Physiotherapy Protocol – Right Knee (Samruddhi Gosavi, 19F)

MRI Findings Summary

• ACL: Hyperintensity, no fiber discontinuity → low-grade (Grade I) ACL sprain, ligament intact
• LCL: Hyperintensity with minimal fluid collection along superficial fibers → Grade I-II sprain/partial tear
• Mild joint + patellofemoral effusion
• Menisci, PCL, MCL, patella, surrounding muscles/tendons all normal

Phase 1: Protection & Effusion Control (Days 0-14)

• Bracing: Hinged knee brace, locked 0-30° flexion initially if any laxity felt on exam; unlocked for gait once pain-free
• Weight-bearing: Full weight-bearing as tolerated with crutches for first few days if antalgic gait; wean off crutches as pain allows
• Ice/Compression/Elevation: 15-20 min, 3-4x/day for effusion
• ROM: Passive/active-assisted knee extension to 0° and flexion to 90° (pain-free range); avoid forced end-range varus/valgus stress
• Muscle activation: Quad sets, straight leg raises (no resistance), ankle pumps, patellar mobilizations
• Avoid: Varus stress (LCL) and pivoting/twisting movements; avoid open-chain resisted hamstring work initially if it stresses the healing ACL fibers excessively
• Milestone to progress: Effusion trace/1+, active knee extension lag <5°, flexion ≥90°, pain-free straight leg raise

Phase 2: Early Mobility & Strengthening (Weeks 2-6)

• Progress ROM to full flexion/extension
• Closed-chain strengthening: mini-squats (0-60°), step-ups, leg press (limited range), calf raises
• Stationary cycling once ROM to 100-110° achieved
• Proprioceptive work: double-leg balance progressing to single-leg on stable surface
• Hip/core strengthening (glute medius/maximus) to offload knee frontal-plane stress
• Continue avoiding varus loading positions (e.g., resisted lateral band walks stressing the LCL) until fibers have matured (~4-6 weeks)
• Manual therapy for effusion/swelling (lymphatic drainage techniques, patellar mobilizations) as needed
• Milestone to progress: Full pain-free ROM, no effusion, normal gait pattern, single-leg stance >30 sec

Phase 3: Progressive Strength & Neuromuscular Control (Weeks 6-12)

• Progressive resistance: squats, leg press, lunges (front/lateral, cautious with lateral lunge given LCL), deadlift pattern with control
• Hamstring/quad strengthening in functional ranges (protects ACL via co-contraction)
• Balance/proprioception on unstable surfaces (wobble board, foam pad), perturbation training
• Introduce light plyometrics once quad strength is ~80% of contralateral side (double-leg jumps → single-leg progressions)
• Sport-specific movement prep: controlled cutting/pivoting drills at low intensity, straight-line jogging progressing to figure-of-8 running
• Continue monitoring for any recurrent effusion or instability with cutting/pivoting - if present, escalate back to orthopedic review

Phase 4: Return to Sport/Activity (Week 12+, individualized)

• Quadriceps and hamstring strength ≥90% of uninjured limb
• Single-leg hop test symmetry ≥90%
• No effusion or pain with high-demand activity
• Confident, symmetrical landing mechanics on jump-landing assessment
• No subjective instability/giving-way with cutting, pivoting, or deceleration

Key Precautions Specific to This Case

1. LCL protection: avoid varus (bow-legged) stress positions and resisted movements that load the lateral joint line until at least 4-6 weeks of healing.
2. ACL monitoring: although fibers are intact, monitor for anterior instability (Lachman/anterior drawer laxity) at follow-up; if laxity or episodes of giving-way develop, this may need re-imaging/orthopedic reassessment for possible progression to partial/complete tear.
3. Effusion: recheck at each session - persistent or recurrent effusion suggests the tissue is being overloaded and rehab should be regressed.
4. Since patient is 19 years old (likely active/sporting), a criterion-based progression with formal strength/hop testing before return to sport is strongly recommended to reduce re-injury risk.

Modalities appropriate for this case

• First-line in the acute phase (days 0-5) for pain and effusion control.
• Also helps reverse "arthrogenic muscle inhibition" - knee effusion reflexively inhibits the quadriceps (vastus medialis), and cold has been shown to disinhibit it, restoring voluntary quad activation.

• Useful for pain modulation, and interestingly the same study that looked at cryotherapy found TENS also disinhibits quadriceps activation after knee joint effusion - so it can be used alongside icing in the first 1-2 weeks to help the patient activate the quad despite swelling and pain.

• Once acute pain settles (end of week 1-2), NMES to the quadriceps is well supported for restoring strength when voluntary activation is limited by effusion or pain, a very relevant issue in this patient given the documented effusion.
• Systematic reviews support NMES for quad strength recovery after knee surgery/injury and in patellofemoral pain, generally as an adjunct to active exercise, not a replacement.
• Typical parameters: biphasic/Russian current, 35-50 Hz, on:off ratio ~1:3-1:5, intensity to visible tetanic contraction, applied during quad-setting/SLR exercises.

• Commonly used clinically for pain and effusion/edema reduction over the knee (low-frequency sweep 80-150 Hz for pain, 1-10 Hz for edema). Evidence quality is only low-moderate, so treat it as a comfort adjunct rather than a primary intervention.

What to avoid or delay

• Deep heating modalities (shortwave diathermy, deep continuous ultrasound over the LCL collection): avoid in the acute/subacute phase while there's an active fluid collection along the LCL's superficial fibers - heat promotes vasodilation and could aggravate the local bleed/effusion. These can be reconsidered later (from ~3-4 weeks) for soft tissue extensibility if needed.
• Therapeutic ultrasound directly over the LCL collection: hold until the collection has resolved on clinical reassessment; low continuous-dose ultrasound may be considered afterward for scar/collagen remodeling, but evidence for accelerating ligament healing is weak.
• Electrotherapy should never replace the phased exercise/strength/proprioception program - overall evidence for electrotherapy modalities in ligament sprain rehab is generally rated low-to-moderate quality and is meant to support (not drive) recovery.

Practical sequencing for this patient

• Week 0-1: Cryotherapy ± TENS for pain/swelling, alongside quad sets/SLR
• Week 1-3: Introduce NMES to the quadriceps if activation lags due to effusion/pain, continue with active ROM and closed-chain work
• Week 3+: Wean electrotherapy as active strengthening becomes tolerable; reserve IFT/TENS only if residual pain limits exercise compliance