the anatomy of a sportex article for new authors case study mcl tear [article strap] [TITLE] Rehabilitation of a medial collateral ligament tear: [SUB TITLE] By Dan Amin BSc INTRODUCTION AND THE NATURE OF THE INJURY [H1] OR [Heading 1] This is a retrospective case study, based on a grade-III tear of the medial collateral ligament (MCL) of the knee in a semiprofessional footballer. The issues faced by the patient and the subsequent management plan are highlighted along with a critical appraisal. Anatomy [H2] OR [Heading 2] [H3] OR Heading 3 The MCL is comprised of superficial and deep portions. The superficial MCL (sMCL) has two tibial attachments: the proximal, which is attached to the anterior arm of the semimembranosus tendon (fig.1); and the distal, which is attached anteriorly to the posteromedial crest of the tibia. The deep MCL (dMCL) has meniscofemoral and meniscotibial components (1). The MCL, in particular, the superficial aspect, is suggested to be the primary knee stabiliser for valgus laxity in both intact and injured conditions (2). At 25° of knee flexion, the MCL provides 78% of valgus-restraining force and at full knee extension it provides 57% of valgus-restraining force (3). Result The MCL is the most commonly injured structure of the knee in the general population and, in sport an equally high incidence of MCL injury occurs. MCL injuries are the second most common knee ligament injuries (29%) and account for 11.3% of all knee injuries sustained in professional soccer (4). This article presents a case study of the diagnosis, treatment and rehabilitation of a medial knee injury sustained by a semi-professional footballer. MCL injuries are the second most common knee ligament injuries in the general population and form a very common class of injuries in professional football. A successful treatment regime is described, and further suggestions are made for expanding this protocol to include more objective measurements of progress, which could lead to more effective healing. [ABSTRACT] ©2011 Primal Pictures Ltd [BYLINE] MCL ligament Figure 1: MCL ligament (reproduced with permission from Primal Pictures) Aetiology [H2] OR [Heading 2] After 65 minutes of match play in a losing game, four games into the competitive season, a player stretched for a loose ball with a near fully extended knee of his non-kicking leg. Simultaneously, an opponent made an effort to reach the ball and, in doing so, imparted a valgus and, potentially externalrotation, force to the player’s knee. The cause of the injury is very similar to many other such cases reported in the literature, with the most likely, statistically significant (P<0.05), occurrence of an MCL tear in soccer being a non-contact injury to the kicking leg of a midfielder, occurring during the last 15 minutes of a losing match (4). Biomechanics and potential contributing factors The majority of MCL tears are isolated, with the mechanism of injury involving valgus knee loading, external rotation, or a combined force vector occurring in sports which require knee www.sportEX.net [Figure] + [IMAGE FILENAME] flexion such as soccer (5). Cadaveric studies have found the MCL to have a yield point of 534.1N and maximal load of 664.4N at a strain of 50cm/min (Kennedy et al., 1976). These studies have also found that the distal sMCL was significantly (P<0.05) stronger than the other medial knee structures with respect to load and stiffness at failure (534.0-557.1 and 63.1 N, respectively) (1). The distal sMCL had a significantly (P<0.05) greater load response to valgus force than the proximal sMCL, particularly at 60° flexion (103.5 versus 71.9 N, respectively) (6). This is probably due to the proximal attachment dispersing the load among the soft tissue it attaches to, in contrast to the distal [Figure number: caption + credit] 25 [table NUMBER: TABLE CAPTION] Table 1: Typical data for professional midfield players. These figures are an indication of what to aim for in a rehabilitation programme (9–12) [table] Test Typical values VO2max 55-68ml/kg/min Half-squat 1-RM 2.2kg/kg body weight CMJ Height 41.6–56.4cm 10m sprint 1.80–1.82s 30m sprint 4.0–4.2s THE REHABILITATION PROGRAMME The rehabilitation programme that was designed for the patient took place over 12 weeks (table 2) and resulted in the successful outcome with the player returning to the first team and not suffering further knee injury for the rest of the season. Indicates it’s an online feature Video 1: Animation showing the footprint of the ACL (reproduced with permission from Primal Pictures) attachment where the tensile force is transferred directly to the distal tibial bony attachment. The response to an external rotation force increased in both distal and proximal sMCL as knee flexion increased from 0° to 60° (2). Perhaps the patient had a weak semimembranosus muscle, which seems to play a positive protective role in the dynamic stability of the medial side of the knee. This muscle tightens the normally lax posterior oblique ligament (POL), which acts as secondary stabiliser to both valgus and external rotation forces. The athlete on presentation Forty eight hours post-injury the patient first presented with valgus laxity of the knee. Pain limited an accurate objective assessment of how much joint-line gapping was present, but valgus instability occurred at both 0° and 30° knee flexion. This suggested a grade III sprain based on Fetto and Marshall’s classification (7). Lachman’s posterior and McMurray’s anterior drawer tests were all negative, which suggested that this was an isolated MCL tear. The entire knee was swollen and warm, but no noticeable heamarthrosis was present. Pain on palpation was located over the joint line and towards the tibial attachment, suggesting this as the primary point of failure. The femoral attachment has been found to be the most common site of failure in the majority of studies, particularly when the knee is in full extension. However, the tibial insertion has also been found to be a common failure location. PROBLEM LIST Actual The actual problems encountered and observed with the patient were the following: general pain; activity-dependent pain; oedema; valgus laxity through a range of knee flexion; low confidence; early non-weight bearing status; limited range, particularly towards full-extension; and diminished cardiovascular and functional capability. [video NUMBER: video CAPTION + credit] Expected Immediately after the injury the knee is likely to hurt across its entirety with limitations to flexion. After several hours heamarthrosis is likely with pain beginning to localise on the medial knee and a side-to-side feeling of instability. In the absence of early intervention, catabolic behaviour means poor quality scar tissue may form, which could cause a grade III MCL injury to never fully “heal” (5). A history of ligament injury is a strong risk factor for subsequent injury, predominantly due to the reparative scar being mechanically deficient at the completion of healing. In general, an isolated MCL tear means valgus laxity in the flexed knee, while injury to secondary stabilisers [ie. POL or anterior cruciate ligament (ACL)] tends to lead to increased laxity in the extended knee.Injuries to the individual components of the MCL also alter the intricate load-sharing relationships that exist between the medial knee structures, including the POL (1). ACL load is statistically (P<0.05) higher in response to valgus or internal rotation torque in a knee with grade III MCL injury at 0° and 30° knee flexion (8). Video embedded within the article sportEX medicine 2011;50(Oct):25-29 26 case study mcl tear Aggressive early rehabilitation had good-to-excellent subjective outcomes Needs analysis of end-stage rehabilitation [quote] Based on the extensive literature available, the following physiological characteristics are said to be the most pertinent for a soccer player. n Aerobic capacity - there is a significant relationship with team performance, though no difference is seen between first and reserve team players. n Anaerobic capacity - high-intensity activities occur every 30s; whereas a maximal, 15m sprint occurs every 90s. Professional v. amateur soccer players’ 10m sprint times are significantly different; however, there is no significant difference in 30m times. n Lower limb maximal strength - most regular first team members have higher lower-limb muscle strength, both concentric and eccentric isokinetic, knee extension and free-weight squatting and a higher ration of eccentric hamstring strength relative to concentric quadriceps strength (Hecc:Qcon). nP ower - counter movement jump (CMJ) height and ball velocity is greater in the elite than in the sub-elite soccer player. referencing Insert the number of the reference in curved brackets at the appropriate point in your text. They should appear in sequential order with the first ref starting at number (1). They should then appear listed in the same order in the reference list at the end of the article. [key point] [Box number: caption] + KEY POINT: Familiarise yourself with the muscles of ambulation and their attachments - to fully understand their actions - both concentrically and eccentrically. A good history and examination will often help locate the source of the ankle ‘problem’. Box 1: Definitions n Fore-foot - consists of the metatarsals and phalanges n Mid-foot - consists of the tarsal bones i.e. navicular, cuboid, and three cuneiforms (see figure 1) n Rear-foot - consists of the talus and calcaneum n Supination - is a 3-D (triplanar) combination movement at the subtalar joint of eversion, abduction and dorsi-flexion – the foot moves down and towards the centre of the body n Pronation - is a 3-D (triplanar) combination movement of inversion, adduction and plantar flexion (i.e. opposite of supination) – the foot moves up and away from the centre of the body www.sportEX.net JUSTIFICATION, CRITICAL APPRAISAL AND REFLECTION OF THE MANAGEMENT PLAN Justification and critical appraisal Grade III MCL tears are often treated non-operatively with good clinical results that are similar to operatively repaired injuries in terms of range of motion, laxity, muscle power, functional activity and Lysholme score (13). Surgery may be indicated in chronic MCL injury or if a major MCL injury is part of a multi-ligamentous knee injury. However, knee flexion and concentric isokinetic (60°/s) quadriceps strength was significantly (P<0.05) poorer in patients who had operative treatment of both ACL and MCL after a combined injury compared with those who just had ACL repair, at 52 weeks’ follow-up (13). Considering the patient had a first-time, isolated MCL grade III tear, it was deemed sufficient to treat him non-operatively. One issue, however, is the different grading systems of MCL injury. Hughston’s definition of a grade III injury is based on laxity at 30° of knee flexion (14) whereas with Fetto and Marshall’s definition, grade III injuries are also unstable at 0° (7). The majority of clinically successful non-operative rehabilitative protocols were not based on Fetto and Marshall’s more unstable grade III injuries. As such, operative treatment is often recommended due to the slightly better results identified regarding reductions in persistent medial instability, secondary ACL dysfunction, muscle weakness, and osteoarthritis (1). As laxity was present at 0° flexion in this case study, the decision to treat the patient purely conservatively may be questioned. Attempts to improve ligament healing have included motion, immobilisation, hyperbaric oxygen, energy application, the use of a knee brace, and treatment with growth factors via gene transfer delivery. NSAIDs and low-intensity ultrasound have also been advocated as they have beneficial effects on ligament healing in animal models, although results have proven inconclusive in human studies (15). Early treatment with protected range-of-motion, progressive strengthening and weight-bearing regimes has been shown to produce excellent results, including high rate of return to sport irrespective of severity (16). Early mobilisation is an important component of non-operative treatment, as it improves the longitudinal alignment and concentration of cells and collagen and thus increases the ultimate load-bearing of the healing ligament (17), and reduces laxity and increases the tensile strength of the healing sMCL in animals. With this in mind, the management strategy applied in this case study should perhaps have involved commencing the progressive strengthening protocol earlier than 2 weeks post-injury. Athletes with isolated grade III MCL injuries who were treated with aggressive early rehabilitation had good-to-excellent subjective outcomes at a 5-year follow-up; however, objective tests revealed that 70% had residual knee laxity (16). This chronic pain and instability is often an indicator for surgeons to favour treatment (18). The literature suggests that early progressive resistance exercises should focus on the adductors as this muscle group crosses the tibiofemoral joint and provides the greatest active muscular stability against valgus motion meaning that there is an increased risk of further injury. 27 Needs analysis of end-stage rehabilitation Based on the extensive literature available, the following physiological characteristics are said to be the most pertinent for a soccer player. n Aerobic capacity - there is a significant relationship with team performance, though no difference is seen between first and reserve team players. n Anaerobic capacity - high-intensity activities occur every 30s; whereas a maximal, 15m sprint occurs every 90s. Professional v. amateur soccer players’ 10m sprint times are significantly different; however, there is no significant difference in 30m times. n Lower limb maximal strength - most regular first team members have higher lower-limb muscle strength, both concentric and eccentric isokinetic, knee extension and free-weight squatting and a higher ration of eccentric hamstring strength relative to concentric quadriceps strength (Hecc:Qcon). n Power - counter movement jump (CMJ) height and ball velocity is greater in the elite than in the sub-elite soccer player. JUSTIFICATION, CRITICAL APPRAISAL AND REFLECTION OF THE MANAGEMENT PLAN Justification and critical appraisal Grade III MCL tears are often treated non-operatively with good clinical results that are similar to operatively repaired injuries in terms of range of motion, laxity, muscle power, functional activity and Lysholme score (13). Surgery may be indicated in chronic MCL injury or if a major MCL injury is part of a multi-ligamentous knee injury. However, knee flexion and concentric isokinetic (60°/s) quadriceps strength was significantly (P<0.05) poorer in patients who had operative treatment of both ACL and MCL after a combined injury compared with those who just had ACL repair, at 52 weeks’ follow-up (13). Considering the patient had a first-time, isolated MCL grade III tear, it was deemed sufficient to treat him non-operatively. One issue, however, is the different grading systems of MCL injury. Hughston’s definition of a grade III injury is based on laxity at 30° of knee flexion (14) whereas with Fetto and Marshall’s definition, grade III injuries are also unstable at 0° (7). The majority of clinically successful non-operative rehabilitative protocols were not based on Fetto and Marshall’s more unstable grade III injuries. As such, operative treatment is often recommended due to the slightly better results identified regarding reductions in persistent medial instability, secondary ACL dysfunction, muscle weakness, and osteoarthritis. As laxity was present at 0° flexion in this case study, the decision to treat the patient purely conservatively may be questioned. Attempts to improve ligament healing have included motion, immobilisation, hyperbaric oxygen, energy application, the use of a knee brace, and treatment with growth factors via gene transfer delivery. NSAIDs and low-intensity ultrasound have also been advocated as they have beneficial effects on ligament healing in animal models, although results have proven inconclusive in human studies (15). Early treatment with protected range-of-motion, progressive strengthening and weight-bearing regimes has 28 been shown to produce excellent results, including high rate of return to sport irrespective of severity (16). Early mobilisation is an important component of non-operative treatment, as it improves the longitudinal alignment and concentration of cells and collagen and thus increases the ultimate load-bearing of the healing ligament (17), and reduces laxity and increases the tensile strength of the healing sMCL in animals. With this in mind, the management strategy applied in this case study should perhaps have involved commencing the progressive strengthening protocol earlier than 2 weeks post-injury. Athletes with isolated grade III MCL injuries who were treated with aggressive early rehabilitation had good-to-excellent subjective outcomes at a 5-year follow-up; however, objective tests revealed that 70% had residual knee laxity (16). This chronic pain and instability is often an indicator for surgeons to favour operative treatment (18). The literature suggests that early progressive resistance exercises should focus on the adductors as this muscle group crosses the tibiofemoral joint and provides the greatest active muscular stability against valgus motion when in a contractile state (19). Konin (19) also advised that resistance to adductor contractions should be placed above the tibiofemoral joint line as this would avoid motion that applies valgus force; however, with this patient, it was believed preferable to place the resistance band gradually more distal as the strengthening protocol progressed in order to actually increase this valgus strain on the knee. The isometric nature of the MCL means that it should be subjected to valgus strains of various forces in order to enhance its load to failure (1). There is very little literature pertaining to the loads exerted by resistance bands (eg. Thera-Band®), so it was felt best to have subjective postactivity pain response as a marker for progression through activity. Cross-fibre friction massage has been recommended as an effective treatment for speeding the healing of the ligament and for promoting a healthy scar tissue formation, when performed in an instrument-assisted manner (using a stainless steel device). Beginning this treatment 1 week post-injury, three times a week for 3 weeks was found to significantly (P<0.05) increase tensile strength by 43.1%, increase stiffness by 39.7% and increase energy before failure by 57.1% (20). Reflections on the management plan The two main limitations of the management plan were the limited resources available (one piece of low resistance band, multiple cones and multiple balls) and low contact time with the case study (5 hours / week). They would have also provided a more objective method of measuring progress, in terms of increased volume load capacity. sportEX medicine 2011;50(Oct):25-29 case study mcl tear FURTHER REsources Engstrom B, Johansson C, Tornquist H. Soccer injuries among female elite players. American Journal of Sports Medicine 1991;19:372–375 Feller J. Anterior cruciate ligament rupture: is osteoarthritis inevitable? British Journal of Sports Medicine 2004;38:383–384 Gray J, Taunton JE, McKenzie DC, et al. A survey of injuries to the anterior cruciate ligament of the knee in female basketball players. International Journal of Sports Medicine 1985;6:314–316 Giza E, Mithofer K, Farrell L, Zarins B, Gill T. Injuries in women’s professional soccer. British Journal of Sports Medicine 2005;4:212–216 Griffin LY, Agel J, Albohm MJ, Arendt EA, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. Journal of the American Academy of Orthopaedic Surgery 2000;8:141–150 References 1. Wijdicks C, Ewart D, Nuckley D, et al. (2010a). Structural properties of the primary medial knee ligaments. American Journal of Sports Medicine 2010;38:1638-1646 2. Griffith C, LaPrade R, Johansen S, et al. Medial knee injury, part 1: static function of the individual components of the main medial knee structures. American Journal of Sports Medicine 2009;37:17621770 3. Grood E, Noyes F, Butler D, et al. Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. Journal of Bone and Joint Surgery (American edition) 1981;63:1257-1269 4. Rahnama N, Bambaeichi E, Daneshjoo A. The epidemiology of knee injuries in Iranian male professional soccer players. Sport Sciences for Health. 2009;5:9-14 5. Wijdicks C, Griffith C, Johansen S, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. Journal of Bone and Joint Surgery (American edition) 2010;92:1266-1280 6. Griffith C, Wijdicks C, LaPrade R, et al. Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. American Journal of Sports Medicine 2009;37:140-148 7. Fetto J, Marshall J. Medial collateral ligament injuries of the knee: a rationale for treatment. Clinical Orthopaedics and Related Research 1978;132:206-218 8. Battaglia M, Lenhoff M, Ehteshami J, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. American Journal of Sports Medicine 2009;37:305-311 9. Aagard P, Simonsen E, Trolle M, et al. Specificity of training velocity and training load on gains in isokinetic knee joint strength. Acta Physiologica Scandanavica. 1996;156:123-129 10. Wisloff U, Helgerud J, Hoff J. Strength and endurance of elite soccer players. Medicine & Science in Sports & Exercise 1998;30:462-467 11. Reilly T, Bangsbo J, Franks A. Anthropometric and physiological predispositions for elite soccer. Journal of Sports Sciences 2000;18:669-683. Further resources These could be books, other references, videos, weblinks, websites - anything at all that you feel might be useful for the reader. TEST YOUR LEARNING - quiz the quiz for this article is called: mcl rehabilitation On successful completion of the quiz you will earn a downloadable/printable CPD certificate which will appear in the ‘Print my certificates’ section of the My Account area. Follow these steps to take part in the online quiz Step 1: Login at www.sportex.net and go to Online Access Step 2: Go to the eLearning section test your learning - Quiz or discussions You have the choice of providing either 4 discussion/debate topics relevant to your article or 10-20 MCQs (multiple choice questions) along with answers (and any accompanying graphics/images) and we’ll turn this into an online quiz. TEST YOUR LEARNING n Should a female footballer with a partial ACL tear have surgery? n How do we decide who is the coper and who is the non-coper? n What are our objective markers for return to play? n How long should we tape ankles for? Does taping give much stability, or does it simply act as proprioceptive feedback? n How good are we at following the concussion guidelines? THE AUTHOR Dan Amin is a lecturer on the BSc (Hons) programme in Sport, Exercise and Health Sciences at The University Centre, Doncaster. He graduated in Sports Rehabilitation and Injury Prevention from Middlesex University in 2007 and is currently undertaking a part-time MSc in Sport Injury Rehabilitation at The University of Salford. Dan has just returned from Romania where, as a guest lecturer, he delivered a week of seminars in “Functional Screening as a Method of Injury prevention” at the National University for Physical Education and Sport in Bucharest. In addition to his lecturing role, Dan worked as the rehabilitator for Ilkeston Town Football Club from 20072009. reference list Numbered corresponding to the numbers in the text and listed in sequential order. Ref format = Ref number. First 1-3 authors. Title of paper. Full name of journal Year of publication; issue/volume:first page-last page www.sportEX.net 29 author biography maximum 100 words with photo PAtient advice If your article could be accompanied by a rehab programme or an information leaflet - we’d love it even more! Rehab leaflets require no more than 8 exercises (usually a mix of stretch/ strength) with an exercise title, short description & reps/sets suggestions (we find the pictures but stick men are a useful aid). Info leaflets can be just text based and sometimes suit the topic matter better. The should be about 700 words in length and pitched at the patient rather than the practitioner. Exercises for MCL rehabilitation stretching and Strengthening exercises Adductor strengthening with ball in supine Sit on a chair, place a towel or ball between your thighs, tighten your buttocks and squeeze your thigh muscles together. Hold this position for 10 seconds before relaxing. Mini squats Begin with small squats on both legs. Squat to 45o if there is no pain (otherwise try reducing the depth of the squat until you can perform it without pain).. If this is easy then progress to holding weights or wearing a rucksuck containing weight. SetsReps 3 10 static quadriceps flexion with heel lift Contract the muscles on the front of your thigh so that your heel raises off the floor (you could put a rolled up towel under your knee to help). Hold for 5 seconds, relax and then repeat. SetsReps SetsReps 3 10 controlled knee flexion Sit on the floor with your knee straight, slowly bend the affected knee (by sliding the foot up to your buttocks) as much as you can. When you feel a stretch in the thigh muscle hold the position for 10 seconds and then straighten. 1 ADDUCTOR STRENGTHENING IN SIDE LYING Lie on your side with your head supported by your hand. Place your top leg forwards so your hip and knee are at 90o. Then keeping the bottom leg straight, raise it upwards towards the ceiling and hold for 5 seconds. SetsReps 3 SetsReps 5-8 prone knee flexion Lie on your front and bend your knee, bringing your heel towards your buttocks as far as it’s comfortable for you. Then lower your leg and foot back to the floor. Both movements should be slow and controlled. 10 10 Quadriceps strengthening – sit to stand Sit on a chair or higher block if a chair is too low, and slowly stand up without using your arms to push off. When you are standing up, return slowly to the sitting position again without using your arms. Repeat this movement 5-10 times as long as it doesn’t SetsReps cause pain. 3 10-15 SetsReps 3 3 10 Adductor strengthening with ball in supine Lie on your back with your feet flat on the floor and your knees bent. Hold a ball or towel between your knees. Tighten your buttock muscles and keeping the ball in position lift your buttocks off the floor. Hold for 5 seconds before returning slowly to the starting position. SetsReps 3 10 The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article. Produced by Animation: Footprint of the ACL online extras We love bringing the articles to life so any videos or animations (or links to those resources), YouTube playlists, websites etc. are all very welcome. This page features some examples. Animation: Biomehanics of the ACL YouTube video: Ottawa ankle rules 31
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