Case Study: Right Grade II MCL Tear in a High School Football Athlete

Georgia College & State University, Milledgeville, GA

David T. Payne IV-ATS

Mount de Sales Academy High School, Macon Georgia

Head Athletic Trainer: Mrs. Amanda Windon

Objective:

To present the case of a senior varsity defensive lineman football player who sustained a right grade II medial collateral ligament tear due to a chop block from the opposing team’s offensive lineman.

Background:

During a regular season Friday night football game, a seventeen year old Caucasian male 5-11”, 235lbs defensive lineman, sustained a chop block to the lateral outside (Valgus force-Anterolateral) portion of his knee from the opposing offensive lineman. Thus, after sustaining this block the defensive lineman quickly went down while grabbing painfully around his knee and rolling onto his side. Immediately, the athletic training staff ran to promptly start assisting him. After first observation, and ruling out all causes of any nerve or cervical issues, swelling was evident. Therefore, the athletic training staff adjusted the patient comfortably on his back (supine) and began evaluating/ special testing the athlete. After evaluation/special tests were concluded, the athlete showed positive indications for laxity/translation in the involved knee compared bilaterally to the uninvolved knee. Some of the tests that showed positive signs or indications were Valgus stress test, pivot shift, and McMurray’s test. The athlete was then aided in getting off the field and helped to the athletic training room.

Differential Diagnosis:

Once the athlete was taken to the athletic training room, the team physician also performed an examination on him and diagnosed him with a grade II MCL tear. The athlete’s knee was wrapped in ice and he was sent to the hospital for imaging. Further imaging provided conclusive evidence of a grade II MCL tear, but with no other ligamentous injuries. The athlete did not have any past or predisposed medical history that would be conducive to this injury. The differential diagnosis for this athlete was a medial collateral ligamentous-grade II tear, with a possible medial menisci horn tear to the right knee.

Treatment:

The overall treatment for this athlete was broken down into a twelve week rehabilitation program. The twelve week program was then broken into four separate phases each consisting of four separate weeks. Each phase consisted of separate goals that should be reached before progressing to the next phase, along with each phase having its own specialized rehabilitative exercises. Before every exercise or treatment period we utilized a moist heat pack for twenty minutes to increase mobility, decrease stiffness, and ready the athlete for exercise. During phase one consisting of weeks zero through four, the primary goals for this athlete were to decrease swelling/edema, knee flexion to 90 degrees, knee extension to -30 degrees, quadriceps 4/5 strength, with hamstring 4/5 strength, and gluteal being 4/5 strength. During week three we introduced ultrasound over the medial aspect of the knee with a superficial setting of 3.3MHz for five minutes. This modality was used to reduce pain, but to also reduce the prevalence of scar tissue building. Post-exercise we utilized IFC electrotherapy with an ice pack for around thirty minutes to reduce pain to the affected area. Overall treatments were set to knee bracing limiting knee flexion to 45 degrees, cease device when the patient is walking with neutral gait, weight bearing as tolerated (WBAT) with crutches as needed, knee flexion/extension exercises as tolerated, quadriceps exercises with VMO strengthening exercises, gluteal calf and hamstring strengthening, with gait retraining exercises.

After full completion of this phase the athlete was then moved into phase two consisting of weeks four through six. The primary goals through these weeks consisted of being full weight bearing, again eliminating swelling, full knee range of motion, and gaining all quadriceps, hamstring, and gluteal strength to a grade of 5 on manual muscle testing. The primary treatment consisted of range of motion exercises, stationary bike, with specific muscle exercises as tolerated, progress from specific exercises to functionalized exercises once full range of motion/strength is achieved, including proprioception, agility, balance, sports specific exercises, and now opening his brace to 90 degrees.

Furthermore, phase three goals consisted of weeks six through ten with the athlete’s goals set to gaining full range of motion, strength with squats, proprioception training, return to light jog, and return to restricted sport-specific drills. The treatments consisted of mostly the same exercises as in phase two, but increasing complexity, weights, and repetitions. During this phase we also incorporated jumping/landing drills and agility drills specific to the upcoming sport of wrestling.

In conclusion, phase four consisted of weeks eight through twelve with the phase goals still consisting of increasing full range of motion, strength, and endurance with all exercises increasing complexity, weights, and repetitions within sport specific exercises of treatment. Ultimately, the goal of this final phase was having the athlete return to play. At the conclusion of

this phase, the athlete was able to return fully to start his wrestling season, but continued to wear his knee brace during activity.

Uniqueness:

The uniqueness of this case is with the athlete sustaining a grade II MCL (medial collateral ligament) tear never having to acquire surgery. The athlete was able to be PWB (partially weight bearing) with crutches and then moved to FWB with assisted brace into FWB (full weight bearing). The athlete was eagerly ready to start his individualized rehabilitation program in hopes of competing in the upcoming wrestling season.

Conclusion:

The athlete was diagnosed with a grade II MCL (medial collateral ligament) tear, with a possible meniscal horn tear. The athlete’s eagerness and responsiveness greatly showed while completing his individualized rehabilitation program; thus, giving him the strength and ability to perform now in wrestling season. The athlete was cleared to compete with no restrictions, but will continue to wear his brace during activity. 

References

Howard J. Luks,MD.What Is An MCL Tear? Terminology Tuesdayhttp://www.howardluksmd.com/orthopedic-social-media/what-is-an-mcl-tear-terminology-tuesday/-tripdatabase. Accessed November 25, 2015.

Medial Collateral Ligament (MCL) Injury - Topic Overviewhttp://www.webmd.com/fitness-exercise/medial-collateral-ligament-mcl-injury- topic-overview. Accessed November 25, 2015.

Image 1: Different grades of injury: http://sportskneetherapy.com/torn-mcl-symptoms-diagnosis-and-treatment/. Accessed November 30, 2015.

Image 2: Meniscal horn tear: http://www.regenexx.com/knee-meniscus-tear-treated-without-surgery/. Accessed November 30, 2015.

Image 3: Grade II MCL Tear http://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal-pathology.html. Accessed November 30, 2015.

Image 4: Chop Block: http://www.businessinsider.com/nfl-wants-to-ban-cut-blocks-2012-11. Accessed November 30, 2015.