (controlled)
  • Single-leg calf raise eccentric
  • Single-leg squat to 60° depth
NMT + PLYO + DECELERATION
  • Single-leg balance perturbation (frontal AND transverse plane gradually
  • BOSU dome-up SL squat
  • Bilateral box jumps (15 cm) with stick landing: patellar tendon NRS check before progressing
  • Broad jump-and-stick (60–70 cm)
  • Single-leg hop-and-stick (low amplitude, sagittal)
  • Lateral hop-and-stick (frontal plane, low amplitude)
  • Deceleration drills at 80% effort
  • Curvilinear running (large radius): figure-8 at 70–80% Vmax
HSR & SPRINT BUILD
  • Day 21–24 HSR introduction
  • Day 24–27 Build to 85% Vmax
  • Day 27–30 Near-maximal
  • Day 30–33 Maximal
  • Acceleration / deceleration
DAILY TESTING
  • Pre-session: NRS (knee + patellar tendon), ROM, valgus stress at 30°, SL squat screen
  • HHD knee ext/flex (Mon, Fri)
  • ForceFrame hip ABD/ADD (Tue, Fri)
  • SL squat video (Wed)
  • CMJ + RSI hops (Fri)
  • Y-Balance Test (Wed)
  • Effusion check post-each session
  • Patellar tendon palpation + iso loading daily
PROGRESSION CRITERIA (→ Phase IV)
  • Pain 0/10 in all activities including HSR and hops
  • Effusion = 0 across full week
  • Painless valgus stress at 30° AND 0°, FIRM end-point
  • Quad LSI ≥ 85%; Ham LSI ≥ 85%
  • ForceFrame ABD/ADD ≥ 85%
  • SL squat 10 reps clean, no dynamic valgus
  • SL hop-and-stick LSI ≥ 80%
  • CMJ < 15% off-shift
  • Vmax ≥ 90% pre-injury baseline
  • Deceleration drills tolerated at 80% intensity, no reactivity
  • Patellar tendon NRS ≤ 2 with full plyometric and heavy CKC load
REGRESSION / RED FLAGS
  • Regression: medial knee pain during HSR or deceleration; loss of FIRM end-point on valgus stress; strength drop > 10%; effusion; patellar tendon NRS > 3 with loading
  • Red flags: sharp medial pain during lateral hop / cutting prep STOP; valgus instability sensation; locking; new MPFL territory pain

PHASE IV COD, FOOTBALL-SPECIFIC, CONTACT & RTP

Sport-specific cutting and COD + controlled contact exposure + RTT gating final progression

Days 35–42+
PREREQUISITE
  • Mandatory: all Phase III criteria met, MD clearance, athlete subjective ≥ 8/10
GOALS
  • Quad LSI ≥ 90–95%; Ham LSI ≥ 90–95%
  • ForceFrame ABD/ADD ≥ 90–95%
  • All 4 hop tests LSI ≥ 90%
  • CMJ off-shift < 10%; SL CMJ < 10%
  • Vmax ≥ 95% pre-injury × 2 separate sessions
  • Tolerance to maximal COD asymmetry < 5%
  • Tolerance to football-specific cutting and pivoting
  • Tolerance to controlled contact (graduated)
COD PROGRESSION
  • Day 35–36 Pre-planned COD at 70%: 45° cut
  • Day 36–37 60–80% intensity: 90° cuts pre-planned
  • Day 37–38 85–95% intensity
  • Day 38–39 Reactive COD:
  • Day 39–40 Maximal multidirectional
  • Football cutting drills.
CONTACT PROGRESSION (graduated)
  • Day 35–36 Non-contact football
  • Day 37–38 Light contact
  • Day 38–39 Moderate contact
  • Day 39–40 Full contact
  • Day 40–42 Full training
  • •
STRENGTH & POWER MAINTENANCE
  • NHE
  • Heavy RDL
  • Single-leg press
  • Hip thrust + SL work
  • Plyometrics
  • Sprint maintenance
  • Patellar tendon iso maintenance
TESTING BATTERY (Day 38–40)
  • 90:20 conventional
  • ForceFrame hip ABD/ADD
  • NordBord eccentric hamstring
  • Hop battery
  • CMJ
  • Vmax
  • COD
  • Clinical
  • Athlete subjective
RTP CRITERIA (all required)
  • Pain: 0/10 across full week
  • Effusion: 0 across full week
  • ROM: full and symmetrical
  • Strength: ≥ 90–95%
  • Sprint: ≥ 95% pre-injury Vmax
  • •

3. Scientific references

  1. Vosoughi F, Rezaei Dogahe R, Nuri A, Ayati Firoozabadi M, Mortazavi SMJ. Medial Collateral Ligament Injury of the Knee: A Review on Current Concept and Management.
  2. Svantesson J, Piussi R, Weissglas E, et al. Shedding light on the non-operative treatment of the forgotten side of the knee: rehabilitation of medial collateral ligament injuries
  3. Lavoie-Gagne OZ, Retzky J, Diaz CC, et al. Return-to-Play Times and Player Performance After Medial Collateral Ligament Injury in Elite-Level European Soccer Players
  4. Szeles PRQ, Ramos LA, Yamada AF, Cohen M, Sayers M, Ejnisman B. Dynamic ultrasound enables quantitative assessment of medial knee instability: A scoping review
  5. Sonnery-Cottet B, Saithna A, Quelard B, et al. Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions.
  6. Russell ER, et al. Osteoarthritis hospital admission in former professional male soccer players (population-level cohort). 2023
  7. Driller M, Leabeater A. Fundamentals or Icing on Top of the Cake? A Narrative Review of Recovery Strategies and Devices for Athletes. Sports (MDPI)
  8. Haller N, Hübler E, Stöggl T, Simon P. Evidence-Based Recovery in Soccer Low-Effort Approaches for Practitioners. J Hum Kinet.

4. Limitations & Assumptions

  1. The 6-week timeline aligns with the plan
  2. The Performance Optimisation block (Weeks 7–9) is a graduated
  3. This protocol is a living document. Adjustments expected at each gate (Phase I→II, II→III, III→IV, RTT, RTP, and end of Performance Optimisation block). Not a substitute for in-person clinical reasoning.
All steps and phases must be progressed according to the proposed targets and must always be re-evaluated when progression to the next phase is not possible. For any consultation regarding the rehabilitation and readaptation protocol, please contact Ivan Lopez Martínez.