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  • Lionel Pannunzio PT / SCS

Introduction


Medial collateral ligament (MCL) injury is one of the most common knee injuries, especially in young athletic patients.


Anatomy of the Injury






The medial collateral ligament (MCL) is a broad, thick band found on the inside area of the knee. It runs from the upper/inside surface of the shin bone (tibia) to the bottom/inside surface of the thigh bone (femur).

This ligament stabilizes the joint on the inside of the knee. The MCL is one of the most common knee injuries in competitive and recreational soccer. It can occur by itself or in combination with other ligaments.

Incidence and statistics

Lundblad M, Walden M, Magnusson H, et alThe UEFA injury study: 11-year data concerning 346 MCL injuries and time to return to playBr J Sports Med 2013;47:759-762.

This study followed 27 professional European teams over 11 seasons.

This largest series of MCL injuries in professional football In overall terms, 8029 injuries were documented. From those 8029 injuries, 346 (4.3%) were MCL injuries.

The average lay-off was 23 days. Most MCL injuries can be managed conservatively with good results.

When the injury is solely in the MCL, player can recover without the need of surgery.

The MCL is an extra articular ligament with good blood supply that warrants full recovery most of the time.

On the other hand if the MCL is part of an array of injuries like ACL or meniscus that other condition may need surgery but the MCL will heal but itself.MECHANISM OF INJURY ⚽️




Mechanism of Injury



It has been documented that most MCL injuries (75%) occurred with a contact mechanism, where the two most common playing situations were being tackled and tackling.

Other Common Mechanisms

  • Outside stress to the knee (i.e. when the soccer player's foot is caught while preparing to kick the soccer ball with the side of the foot).

  • Combined outside force and outside rotation force to the knee (i.e. when your player's cleat is stuck while attempting to cut away from that side).

  • Direct blow to the outside part of the knee (i.e. from a side tackle).

  • Non-contact through fall to the side with the foot firmly fixed.

How Does it Feel ?

When you experience an MCL injury, you may feel:

1. Pain on the inner side of the knee

2. Swelling and bruising at the inner side of the knee

3. Swelling that spreads to the rest of the knee joint in 1 or 2 days following injury

4. Stiffness in the knee

5. Difficulty or pain especially when trying to bend or straighten the knee

6. An unstable feeling, as though the knee may give out or buckle

7. Pain or difficulty walking, sitting down, rising from a chair, or climbing stairs





Types of Injuries



There are 3️degrees of sprains to the MCL:

A grade 1 MCL injury is the least severe. It means that your ligament has been stretched but not torn.

Recovery from a Grade 1 MCL injury can take from a few days to a week and a half to heal sufficiently for you to return to normal activities, including sports.

A grade 2 MCL injury means that your ligament has been partially torn.

This usually causes some instability in your knee joint. It can take from 3 to 8 weeks.

A grade 3 MCL injury is the most severe type of ligament injury.

It occurs when your ligament has been completely torn.

Joint instability is common in a grade 3 MCL sprain.

Healing time will be 6-12 weeks unless it is associated with damage to the ACL, in which case the recovery time may be longer.

Most MCL injuries can be managed conservatively with good results.

The average lay-off In Professional Soccer was 23 days.

In the amateur or recreational player the average time for recovery will be 6 weeks.

When the injury is solely in the MCL, player can recover without the need of surgery.

The MCL is an extra articular ligament with good blood supply that warrants full recovery most of the time. On the other hand if the MCL is part of an array of injuries like ACL or meniscus, this other condition may need surgery but the MCL will heal but itself. There are some cases that the surgeon will need to reattach ligament through a surgical procedure but it less common.





Conclusion

  • MCL tears are the most common ligament injury in the knee for soccer players

  • Most of the MCL injuries can heal with rehabilitation without surgery

  • The average time for recovery is 6 weeks


Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages Finally we would like to invite you to follow us  at our: Facebook Page Google Plus Page Instagram Page where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport. Lionel Pannunzio Physical Therapist Board-Certified Sports Specialist Owner of White Bay Physical Therapy





Introduction


Iliotibial Band Syndrome is the common term used to describe any one of several conditions that cause pain around the kneecap, also known as the patella.


The two most common conditions include

  • anterior knee pain syndrome also known as Patellofemoral Pain Syndrome (PFPS), patellofemoral malalignment, chondromalcia Patella ( see our Blog post on this topic )

  • Iliotibial Band Syndrome ( ITBS)

In this blog we will focus on explaining causes and treatments for ITBS



Incidence


Iliotibial band syndrome (ITBS) is one of the most common causes of lateral knee pain, particularly in individuals involved in sports like soccer. It accounts for up to 5-12% of soccer injuries. ITBS is typically managed conservatively through physical therapy and temporary activity modification.


What is Iliotibial Band Syndrome (ITBS)?





Iliotibial band syndrome (ITBS) occurs when excessive irritation causes pain at the outside (or lateral) part of the knee.


The iliotibial band (ITB), often referred to as the "IT band" is a type of soft tissue that runs along the side of the thigh from the pelvis to the knee.


As it approaches the knee, its shape thickens as it crosses a prominent area of the thigh (femur) bone, called the lateral femoral condyle.


Near the pelvis, it attaches to 2 important hip muscles, the tensor fascia latae (TFL) and the gluteus maximus.


Irritation and inflammation arise from friction between the ITB and underlying structures when an individual moves through repetitive straightening (extension) and bending (flexion) of the knee.


Typically, ITBS pain occurs with overuse during activities such as running, sprinting and change of direction.


ITBS involves many lower extremity structures, including muscles, bones, and other soft tissues. Usually discomfort arises from:

  • Abnormal contact between the ITB and thigh (femur) bone

  • Poor alignment and/or muscular control of the lower body

  • Prolonged pinching (compression) or rubbing (shearing) forces during repetitive activities.



The common structures involved in ITBS are:

  • Iliotibial band

  • Bursa (fluid-filled sack that sits between bones and soft tissues to limit friction)

  • Hip muscles

ITBS can occur in:

  • Athletes performing repetitive activities, such as squatting, and endurance sports such as running and cycling

  • Individuals who spend long periods of time in prolonged positions, such as sitting or standing for a long workday, climbing or squatting, or kneeling

  • Individuals who quickly start a new exercise regimen without proper warm-up or preparation




Signs and Symptoms





With ITBS, you may experience:

  • Stabbing or stinging pain along the outside of the knee

  • A feeling of the ITB “snapping” over the knee as it bends and straightens

  • Swelling near the outside of your knee

  • Occasionally, tightness and pain at the outside of the hip

  • Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position

  • Pain is usually most intense when the knee is in a slightly bent position, either right before or right after the foot strikes the ground. This is the point where the ITB rubs the most over the femur.


How Is It Diagnosed?


Your physical therapist will ask you questions about your medical history and activity regimen. A physical examination will be performed so that your physical therapist can collect movement (range of motion), strength, and flexibility measurements at the hip, knee, and ankle.

When dealing with ITBS, it is also common for a physical therapist to use special tests and complete a movement analysis, which will provide information on the way that you move and how it might contribute to your injury. This could include assessment of walking/running mechanics, foot structure, and balance. Your therapist may have you repeat the activity that causes your pain to see firsthand how your body moves when you feel pain. If you are an athlete, your therapist might also ask you about your chosen sport, shoes, training routes, and exercise routine.

Typically, medical imaging tests, such as x-ray and MRI, are not needed to diagnosis ITBS.


There are many potential factors. (see picture below)


Dynamic Valgus Alignment and Iliotibial Band Syndrome





Dynamic Valgus happens during normal single leg activities. With poor mechanical control of the Pelvis and Lower Extremity the knee will go into an Excessive Dynamic Valgus . In this case the Patella and the lateral aspect of the Knee Joint (condyle) will come under excessive stress. All these deviations are even more noticeable when striking on the foot during running.


Excessive Dynamic Valgus components:

  • Pelvis Drop

  • Femur rotates internally

  • Tibia also rotates internally

  • Foot collapses inwards (excessive pronation)




Physical Therapy Treatment


Due to multifactorial causes of Iliotibial Band Syndrome we need to Identify the cause first and then treat it accordingly


Possible Causes of ITBS


1 - Weak Hip Muscles - Excessive Dynamic Valgus

Weak muscles in the hip tend to cause your running form to break down, which puts a lot of stress on the tissues in the knee

Weakness in Gluteal Muscles is always found in ITBS, where these muscles are unable to control the dynamic valgus alignment of the lower extremity causing excessive use of the Iliotibial Band for maintaining the running form.


Treatment

Hip dominant exercises to increase strength of Hip extensor and Hip External rotators muscles: clam shells , hip abduction and bridges


Clam shells




Isometric Hip Abduction




Bridges






2- Shoe or Foot Issues


Overworn cleats can cause your foot to land at awkward angles, which transfers a lot of stress to the knee and hip, so keeping your shoes within their recommended mileage is critical

Foot deviations can also contribute to ITBS

Treatment

Replace old cleats that shows that are worn out




3 - Overuse: Too much load , too Fast as the cause of ITBS


Overuse, in this case means an overload to the ITB. Think about building friction over time: more training ( rapid increase in practices and games), more intensity of the training (hill workouts , repetitive jumps)

Returning to playe after a long period of inactivity

Too much Load, applied too fast...

In these situations, the Iliotibial band will became irritated first and more painful over time. Runner will continue training at the beginning because pain usually goes away with warm up. As the condition progresses and the root of the problem is not solved , pain will continue increasing in intensity and it will not disappear with warm up, continuing getting worse till one day the athlete can not compete anymore

So we as therapist will look for recent alterations in sporting activities. Any changes in the frequency, duration and intensity of training should be investigated in detail. The training program also should be appraised for errors, including increasing exercise intensity too rapidly, inadequate recovery time and extreme hill workouts.




Treatment

Educate the soccer player in the importance of loading the joint progressively. For example, return to play in small amounts and with proper rest time in between practices or games. Increase load very slowly and paying a lot of attention to the Pain during these practices and the pain afterwards to decide when to load the joint again.





5 - Increased tightness and pain in ITB


The ITB is a very thick tissue with almost no ability to stretch so trying to stretch the Iliotbial band is a waste of time.



Treatment

With this in mind, We at White Bay Physical Therapy , use a combination of techniques ( cupping and Instrument Assisted Soft Tissue Mobilization) to modulate and decrease pain in this area, not with the purpose of stretching anything but with the idea of modulating the pain and increasing the tolerance to the activity. By moving the area properly the pain will get better soon.




Foam Rolling: it may help a little bit as well in terms of modulating the pain but be sure your roll it on the side of the thigh from the middle up, Do not foam roll the painful area by the knee, this will only increase the irritation on the band.





Conclusion:


  • Iliotibial Band syndrome is a complex condition.

  • Solving this condition requires a comprehensive approach to correct all deficits that can be causing the lateral knee pain .

  • Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to ITBS

  • Taping and Orthotics are secondary tools that can be using in the treatment of ITBS



Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages


Finally we would like to invite you to follow us at our:

Facebook Page

Google Plus Page

Instagram Page


where you will receiving information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.



Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”








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ACL On-Field Rehabilitation


The last two blogs posts we tried to explain the complexity of an ACL tear and the process of returning to play after the surgery.


Today we will focus on field work



The two main goals of an On-Field program are


  1. Restoring Physical Conditioning and

  2. Movement Quality



Restoring Physical Conditioning






During a typical soccer match, top-level outfield male players cover up to 13km, at an average intensity close to the anaerobic threshold (ie, 80%-90% of maximal heart rate).


Soccer players are constantly accelerating and decelerating in high-intensity intervals of 4 to 6 seconds.


This activity is supported by the Anaerobic system ( Anaerobic glycolytic sources).


Therefore during the rehabilitation process this Anaerobic Glycolytic system needs to be developed again.

Video 1 shows a progressive sprint series with constant change of rhythm 25 to 50% , 50 to 75 % , 75 to 90 % , start , stop, accelerate , decelerate , 4-6 seconds on, 4-6 seconds off .

Fatigue plays an important role in many injuries that’s why training to become resistant to fatigue is a key component of the on-field rehabilitation.

Research has shown that fatigue may increase the risk for ACL injury.

When we have a fatigated player and we add an unanticipated movement (very typical in soccer ) the risk for ACL injury or any other injury increases substantially .


Once some level of fitness has been achieved the On-Field rehab must include game situations.



Moving quality



After the player has some physical fitness and has conquered the linear task , preplanned multidirectional movements of increasing speed and complexity need to be added to the On-Field Rehabilitation.

Video 2 shows preplanned “cutting” movement with an angle progression of 135 to 90 to 45 degree cuts without and with ball.

The goal of this more complex task is to challenge the Limb to change directions.


Gym based exercises do not directly improve movement quality during sport-specific movements. There is a need to incorporate sport-specific movement practice to relearn and improve movement coordination during sport-specific movements.

It is essential to train motor control progressively with small increments in movement complexity.

Therefore , once the player can manage high-speed linear running, accelerations, and decelerations, more complex multidirectional and change-of-direction drills, can be added to the rehabilitation program. This drills must be done at or near full capacity / speed to continue training energy systems especially with anaerobic demands . It is very important that there is no clear deficits in biomechanics or poor form to avoid training a faulty movement. In this video player is required to move quick side to side over small hurdles balance on one leg and kick. Immediately after the kick accelarate in the opposite direction and repeat .


Also here, player will accelarate forward backwards diagonals and jump to head the ball.





Continuing with more complex activities the player will initiate practicing preplanned soccer-specific drills and game situations. First with no pressure. Then adding external demands and more neurocognitive demands to challenge the athlete. Reactive-movement: for example running forward and changing direction at the cone, either right or left, depending on how the player reacts to the cue presented immediately before the required task.

In this video the player will react to clues or instructions or just react to game situations. . Player contact should be also added to challenged automatic body reactions to adapt to the situation.


Return to Practice

Once a player can demonstrate he or she is safe to execute high-speed multidirectional movement drills while fatigued , the next stage is to progress toward team practice. Now the player can participate in modified team practice for example join in the warm-up and technical skills sessions, with his teammates. Emphasize group-based technical and tactical drills, including possession drills in 1-versus-1 and 2-versus-2 situations.

The player must perform at a minimum of 90% of the required practice intensity and complete at least 90% of the preinjury training volume .


In addition, the soccer player should have reached at least 70% of the preinjury chronic training load (or relative to normative values) in all relevant physical workload metrics.

Criteria for return to unrestricted team practice include


  • clinical: pain, swelling, stability/laxity, range of motion,

  • functional :strength, endurance, body composition,

  • biomechanical: movement analysis testing,

  • psychological fear of re-injury, confidence, and

  • sport-specific ability to support volumes and work intensities in training, sport-specific physiological screening factors.



Conclusion


  • ACL Patient must undergo a long rehabilitation process not only in the clinic setting but also on the field .


  • The two main goals of On-Field Rehab are Restoring Physical Conditioning and Movement Quality


  • Research has shown that fatigue may increase the risk for ACL injury reason why physical conditioning is necessary during the on-field rehab


  • The player must be able to manage high-speed linear running, accelerations, and decelerations, complex multidirectional and change-of-direction drills before allowing practicing with the team, all pillars of the On-field program


  • Patient must demonstrate full capacity before returning to play.




Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries.

With more than 20 years of experience helping athletes return to their sports after an injury.

He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy



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