The Injured KneeThe Injured Knee

The The “Freakish”“Freakish” MCL Tear MCL TearDr Riaan BarnardDr Riaan Barnard

M Sport Med (3’rd yr)M Sport Med (3’rd yr)May 2011May 2011

Case HistoryCase History

• Yonela Madlakane, 17yr old First Team hooker Yonela Madlakane, 17yr old First Team hooker injured R knee on 6 April while on tourinjured R knee on 6 April while on tour

• Played into middle of second half; replaced for Played into middle of second half; replaced for rotation; took over line-man dutiesrotation; took over line-man duties

• Then the Then the “FREAKISH”“FREAKISH” accident occurred… accident occurred…• While holding flag high, one player “swung” While holding flag high, one player “swung”

another out, with the latter hitting Yonela’s knee another out, with the latter hitting Yonela’s knee with valgus force onto lateral knee aspect.with valgus force onto lateral knee aspect.

• Yonela immediately felt a sharp, tearing pain on Yonela immediately felt a sharp, tearing pain on the medial aspect of the R knee; knee suddenly the medial aspect of the R knee; knee suddenly “gave away”…“gave away”…

Almost as “Almost as “FREAKISHFREAKISH” as this ” as this one ! one !

To Diagnose “Sharp Pain”To Diagnose “Sharp Pain”

Immediate Assessment…Immediate Assessment…

PRICE RxPRICE Rx

Typically a young player…Typically a young player…

Clinical ExaminationClinical Examination

• Walked into surgery, PWB on crutchesWalked into surgery, PWB on crutches• Passive + active knee flexion / extension painPassive + active knee flexion / extension pain• Pain palpation over medial aspect + medial joint Pain palpation over medial aspect + medial joint

line. Local swelling MCL. Effusion = 10mmline. Local swelling MCL. Effusion = 10mm• MCL Stability test R vs. L ligament laxity of < MCL Stability test R vs. L ligament laxity of <

5mm; definite endpoint. Valgus stress = ++ pain5mm; definite endpoint. Valgus stress = ++ pain• McMurray’s test positive at max knee flexion and McMurray’s test positive at max knee flexion and

ext rotation tibia, but no definite “clunk”ext rotation tibia, but no definite “clunk”• Functional squat caused medial knee deviationFunctional squat caused medial knee deviation• Appley’s grind test negative, as well as all other Appley’s grind test negative, as well as all other

ACL, PCL, LCL tests ACL, PCL, LCL tests

Differential DiagnosesDifferential Diagnoses

• Medial Collateral Ligament Medial Collateral Ligament Tear R Knee, Clinically Grade Tear R Knee, Clinically Grade IIII

• Accompanied / Complicated Accompanied / Complicated by either Coronary Ligament by either Coronary Ligament Sprain or Medial Meniscus Sprain or Medial Meniscus InjuryInjury

Special InvestigationsSpecial Investigations

• X-rays showed no pathologyX-rays showed no pathology

• Sonar confirmed Grade II Sonar confirmed Grade II Sprain of R MCL with small Sprain of R MCL with small effusion medial joint lineeffusion medial joint line

3 Stage Summary3 Stage Summary

• Bio-Clinical:Bio-Clinical:Grade II MCL tear with Coronary Ligament tearGrade II MCL tear with Coronary Ligament tear

• Personal/Psychological:Personal/Psychological:Beginning season – just became first choice Beginning season – just became first choice

hookerhooker

• Social/ContextualSocial/ContextualNo Medical Insurance / cannot pay for rehab No Medical Insurance / cannot pay for rehab

bracesbraces

Integrated DiscussionIntegrated Discussion

• PlanPlan

• ProgressionProgression

• DiscussionDiscussion

• Learning ExperienceLearning Experience

Key to Successful RehabKey to Successful Rehab

• Rehab explained to pt in simple terms Rehab explained to pt in simple terms with time frameswith time frames

• Provide precise prescription, including Provide precise prescription, including correct techniques and executioncorrect techniques and execution

• Make the most of available facilitiesMake the most of available facilities

• Begin asap !Begin asap !

Phase IPhase I – the first week – the first week

• ““P” – protection further stresses – BRACE !!P” – protection further stresses – BRACE !!• RICE + Analgesics + Ext 20RICE + Analgesics + Ext 20° + Flex 100°+° + Flex 100°+• Physio – gentle ROM, US, Gait education crutchPhysio – gentle ROM, US, Gait education crutch• Isometric - 5sec / 10sec – 10 rep sets, 15° Isometric - 5sec / 10sec – 10 rep sets, 15°

overflow principle until full arc motionoverflow principle until full arc motion• VMO activation, progressed to bilat calf raises, VMO activation, progressed to bilat calf raises,

hip abduct / ext by physio, later with rubber bandhip abduct / ext by physio, later with rubber band• Towards end of week: FWB on crutches, straight Towards end of week: FWB on crutches, straight

leg raises, slide squats from physio bed. leg raises, slide squats from physio bed. Progressed to wall slide squatsProgressed to wall slide squats

• Hams/Gastroc/Soleus flexibility with stretchesHams/Gastroc/Soleus flexibility with stretches

Phase II – weeks 2 & 3Phase II – weeks 2 & 3

• Swelling 90% less; tender prox origin MCL; full Swelling 90% less; tender prox origin MCL; full flex ROM back; brace set to 10flex ROM back; brace set to 10° ext. Brace on ° ext. Brace on with exercising; off towards end 3’rd week.with exercising; off towards end 3’rd week.

• Physio – less soft tissue work. Started core, Physio – less soft tissue work. Started core, balance + proprioception. Single leg stance balance + proprioception. Single leg stance without brace; wobble board; mini trampolinewithout brace; wobble board; mini trampoline

• Sport Scientist: took to gym for mini squats, Sport Scientist: took to gym for mini squats, lunges, leg presses, bench step-ups, hip abd + lunges, leg presses, bench step-ups, hip abd + ext on pulleys, calf raises, stationary cyclingext on pulleys, calf raises, stationary cycling

• Towards end 2’nd week light jogging with brace Towards end 2’nd week light jogging with brace on; end of 3’rd week – jogging with more speed, on; end of 3’rd week – jogging with more speed, but brace offbut brace off

Phase III – Phase III – week 4week 4

• Minimal pain - ?early Pelligrini-Strieda??Minimal pain - ?early Pelligrini-Strieda??• Sport Scientist prescription changes: Yonela had Sport Scientist prescription changes: Yonela had

full ROM with good strength & endurance. full ROM with good strength & endurance. Commenced full squats in gym; increased FITT Commenced full squats in gym; increased FITT for gym work; jump + land drills in gym; for gym work; jump + land drills in gym; functional agility with ball exercisesfunctional agility with ball exercises

• Back on rugby field, side line: progressive Back on rugby field, side line: progressive straight-line running with acc/dec phases; side + straight-line running with acc/dec phases; side + backwards running; hopping & jumping drills; backwards running; hopping & jumping drills; large figure 8 running drills; beginning week at large figure 8 running drills; beginning week at 70% - towards end 90% ability; good warm-up & 70% - towards end 90% ability; good warm-up & warm-down with general lower limb stretchingwarm-down with general lower limb stretching

Phase IV – week 5Phase IV – week 5

• Yonela met criteria for RTS – first criteria is to Yonela met criteria for RTS – first criteria is to observe the full time constraints of soft tissue observe the full time constraints of soft tissue healing..healing..

• Personally did final fitness testing: Personally did final fitness testing: Warm-up; sprinting from standing position to full Warm-up; sprinting from standing position to full

acceleration to deceleration over 50m; cones set-acceleration to deceleration over 50m; cones set-up for forwards/backwards/sideways run at high up for forwards/backwards/sideways run at high speed; large to small fig 8 running at high speed; speed; large to small fig 8 running at high speed; high speed cutting from injured side; standing high speed cutting from injured side; standing plyometric jumps with “sticking” landing; plyometric jumps with “sticking” landing; plyometric jumps over bench, double/single plyometric jumps over bench, double/single sideways hopping; place kicking rugby ball. sideways hopping; place kicking rugby ball.

• Cleared as fit! Played end of that week 2’nd halfCleared as fit! Played end of that week 2’nd half

Ligament BracingLigament Bracing

• Post-injury / Post-operative:Post-injury / Post-operative:1.1. Protects healing graftProtects healing graft

2.2. Allows controlled ROMAllows controlled ROM

3.3. Reminds pt to take careReminds pt to take care

4.4. Reminds those around pt to be carefulReminds those around pt to be careful

5.5. Prevents damage during healing processPrevents damage during healing process

How do ligament braces protect How do ligament braces protect the knee ??the knee ??

Four Points of Leverage SystemFour Points of Leverage System

This system reduces anteriorThis system reduces anterior

component of translation andcomponent of translation and

therefore controls rotationtherefore controls rotation

How does it work ?How does it work ?

Through the Four-Points-Through the Four-Points-

of-Leverage cuff and strapof-Leverage cuff and strap

configuration, a posteriorconfiguration, a posterior

force is applied to the tibiaforce is applied to the tibia

preventing anteriorpreventing anterior

movementmovement

““Mechanics” of BraceMechanics” of Brace

• 1 & 2 :1 & 2 :Both the femur and tibiaBoth the femur and tibiaanchored by cuffanchored by cuff• 3 :3 :Post thigh strap pushes Post thigh strap pushes femur ant, drawing hingesfemur ant, drawing hingesposteriorposterior• 4 :4 :Generates crucial opposing force. Applies anGenerates crucial opposing force. Applies anactive constant load to prevent anterior tibialactive constant load to prevent anterior tibialtranslation and draws hinges into proper positiontranslation and draws hinges into proper position

Strap PlacementStrap Placement

Different Types of HingesDifferent Types of Hinges

““Just before the Pain begins..”Just before the Pain begins..”

World’s Best Running Shoes?World’s Best Running Shoes?

ReferencesReferences

• Brukner & Khan, Chapters 12 & 27Brukner & Khan, Chapters 12 & 27

• DonJoy BrochuresDonJoy Brochures• Joint/Bone/Spine, Joint/Bone/Spine, Clinical practice guidelines for Clinical practice guidelines for

rest orthosis, knee sleeves, and unloading knee braces rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis. Beaudreuil, J, et al. 2009.02.002in knee osteoarthritis. Beaudreuil, J, et al. 2009.02.002

• Journal of Biomechanics, Journal of Biomechanics, The effect of valgus The effect of valgus braces on medial compartment load of the knee joint – in braces on medial compartment load of the knee joint – in vivo load measurements in three subjects. Kutzner, I, et vivo load measurements in three subjects. Kutzner, I, et al. 2011.01.014al. 2011.01.014

• Prentice, W.E., Chapter 22Prentice, W.E., Chapter 22