Knee injuries in sports are becoming very common among the athletes. In an recent research done by Richard J. Dallalana et al (2007) they found that Injuries to the knee accounted for the highest numberof days absent due to injury (7776 days, 21%) and were typicallysevere, with a excessively high number of days missedper injury (37 days). The incidence of knee injuries duringmatches was higher than that reported in all other footballcodes, surpassed only by rugby union at the international level.Knee injuries accounted for the highest player absence due toinjury; 5% of an average playing squad were absent at any onetime due to knee injuries.
In knee the medial collateral ligament is the most commonly injured ligament in the knee. All isolated grade I and II tears and most grade III tears can be treated nonoperatively with a supervised, functional, rehabilitation program (Bradley F et al 2006). During the case study the treatment of knee MCL injury with a combination of Transverse Friction Massage (TFM) and rehab exercises are explored.
HISTORY – SUBECTIVE EXAMINATION
This was a female patient age 28yrs and by occupation was a professional football player and plays football at national level. Usually plays 3 times a week and spends most time in exercising and fitness. The lifestyle of the patient is very active, no smoking or drinking. Apart from football also does swimming, golf and dancing.
Site and spread of pain and other symptoms:
- Had recent excessive valgus force applied to a partially flexed right knee while playing foot ball about 24 hrs back.
- Patient said she is feeling pain and stiffness in the medial aspect of the knee.
- There is also mild swelling on the medial aspect of the knee.
- Following the incidence was not able to continue the game and had intense pain in the medial aspect of the knee gradually building up.
- Was given icepacks and pain relief spray by the on field first aid and was sent home with compression bandage.
- Currently the patient is experiencing aching and some times sharp pain on the medial aspect of the knee and sometimes radiating to the thigh.
Behaviour of pain and other symptoms
Pain on weight bearing and when trying to move the knee. Patient says that the pain is decreasing since the injury happened 24hrs back but is still very tender to touch and painful to walk on. Pain was much localised to the medial aspect of the knee and little pain in the lateral aspect as well.
Past medical history:
There is no other medical history.
Not seen her GP but the patient said she is taking paracetomol 500mg for pain relief twice a day.
EXAMINATION – OBJECTIVE
- Patient was standing partial weight bearing due to pain.
- No malalignment at the knee (any observable malalingment of the knee may lead to or be result of malalignment elsewhere – Riegger-Krugh,C and J.J. Keysor 1996).
- Presence of mild swelling over the medial aspect of the knee (ME Schweitzer et al 1995)
- No discolouration or bruising.
The patient held her knee in slight flexion due to pain but could extend passively with pain. There was no obvious bony deformity or protrusion. The popletial crease was in line and the gluteal crease was in line. There was no noticeable limb length discrepancy. Gait was observed for general knee function and compared with the normal knee and was all normal. Effusions was checked by noticing any general fullness to the knee anteriorly or a loss of peripatellar dimples (Anderson RJ, Anderson BC 2004). Brief assessment of hips and ankles was also done to rule out any kind of referred pain to the knee.
Range of motion was checked first actively. Extension was checked by having the patient sit at the edge of the examination table and extend the knee against gravity. Active flexion was checked by seeing if the patient can touch the buttocks with the heel while in the supine position (Austermuehle PD 2001)
Following range of motion palpation was done to assess for normal knee anatomy. Muscle strength was assessed using the method learnt in the orthopaedic medicine course module B. Normal leg was tested first for knee extension with the patient lying in prone position on the couch and knee bent at 90 degree the limb was stabilised at the back of the thigh using one hand and the other hand was used to grasp around the leg to be tested which rested on the examiners forearm. Patient was advised to push the knee against the hand the strength was determined. Same procedure was followed for the affected knee. Patient complained of pain when pushing with the affected leg. Knee flexion was tested with patient in prone and by stabilizing the same side hip with one hand and holding the ankle of the leg with other hand. Patient was advised to push against the resistance and the test was repeated for the injured knee. Patient complained of pain in the knee. There was also loss of muscle strength on testing.
From the history and clinical examination it was obvious that there was medial collateral ligament injury. In this light of information, the valgus stress test was done. A valgus stress was applied at the knee while the ankle was stabilised with the leg held between the examiners arm and trunk. The knee was first kept in full extension and then it was slightly flexed so that it is unlocked 20-30 degree.
After careful examination the patient was diagnosed as having a Medial Collateral Ligament injury. Further test could not be done to rule out any associated Anterior Cruciate Ligament due to pain in the knee.
From the clinical impression, a combination of Transverse Friction Massage (TFM), a selective rehabilitation programme and relative rest would be the best course of action to treat the injury. Since this patient was a professional player it was also vital to aim at getting her back into her sports in her full capacity as early as possible. This was another challenge. Ligaments are extremely slow healers because they have a slow metabolic rate it can take anything up to 6 – 8 weeks, thus making the recovery process a long wait (Kurosaka et al 1998 & D. Kobayashi et al 1997). Patient was explained about the treatment and rehabilitation plan and was advised not to rush back into sports until advised to do so. Patient was taught to perform the transverse frictions on her during the days she is not in for physiotherapy.
The aim of the transverse frictions was to place longitudinal tension on the injured structures and this has been shown to breakdown excess cross-links and to increase the tendons tensile strength. Patient wad advised to start with gentle frictions working lightly until numbing effect has set in and then later progress to working on deeper frictions but in her comfortable zone and not painful.
Cyriax developed this technique from Mennell (1982). Transverse frictions were started from the day one of contact. Deep friction massage was taught to the patient and was intended to reach the deep structures of the body such as ligaments in this case (Cyriax 1984). Patient was also advised to start with gentle transverse frictions to gain some movement of the ligament over the underlying bone and gradually increase the pressure depending upon the irritability of the structure as advised by the course tutors at the Orthopaedic Medicine course.
Positioning for the transverse frictions:
Patient was asked to be in half lying and pillows were kept under her knee until she could extend her knee to the maximum in her pain free range. Palpation of the structure was done by identifying the joint line. Three fingers were kept over the tissue to target and cover the wide area and gentle transverse frictions were carried out and patient was advised to
Rehabilitation of the MCL ligament
Following rehabilitation protocol was followed which I had studied from various sports rehabilitation and sports physiotherapy books backed by evidence based practice. The rehabilitation protocol was allowed alongside the transverse frictions massage.
Days 1 to 3 – Acute Phase
Patient was advised to rest from activity.
Protect the injury site from further damage by using crutches to avoid putting any weight through the injured leg.
Apply ice packs or a ‘cryo-cuff’ device for 20 minutes every 2 hours and advised never to apply ice directly to the skin. Icing was advised since this will have pain-relieving effect and will also help to control the swelling (Bleakley C 2004). Compression bandage was applied to limit the joint swelling. The patient was asked to keep the injured knee elevated in order to control and reduce swelling. Patient was also advised to take some oral anti-inflammatory medication prescribed by her doctor to help with pain and inflammation. Patient was advised to do static quadriceps exercises on the bed as pain permits.
Days 4 to 14 – Sub-acute Phase
On day 4 the patient came in and said that she was feeling lot better and pain had reduced a lot. Was able to move the leg more and was functionally more active. Reassessment was done to check if there was any ACL involvement. The integrity of the ACL was tested by conducting special ligament stability tests, with the knee bent to 30 degrees; the tibia was gently pulled to check the forward motion of the lower leg in relation to the upper leg. A normal knee will have less than two to four mm of forward movement, with a firm stopping felt when no further movement is observed. In contrast, a knee with an ACL tear will have increased forward motion and a soft end feel at the end of the movement. This is because of the loss of restraint of the forward movement of the tibia due to the torn ACL. And the patient had normal response to the test with no pain.
Another test was done, just to confirm that the ACL is not involved, test is called the pivot shift test, in which greater stresses are put on the knee as it is straightened from a bent and inwardly rotated position. If the knee “gives,” this is an indication that other stabilizing structures inside the knee must be torn besides the ACL. Even this test was negative.
Following the reassessment the patient was advised to continue to protect the injured knee from further damage by avoiding any kind of twisting, jogging etc. Advised to start partial weight-bearing on the affected leg whilst continuing to use the crutches if the pain is limited. To further protect the knee a hinged knee brace was given to prevent stress on the medial ligament. This was locked between minus 10 degrees of extension and 90 degrees of flexion (Burger RR 1995).
The inflammatory response from the damaged tissue usually settles in about after 3-5 days and the ligament begins to lay down scar tissue to repair itself. It is thought that this process can be encouraged with the use of electrotherapy treatments such as ultrasound and pulsed short-wave diathermy (Leung MC 2004). Ultrasound treatments after ligament injurymay facilitate earlier return to activities and decrease riskof reinjury (Karen J. Sparrow et al 2005). Ultrasound was given every alternate day. Patient was advised to start exercising the hip and ankle starting with active exercises on partial weight bearing leg and then later progress to resisted exercises as pain permits. Active exercises were advised to be done in pattern of 10reps x 3 sets, once n the morning and once in the evening.
Weeks 2 to 4 – Early Active Rehabilitation Phase
The patient was advised to wear hinged knee brace at all times during the early active rehabilitation phase, and was set between minus 5 degrees of extension and 110 degrees of flexion. Since the patient said that she was feeling lot better and the pain was significantly decreased, full weight-bearing was encouraged and the crutches were abandoned. Patient was also advised to focus on the normal gait pattern with the heel striking the ground first and the toes pushing off for the next step. Exercises were further increased to doing 3 sets x 15 reps of isometric quadriceps in the pain-free range of movement, 3 sets x 15 reps Straight leg raising to reinforce quads contractions. Gentle range-of-movement exercises were encouraged between 90 to 30 degrees of knee flexion. Early proprioception exercises were initiated like swiss ball, wobble board balance etc.
Weeks 4 to 6 Active Rehabilitation Phase
The patient was again advised to wear the hinged knee brace at all times during the active rehabilitation phase but there was no restriction of knee extension or flexion. Range-of-movement exercises were continued and some resisted exercises like quadriceps chair, half squats etc. Resistance on static cycling was increased. Isotonic muscle strengthening exercises were initiated and resistance gradually increased (leg press/squats/ham curls/quads extensions). Continue proprioceptive training.
Weeks 6 to 10 – Late Active Rehabilitation Phase
The hinged knee brace was continued to be worn, without restriction of knee extension or flexion. Range-of-movement exercises were continued, until full range of extension and flexion is pain free. Isotonic muscle strengthening was continued, so that the affected knee’s quads and hamstrings have 90% strength of the unaffected knee. Static cycling with increase resistance was encouraged. Once the patient was confident straight line running was encouraged, gradually increasing the pace and later ‘figure-of-eight’ running was initiated, gradually increasing turns. Begin ‘fitter’ exercises.
Weeks 10+ Functional Rehabilitation Phase
The hinged knee brace was discarded. Isotonic muscle strengthening continued, increased resisted static cycling, increase speed of running and increase turning angle to 180 degrees. Cliniband lateral agility/running exercises and star jumps were initiated. Hop distance should be 100% of opposite knee. Kicking the ball/block tackling.
Discussion & Evaluation
The diagnosis of the patient was straight forward from the history and nature if the injury. The patient showed good improvement throughout the different stages with decreasing pain and improving range of motion. The initial effort in making sure that the patient understood the pathology of the injury and the reasoning behind the treatment and the realistic time frame given regarding return to sports seemed to have helped in the rehabilitation. The transverse fictions along with the ultrasound proved to be very helpful especially in the early stages of the injury to tackle with pain and range of motion. Over all the patient was very satisfied with the timely progress and there was no complications out of the condition.
This course of orthopaedic medicine tremendously contributed to my confidence and knowledge base to better manage similar and other conditions. This course has greatly influenced the way I assess and deal injuries. I feel that this has helped me in enhancing my existing clinical skills greatly, especially the evaluation process, as it being fast and if carried out correctly in combination with a good history can help on accurately diagnose a condition because having an accurate diagnosis leads to more effective treatments and much better results for the patients.
Writing the case study was not only a good way of learning things and storing in the memory but it has also given me an opportunity to do my own research thereby helping in incorporating what I have learned within an evidence based practise framework. I look forward and am excited in attending the other modules and also plan to pursue MSc in Orthopaedic Medicine in future. Thank you for giving me an opportunity to express myself and teaching me in the best possible way.
AndersonRJ, AndersonBC(2004). ‘Evaluation of the patient with knee pain’ Available at: www.uptodate.com accesssed May 10.
Austermuehle PD (2001) ‘Common knee injuries in primary care’, Nurse Pract.;26(10):26,32-45
Bleakley C, McDonough S, MacAuley D (2004). ‘The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials’. Am J Sport Med; 32:251–261
Burger RR. Knee braces. In: Baker CL, Flandry F, HendersonJM, eds. ‘The Hughston Clinic sports medicine book. Baltimore: Williams & Wilkins, 551-8.
Giannotti, Bradley F. MD, FACS; Rudy, Todd PA-C; Graziano, Jim PT-C (2006) ‘The Non-surgical Management of Isolated Medial Collateral Ligament Injuries of the Knee’Sports Medicine & Arthroscopy Review. 14(2):74-77.
Karen J. Sparrow, Sheryl D. Finucane, John R. Owen and Jennifer S. Wayne, (2005)’ ‘The Effects of Low-Intensity Ultrasound on Medial Collateral Ligament Healing in the Rabbit Model’The American Journal of Sports Medicine 33:1048-1056
Kurosaka et al (1998) ‘Spontaneous Healing of a Tear of the Anterior Cruciate Ligament’. J Bone Joint Surg Am; 80: 1200-3
D. Kobayashi, M. Kurosaka, S. Yoshiya, K. Mizuno (1997) ‘Effect of basic fibroblast growth factor on the healing of defects in the canine anterior cruciate ligament‘ Knee Surgery, Sports Traumatology, Arthroscopy; Volume 5, Number 3, 189-194.
Leung MC, Ng GY, Yip KK (2004). ‘Effect of ultrasound on acute inflammation of transected medial collateral ligaments’. Arch Phys Med Rehabil;85:963–6
Richard J. Dallalana, John H. M. Brooks, Simon P. T. Kemp, Andrew M. Williams (2007) ‘The Epidemiology of Knee Injuries in English Professional Rugby Union’ The American Journal of Sports Medicine 35:818-830.
Riegger-Krugh,C and J.J. Keysor (1996) ‘Skeletal malalignments of the lower quarter: Correlated and compensatory motions and postures’ Journal Orthopaedic Sports Physiotherapy, 23:164-170.