Rehabilitation of a High Grade MCL Tear - Utilising a Systems Based Approach

August 24th, 2023

For contact sport athletes, a common injury which is prevalent is an injury to the Medial Collateral Ligament (MCL) of the knee. As a diagnostic and rehabilitation professional, it is important to understand the mechanics of the anatomy of the MCL in order to accurately diagnose the injury and the recondition an athlete back to their full performance capacity. The purpose of this blog will be to outline the epidemiology of isolated high grade MCL injuries; differential diagnosis and the rehabilitation process from Protection to Return to Performance utilising a systems based approach that can be applied to multiple knee pathologies.

Anatomy & Function of the MCL

Crucially it is important to understand that the MCL is composed of two distinct bands that allow it to perform its anatomical role. These are known as the Superficial MCL (sMCL) and the Deep MCL (dMCL). The superficial and deep ligaments each have a unique function, making the MCL the primary responder to valgus stress and a secondary restraint to rotational forces. The sMCL, specifically the proximal division, resists valgus forces through all degrees of knee flexion. The distal division of the sMCL helps stabilize external rotation of the knee at 30-degree flexion. The dMCL helps stabilize internal rotation of the knee from full extension through 90-degree flexion (Juneja et al 2022).

The sMCL has its proximal insertion at the medial epicondyle of the femur where it blends into the semimembranosus tendon. The distal attachment is at the posteromedial surface of the tibia. The dMCL is composed of 2 ligaments: meniscofemoral and meniscotibial. The meniscofemoral has its proximal insertion at the femur just distal to that of the sMCL; it attaches to the medial meniscus. The meniscotibial ligament is thicker and shorter. It travels from the medial meniscus to the distal edge of the articular cartilage of the medial tibial plateau (Juneja et al 2022).

Anatomy of the sMCL & dMCL
Figure 1: Anatomy of the sMCL & dMCL

Mechanisms of Injury: Contact vs Non Contact

When placed in a situation that an athlete has suffered an acute injury and pain to the medial aspect of their knee, it is important to decipher whether the primary mechanism of injury (MOI) is either contact or non contact. For isolated MCL injuries, ~80-90% of them come from a contact MOI whereby a Valgus stress occurs. In field / court based contact sports, due to the position of the knee and the force vectors, a combined flexion/valgus/external rotation injury is usually the end result. The vast majority of MCL injuries are from a direct blow to the outer aspect of the lower thigh or upper leg (Phisitkul et al 2006). The exception to this is in winter sport athletes such as skiiers who have high rotation loads when cutting and turning. In light of this, if an athlete is subject to a non contact MOI and presents with MCL laxity, a suspicion must be present for a concurrent ACL injury regardless of clinical testing results for the ACL itself.


Immediate Assessment & Management

When determining the grading of an isolated MCL injury, there is a wide variety of presentations that a clinician can be faced with. Particularly important is the athletes natural level of laxity and thus stress test comparisons with the non injured limb is critical to providing an accurate assessment. Gradings for an injury to the MCL can be defined as the following:

Grade 1 - Pain on stress testing at 0 & / or 30 degrees with nil significant laxity in comparison to the contralateral limb

Grade 2 - Pain on stress testing 0 & / or 30 degrees with comparable laxity in comparison to the contralateral and a presence of a ligamentous end feel

Grade 3 - Pain or no pain on stress testing 0 & / or 30 degrees with significant laxity in comparison to the contralateral and no end feel.

Palpation is an important tool in conjunction with radiographic imaging in determining whether the injury has been sustained to either of the: Femoral component; mid belly MCL or Tibial component of the ligament. Prognosis can differ with slower recoveries indicated for injuries to the tibial insertion of the MCL due to it's thinner anatomical insertion

Cadaveric model of the anatomy of the sMCL
Figure 2: Cadaveric model of the anatomy of the sMCL

As this blog is dedicated towards a high grade injury, when a grade 2 and above injury is suspected, the clinician should place the athlete in a hinged knee brace restricting the athlete from end ranges of extension and flexion that place higher strain on the MCL (Vosoughi et al 2021). Conjecture exists surrounding the natural history and recommendations for bracing, there are no set rules on how long an athlete should be braced for and a principle that I like to live by is that an athlete will remain braced until the ligament stabilises. An example 6 week bracing progression is listed below

Weeks 1 & 2: 30 - 60 degrees
Week 3: 20 - 70 degrees
Week 4: 10 - 80 degrees
Week 5: 0 - 90 degrees
Week 6: 0 - 120 degrees
Week 7: Brace off

Importantly, a clinician should not regularly assess healing of the MCL as this may disrupt fibres that are attempting to scar and realign. Personally I re-assess the MCL at the week 4 mark after initial collagen has had time to be laid and then at 2 week intervals until it has stiffened up to the comparable marker of the contralateral limb.

*A clinical observation I have made is that assessment at 0 degrees of extension stabilises and reduces in irritability far faster than at 30 degrees of flexion.


Radiography: What value can it add?

Radiographic Stress X Ray Assessment of the MCL
Figure 3: Radiographic Stress X Ray Assessment of the MCL

As mentioned above, radiography can assist with a clinical diagnoses in many ways:

  1. In the presence of non contact injury confirm Dx for concomitant pathology

  2. Confirm clinical grading of MCL injury

  3. Confirm location of MCL injury

Different methods of radiographical assessment exist, namely through the form of valgus stress x rays or MRI. I havn't come across a scenario where valgus stress x rays are practical so in that space MRI imaging should be ordered.

MRI imaging of a High Grade Injury to the Tibial Portion of the sMCL
Figure 4: MRI imaging of a High Grade Injury to the Tibial Portion of the sMCL

Rehabilitation Planning:

Importantly, part of my process for any long term rehabilitation planning is to map out the projected journey from start to finish and break it down into our 5 phases of rehabilitation that we utilise at Athletes Authority.

The 5 stages of Athletic Rehabilitation at Athletes Authority
Figure 5: The 5 stages of Athletic Rehabilitation at Athletes Authority

By detailing the rehabilitation plan it allows myself as the clinician to be targeted and objective my staged progression as well as giving the athlete context to each mini progression and goal that we tick off along the way. Below is an example of a full detailed rehabilitation plan for a high grade isolated MCL injury.

Example G3 MCL Rehabilitation Plan
Figure 6: Example G3 MCL Rehabilitation Plan

Important key themes within the progression of the rehabilitation plan include the restoration of physiology in the Protection phase. Development of base strength capacity in the Load Introduction phase. Restoration of plyometric capacity, particularly within the frontal plane in the Strength Accumulation phase; in tandem with return to run. Late stage return to contact and skill demands in the Training Integration & Return to Performance phase.

Following on from this macro rehabilitation plan, I then look to design integrated training weeks with the athlete in the form of a micro weekly rehabilitation plan. This allows for appropriate measures of load monitoring and session timing when designing a program that encompasses for local tissue restoration; full body strength capacity & cardiovascular reconditioning.

Example Weekly Micro Planning Sheet
Figure 7: Example Weekly Micro Planning Sheet

Whilst giving complete insight into an athletes full journey is impractical deliver on a blog, below I will outline some key training program progressions that could be utilised in different phases of the rehab journey.

Protection Phase:

Protection Phase
Figure 8: Protection Phase

Within the protection phase, our primary focus is to facilitate an environment that allows the MCL to gain strong foundations of anatomical healing and scar formation. First and foremost ensuring that the hinged ROM brace provided to the athlete is fitted correctly and that compliance is maintained to wearing the brace is priority number 1. I have experienced scenarios in the past whereby I felt my rehabilitation planning and implementation was incredibly spot on however once we got to clinical re-assessment date it came to my surprise that there was still significant laxity in the ligament. Upon further questioning I would then discover compliance with the brace had deteriorated because the athlete felt it was impacting their ability to perform their rehabilitation. Ironically, this desire to improve their rehab became their downfall. An important lesson for me to learn and a reminder that in rehabilitation, the basic principles of tissue healing come before those of strength & conditioning restoration.

With this in mind, second order principles are the following:

  1. Reduction of pain & swelling

  2. Re-activation of Quadriceps

  3. Maintenance of Hamstring, Calf & Foot strength

  4. Development of single leg stance and lateral hip rotation control

  5. Energy Expenditure


Reduction of pain & swelling:

Despite a lack of concrete evidence existing for the efficacy of cryotherapy against reduction in localised inflammation post injury, there remains a strong level of evidence for the use of cryotherapy in the improvement of function post severe trauma to the knee (Dambros et al 2012). My preference in clinic is to utilise Game ready protocols of 30 minute sessions whenever the athlete is in the facility, before and after they perform their rehabilitation. Analgesic effects provided from cryotherapy can reduce arthrogenic muscle inhibition (Rice et al 2009) as well as providing improvements in joint range of motion (Dambros et al 2012, Rice et al 2009). For maintenance at home, I would provide a compression sleeve for the athlete to wear in conjunction with regular icing whenever they are sedentary at home.

Amongst passive protocols, it is important for an athlete to maintain an active approach to this process. Utilisation of the skeletal muscle pump in the lower limbs can be an effective way of clearing fluid, particularly as in the instance of a high grade injury and that the MCL is an extracapsular structure, swelling may pool well below the knee into the calf and ankle.

Simple protocols such as ankle pumps can be scaled effectively to an athlete wearing a brace, can be done anywhere and place no undesired load onto the healing MCL.

Video 1: Ankle Pump Example (No Brace Worn)

Re-activation of Quadriceps:

Acute trauma and associated joint swelling are key contributors to arthrogenic muscle inhibition of the quadriceps. AMI is caused by a change in the discharge of articular sensory receptors whilst the importance of the quadriceps to overall knee function surrounds the relationship between skeletal muscle and their role in providing shock absorption towards articular joints (Suzuki et al 2022).

Key principles are to develop quadriceps strength within the allowances that the hinged ROM brace provides to the athlete. A high variability in athlete function can exist within this population and it is important to achieve a stimulus that is great enough to overcome aforementioned AMI and redevelop quadriceps capacity. Having a continuum of early stage exercise progressions is critical in being able to apply the appropriate progressions towards the athlete in front of you. Below are some examples of protection phase quadricep focused options that you may utilise with an athlete.

Protection Phase Quadricep Based Exercise Options
Figure 9: Protection Phase Quadricep Based Exercise Options

Below are three examples of early stage protection phase quadricep exercises. I normally combine all of these with NMES and BFR for increased neural drive and metabolic stress production.

Video 2: Inner Range Quadriceps Contraction (pictured with no brace)
Video 3: Banded TKE to A Frame (Pictured with no brace)
Video 4: Swiss Ball Leg Extension Isometric Push

Maintenance of Hamstring, Calf & Foot Strength:

Whilst quadriceps are the key priority in the early stages of rehabilitation, the importance of the hamstrings, calves and feet are paramount in ensuring optimal functional rehabilitation once an athlete enters a more integrated pattern of movement demands. As discussed in a previous blog (https://www.sportsrehab.physio/post/failure-of-hamstring-graft-aclr-part-1-the-role-of-eccentric-strength); the hamstrings play an intricate role in the protection of knee health, whilst the calf and feet are gaining increased attention due to it's role in force production, absorption & neuromuscular control when running (Bohm et al 2021).

A consideration for the rehabilitation professional when it comes to hamstring exercise prescription is the interrelationship between the MCL and the insertion of the distal hamstrings at the pes anserinus (Vosoughi et al 2021). During knee joint flexion, the semimembranosus muscle contracts and tightens the posteromedial knee capsule and the POL. It also pulls the medial meniscus posteriorly and prevents the anterior subluxation of the tibia. Another important role of the semimembranosus muscle is internal rotation of the tibia (Vosoughi et al 2021). Matching this with literature suggesting that exercises such as lying leg curls may preferentially activate the medial hamstrings in comparison to the lateral hamstrings (Bourne et al 2017) the rehabilitation professional should monitor with caution patient responses to traditional concentric based hamstring exercises.

Posteriomedial Corner Anatomy
Figure 10: Posteriomedial Corner Anatomy

With this anatomical consideration in mind, my hamstring based progressions typically are centred around the projected load that I believe will be placed on the posteriomedial corner (PMC) of the knee. Below is an example exercise progression based around this concept with some notes on progression of exercise options. It is important to note that progressive overload should be kept front and centre in mind as the athlete recovers and we can utilise increased loading and volumes in conjunction with more challenging exercise progressions

Protection Phase Hamstring Exercise Progressions
Figure 11: Protection Phase Hamstring Exercise Progressions

When evaluating options for the foot and calf, my focus is on increasing the force production of the Gastrocnemius and Soleus musculature whilst improving the proprioceptive capacity of the foot intrinsics, extrinsics and ankle stabilisers. As stated above, options should be scaled to the athletes level of competency and function whilst what also should be kept in mind is that they will be bound to the ROM restrictions of a brace so expectations should be that particularly for calf based options that the soleus will end up with greater loading than the gastrocnemius in this phase of rehab.

Below are some examples of accessory foot and calf options that I typically prescribe:

Accessory Foot & Calf Exercise Options
Figure 12: Accessory Foot & Calf Exercise Options
Video 5: Seated Arch Doming

Development of Single Leg Stance & Lateral Hip Control

An area I wouldn't place a large deal of emphasis on early however is pivotal during the back end of protection and during the load introduction phase. Primary reasoning for me behind not placing it as a priority (at least in functional positions) early in rehab is due to the fact that the athlete will be stuck in a position of mini knee flexion and thus prolonged time loading in single leg stance may lead to overload of the patellofemoral joint. Nevertheless an example stream that may assist in the development of the lateral hip has been placed below for consideration.

Example Accessory Lateral Hip Options
Figure 13: Example Accessory Lateral Hip Options

Energy Expenditure:

One of the biggest issues that athletes face when they are compromised of their usual training routine is that metabolically they face an imbalance of calorie in and calorie out energy expenditure. Whilst the purpose of this blog is not to discuss the ins and outs of energy intake requirements during rehabilitation (which is generally higher to support tissue healing) and that certain supplementation may assist in recovery (I'll leave this to my Dietitian friends), when an athlete suddenly loses their greatest contribution of energy output in their team training it can be useful to substitute this with off leg conditioning options.

Something I find important to stress is that particularly in the early stages of rehabilitation when an athlete is completely leg compromised when it comes to cardio training options, we shouldn't expect much development when it comes to higher end aerobic adaptation due to the inability for the athlete to reach Vo2 Max when it comes to upper body only cardiovascular training. In this light I like to keep Intervals short, Intensities high and recovery low.

A sample session I like to utilise is very simply a 20/10 Tabata interval session x 8-10 reps x 2-4 sets at the end of an athletes strength training session. Similarly, placing time caps on an athletes strength component of their sessions can increase overall metabolic output through decreasing rest periods between sets.


Load Introduction Phase:

Load Intro Phase Mapping
Figure 14: Load Intro Phase Mapping

With solid foundations laid in the Protection Phase, my key foci in the Load Introduction Phase are namely to increase the intensity of the strength training that has been established in the protection phase; increase ROM allowances and transition the athlete towards more functional, unilateral training and most importantly; introduce plyometric and modified surface running demand.

When it comes to progressing an athlete in quad dominant lifting exercises, my preference is to transition athletes from Bilateral --> Unilateral Oriented --> Unilateral progressions. Namely due to the demands that unilateral closed chain training places on valgus control on the knee. Hypothesising decreased proprioceptive control during the initial stages post healing, it makes sense to me to develop proficiency with an increased base of support prior to moving on to true unilateral streams.

As the athlete shifts into more functional lifting, combination cueing can be utilised such as medially banding split squats to further constrain the athlete and force greater deep gluteal external rotation and abduction activation to prevent valgus force on the knee.

MCL Quad Dominant Progressions
Figure 15: MCL Quad Dominant Progressions

Developing a Performance Profile

Once an athlete has full terminal extension, nil effusion, a solid end feel on clinical testing and 80% quadricep, hamstring and calf strength capacity; this is enough for me to commence low amplitude plyometrics.

Assessment procedures I utilise are via the VALD Performance Dynamo for quadricep testing, VALD Performance Nordbord & Forcedecks for Hamstring testing as seen in a seperate blog (https://www.sportsrehab.physio/post/assessment-of-hamstring-strength-post-aclr) and a combination of VALD Performance ForceFrame & ForceDecks for maximal straight knee and bent knee calf torque. These maximal torque tests are performed in conjunction with capacity based endurance testing of single leg squats, single leg foot elevated hip bridges and single leg straight knee & seated calf raises.

When creating a velocity profile for the athlete, I believe it is important to get an idea on how an athlete produces force both bilaterally and unilaterally as well as in horizontal and vertical vectors. This is largely centred around the altering contribution of the hip, knee and ankle in the propulsion and landing phases of both horizontal and vertical jump tasks (Kotsifaki et al 2021; Kotsifaki et al 2022).

A full list of assessments that I utilise to begin my performance profiling in the load introduction phase is displayed below:

Load Intro MCL Performance Profile Testing
Figure 16: Load Intro MCL Performance Profile Testing

Redeveloping Plyometric Capacity:

As an introduction to low amplitude plyometrics, similarly to my strength progressions I progress the athletes from Bilateral --> Unilateral Oriented --> Unilateral Tasks. I find Pogo jumps to be incredibly versatile in this space and an excellent precursor to shifting athletes towards more specific skipping based drills which are effective in promoting the 'bounce' component of the Max Velocity phase that we want to see in an athletes running.

Below are some examples of progressions from bilateral to unilateral low amplitude plyometrics:

Video 6: Low Amplitude Pogo Jumps
Video 7: Low Amplitude Ankle Skips
Video 8: Single Leg Pogo Hop

One important bug bear of mine to note is that when I see athletes performing pogo variations, a common error I see is far too much knee flexion when the athlete hits the ground. This is not only inefficient in the sense of increasing ground contact time and shifting energy up the kinetic chain, it can also lead to overload of the PFJt. When prescribing pogo jumps, the objective is to gain maximal output from the calf-achilles complex and thus cueing strong active dorsiflexion when in the air, plantarflexion to hit the ground hard and maintain stiff knees is critical.

In addition to low amplitude plyos, I believe in the Load Introduction Phase we can also expose the athlete to a good base of eccentric absorption type plyometric progressions to assist in increasing the athletes eccentric rate of force development (RFD) in their quadriceps. Tall to Short and Altitude Landing variations are my preferred go to in this space, however I find that we as professionals typically under load these exercises. My objective is to progress athletes towards loading these with dumbbells and eventually a heavy trap bar in hand

Video 9: Tall to Short - Single Leg
Video 10: Tall to Short - Loaded
Video 11: Tall to Short - Single Leg Loaded

Restoration of Gait Mechanics:

When it comes to restoring an athletes gait mechanics prior to returning to run, I follow a very simple model of stepped progression. This is based around certain positions of athletic movement and then broken into different stages of complexity and intensity.

The athletic positions I place emphasis on are the:

  1. Acceleration Position

  2. Max Velocity Position

  3. Frontal Plane / Lateral Position

Position Based Reconditioning
Figure 17: Position Based Reconditioning

Selection of emphasis for these particular positions to train varies pending the injury in question. For an MCL I will place greater scrutiny on the Frontal / Lateral plane position and then look to identify which out of Acceleration & Max Velocity positions that the athlete is at their weakest.

Once a position has been selected then the next stage in the development of drills is to identify at what stage of complexity and intensity the athlete can comfortably manage. For me I break this down into 4 stages:

  1. Positional Sense Drills

  2. Walking Drills

  3. Low Amplitude Drills

  4. High Amplitude Drills

Competency / Tolerance Continuum
Figure 18: Competency / Tolerance Continuum

Below are some examples of some drills that I may utilise in the Load Introduction Phase with an athlete:

Video 12: Walking Frontal Plane Option - mBand Push to Base
Video 13: Walking Acceleration Option - Sled March

Role of Alter G Running:

I believe where available, anti gravity treadmill running can have a significant role to play both physically and psychologically in the transition from gym based rehabilitation to field based running. In contrast to more longer term rehabilitation such as ACL rehab, in the context of MCL reconditioning I am happy to start at a relatively higher % of body mass (%BM) and to allow the athlete to self select a comfortably jogging speed. Normally I would implement these sessions in the week after the athlete has had their brace removed and prior to them returning to running on the field. I like to see the athlete tick off 3 sessions with a ramped increase in %BM whilst leaving the other parameters consistent. A sample week of sessions could look like the following:

Session 1 --> 5 x 1 min Jog / 1 min Walk @ 80%BM
Session 2 --> 5 x 1 min Jog / 1 min Walk @ 90%BM
Session 3 --> 5 x 1 min Jog / 1 min Walk @ 100%BM


Integration Of ESD? Development of Aerobic Capacity

Whilst the focus in the Protection Phase when it came to cardiovascular training was largely centred around energy expenditure, development of Aerobic Capacity in the Load Introduction phase will create a framework for on legs conditioning when the athlete returns to running whilst also assisting to break up the monotony that strength training can sometimes give. Prior to an athlete achieving a great enough level of knee flexion that can facilitate Watt Bike conditioning, I will steer towards the ski erg and cue the athlete for a more hinge dominant pulling pattern rather than a squat based pulling pattern. Additional cues for the athlete during these sessions is to focus on consistency of stroke rate and breathing rather than aiming to pull as hard and fast as they can. A sample session which I might prescribe on the ski erg is the following:

Ski Erg Session Sample - 5 x 5 mins @ 75%RPE / 1 min Passive Recovery (PR)

Once an athlete is able to perform Watt Bike based conditioning I will get a measurement of the athletes Maximal Minute Power (MMP) so that I can utilise accurate intensity targets. A sample Watt Bike session is as follows

Watt Bike Session Sample - 5 x 4 mins @ 70% MMP / 2 mins @ 55% MMP

When it comes to weekly prescription, you really need to get a gauge of your athlete as to how much they can commit to their reconditioning program, particularly in amateur and semi professional settings. In these instances I'll aim for ~1-2 sessions per week whilst for the professional athlete I'd aim for ~2-3 sessions per week.

An example Load Introduction Microcycle could look like the following:

Figure 19: Load Introduction Phase Microcycle Plan

Within the above plan we allow for the following sessions

  1. 3 x High Day Strength Sessions

  2. 3 x Alter G Sessions

  3. 0-4 x Low Day Rehab Sessions

  4. 1-2 x Off Feet Conditioning Sessions

Weekly planning in my opinion has to be completely individualised, as for many factors certain athletes may be able to dedicate and tolerate more or less than others. In light of this there are no rules in this space and session prioritisation has the utmost importance attached to it in environments where athletes can perform limited sessions


Strength Accumulation Phase:

The primary focus that I want to place emphasis on in the Strength Accumulation phase is the athletes return to running as this certainly a cap in the sports rehabilitation field that I feel is present, particularly in the private sector.

In the context of an MCL injury, the demands of running will increase quickly and I'll aim to develop the following in order:

Target 1 - Volume Tolerance
Target 2 - Speed + Planned COD
Target 3 - Unplanned COD (+ Consolidation of the above)

Usually I will aim for ~2 sessions per week and a rough starting point I like to shoot for is 1000m volume for the athletes first running session and then bumping this up to ~40-50% match volume in session two.

In the initial return to run (RTR) week, the volume that the athlete achieves will not produce any great metabolic or speed producing effects, thus the rehab professional should ensure that the athletes technical drilling is performed exceptionally well to ensure that they gain the most out of each session. In terms of linear based running drills these can be broken down into the following focus

  1. Cycle - Developing the cyclical action of the lower limbs

  2. Switch - Developing the ability to switch limbs in the air

  3. Bounce - Promoting a strong yielding capacity of the lower limbs to 'bounce' off the ground.

An example of technical drills in each stream are included below:

Video 14: Cycle - Wall Drill
Video 14: Switch - A-Skip
Video 15: Bounce - Ankle Dribble

Looking at Speed Development in a short time frame, my experience has yielded greatest results when utilising a 'Short to Long' approach starting at higher running intensities rather than the reverse gradually developing the athletes running speed. This approach places a heavy emphasis on an athletes acceleration mechanics & capacity which is a heavily relied upon trait in field sports whilst also reducing the risk of over exposure to high speed run metres HSRm as it limits the athlete from opening up and moving faster than they should.

Resisted accelerations through the form of banded and sled runs can assist the athlete in being exposed to a strong forward lean position whilst also providing a constraint to increase force production.

Video 16: Band Resisted Acceleration Run

As the athlete begins to open up to higher speeds, from both a technical and speed management perspective I like to implement 'Wicket' style drills for the promotion of strong front side mechanics as well as ensuring athletes do not move too quickly or over stride, this allows the rehabilitation professional to create as much of. a 'vacuum' environment as possible.

Video 17: Wicket Drill

Speed & Agility Progression

When approaching speed progression in rehabilitation via a short to long approach, the objective is to allow the athlete to reach 100% max velocity over a short distance and gradually build their exposure at 100% max velocity over time. In light of this, there may be many 'sub-levels' within the initial stages of speed exposure in order to build an athlete to 100% of their max velocity. A sample speed progression could look like the following:

Stage 1 - 40m Efforts (10m Build - 20m Hold - 10m Decel) [Build from 80-100% MSS}
Stage 2 - 50m Efforts (10m Build - 30m Hold - 10m Decel) [Build from 90-100% MSS}
Stage 3 - 60m Efforts (20m Build - 20m Build - 20m Hold) @ 95%, 100%, 100% MSS

When looking to recondition an athletes change of direction capacity, consideration needs to be made towards the following variables:

  1. Tissue implicated by injury

  2. Sub-Capacities of COD

  3. Degree of COD

  4. Planned vs Unplanned

I personally really like to hone my focus on developing the sub-capacities of change of direction prior to implementing a COD task on the athlete. When looking at this I break down a single COD moment into involvement an acceleration moment, a deceleration moment, pre-cut strategy, cutting moment and finally a re-acceleration.

Change of Direction Moment Breakdown
Figure 21 - Change of Direction Moment Breakdown

With this in mind, being aware that we have already dedicated a stream to developing acceleration and speed; my primary key focus is to develop an athletes ability to decelerate prior to asking them to cut. To develop deceleration I'll combine both over exertion type drills such as loaded deceleration lunges to develop the athletes ability to eccentrically control their COM via their quads with drills such as planned decel stop runs to instil the behaviour of dropping their COM and shortening their stride prior to stopping (and eventually cutting).

Once I'm confident in my athletes ability to linearly decelerate, then I'll aim to introduce some planned swerving tasks to improve their ability to control rotation at the hips and torso whilst introducing light planned sagittal to frontal cuts in the form of box based drills

Video 18: Box Drill 5x5m Facing Up

The advantage of a sagittal to frontal plane transition is that it forces the athlete in question to develop push off power from their outside leg, which is a precursor to being able to produce an effective sidestep cutting strategy. Common errors I see in 45 and 60 degree cuts is athletes attempting to swerve and using a crossover step strategy to complete the cut. Whilst this is effective from a safety perspective, I don't personally believe it is practical to expect this to carry over to their return to match play.

Progressing past box drills, this is where my focus will shift to the prescription of <90 degree cuts, with the aim of carrying over the body positioning, lateral pushing power and deceleration strategy into these more dynamic and faster paced cuts. Example drills that you can utilise are 'Z' runs and 'Y' drills.

Video 19: Z Drill
Video 20: Y Drill

The primary difference between a cut that is <90 degrees in comparison to a cut that is >90 degrees is in the selection of the cut foot. In <90 degree cuts the most effective cut strategy is to load the outside leg through a sidestep type strategy, whilst for those >90 degree the body position strategy should shift to the athletes bodyweight onto their inside leg to project towards the intended direction of cut. An example of a >90 degree cut drill is displayed below:

Video 21: M Drill

Adding elements of reactivity to both styles of cutting tasks can increase the complexity of the drill. If i'm structuring a session there are three ways I look to prescribe COD drills.

  1. Planned COD (Max Quality)

  2. Planned COD (Metabolic Focus)

  3. Reactive COD (Max Quality)


Plyometric Focus

When it comes to progressing plyometrics from low amplitude and eccentric absorption progressions, focus shifts towards increasing the amplitude of jumps and hops, decreasing ground contact times and integration of lateral and rotational plyometrics.

Simple vector plyometrics are best utilised for improving rate of force development whilst more complex variations such as lateral and rotational options are best for exposing the athlete to increased proprioceptive demands.

Video 22: Box Jump (Concentric Development)
Video 23: Hop - Lateral mHDL Inside Edge (Jump Integration)
Video 24: Hop - Horizontal DC mHDL (Continuous Jumps)

The use of a double contact between a continuous jump / hop can be a useful stepping stone in order to dissipate the pressure that comes from each land and allow the athlete to re-organise themselves prior to the next hop.

Importantly, as running demands begin to increase; adequately prescribing more intensive plyos is critical in active load management for the athlete. I typically try to leave one session per week dedicated to intensive plyometrics (Jump Integration & beyond).


Performance Profiling

In addition to the aforementioned profiling battery listed above in the load introduction phase. Emphasis shifts towards measures of reactive strength index and thus the main additions into my testing battery include:

  1. Triple Hop

  2. Triple Crossover Hop

  3. Timed 40/30 Lateral Hop

  4. Drop Jump

  5. Single Leg Drop Jump

When it comes to benchmarking for these tests, a reasonable starting place is to aim for 90% limb symmetry index on all single leg tests whilst I additionally set the following targets:

Single Leg Hop:
Males >80% the athletes height
Females >70% the athletes height

Timed 40/30
Males >50 hops in 30 seconds
Females >45 hops in 30 seconds

Drop Jump RSI
Males > 2.5
Females >2

Single Leg Drop Jump RSI
Males >1.5
Females >1.25


Training Integration & Return to Performance Phase:

Figure 22: Training Integration & Return to Performance Mapping

Once an athlete reaches the training integration phase, majority of the cogs should be in place when it comes to their physical preparation training in the gym and on the field. In this stage of rehabilitation, the focus and key communication with coaching staff should be around an athletes return to skill exposure, contact and transitioning back to match play.

Figure 23: Return to Contact Guidelines

When it comes to return to contact for athletes, the design of specific drills needs to be individual to an athletes sport in order to yield the greatest gains from a physical and psychological perspective. With this considered, I like to break my drill design down by intensity and position that the athlete is going to be in and then design different categories based upon the athletes sport. Above is an example of a 6 stage return to contact continuum that can be integrated in an athletes session.


Role of PROMs

An under utilised component of assessment in athlete recovery is the utilisation of PROMs throughout a rehab journey. When it comes to knee rehabilitation, I believe a simple IKDC is easy to use and will give the practitioner an insight into the athletes knee health during ADLs



The utilisation of a systems based approach allows a practitioner to be objective, stepped and planned with each stage of an athletes recovery. High grade MCL tears can represent a difficult rehabilitation in the amateur and semi professional space as there are many boxes that need to be ticked both clinically and athletically to ensure an athlete experiences a successful return to performance. Consideration of the mechanism of injury, and the anatomy of the MCL is important to early stage programming, whilst knowledge of integrated athlete programming can help to ensure optimal physical preparation. The above journey is a very non exhaustive list of options in regards to training drills, athlete planning and performance profiling, each athlete must be treated as an individual however I hope there are some takeaways that can be implemented in daily practice. At the very least I hope this blog has gotten you thinking about how your planning process works in the rehabilitation of sporting injuries.

Justin Richardson




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About the Author

Justin Richardson
Head of Sports Rehabilitation at Athletes Authority

Justin Richardson is a qualified Physiotherapist and a professionally accredited Strength & Conditioning Coach. His passion area is ACL rehabilitation and this is the large majority of the athletic population that he treats. Justin is currently in the process of producing a Masters Dissertation at the University of Technology Sydney in this space.

Justin currently provides Sports Rehabilitation services out of Athletes Authority which is based in Sydney, Australia, as well as providing ACL rehab mentorship for clinicians who are looking to up skill themselves in the principles of sports rehabilitation.

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