Anterior Cruciate Ligament Injuries by Neil McDiarmid
MECHANISM OF INJURY
30 year old footballer was playing on a Saturday afternoon in March 07. The footballer had no previous knee problems. During the match he went up for a header and landed awkwardly with his right leg straight. His description was that his knee "went out of joint and he went one way and his knee went the other", furthermore he said he felt and heard a "pop" inside his knee and this was accompanied with huge amounts of pain until eventually the whole leg went numb.
After about five minutes, the player got up and walked to the sideline but as he turned he said his leg "gave way". He got his track suit on and was taken to a local hospital, Accident and Emergency Department, here they did an x-ray, they said "no bones were broken", gave him some crutches, told him it was a "soft tissue injury" and told him to come back at a later date to see a consultant orthopaedic surgeon.
After about three weeks the players swelling and pain reduced. The footballer started to go to the gym and he could do cross trainer, static cycle and rowing machine with no problems, after another week the footballer started running in straight lines again with no problems, so the footballer decided to play and after 25 minutes of the game the footballer attempted to change direction for the ball and he said "his knee gave way". This second episode of "giving way" coincided with the appointment with the orthopaedic specialist who organised a MRI scan of his knee.
After about two weeks and having had an MRI scan (which confirmed the footballer had a ruptured anterior cruciate ligament) and arthroscopy (small camera put inside the knee) to remove any additional meniscal damage, the footballer was given two options as regards reconstruction of the ruptured anterior cruciate ligament.
RECONSTRUCTION OPTIONS
There are two main reconstruction procedures , which are equally as effective as each other and the procedure used normally depends on the consultants preference.
1) Reconstruction using the Mid – Third Patellar Tendon
2) Reconstruction using a Hamstring Graft
After seven weeks post injury the footballer had a reconstruction using the mid – third patellar tendon procedure
TREATMENT AND REHABILITATION
After about two weeks the players wound had healed and he stopped using crutches , the consultant passed him across to myself and my team to commence the long process of getting the footballer back on the football pitch. It was the middle of May and we would expect the the player to resume full first team duties around six months after the operation, I have designed a programme for an anterior cruciate rehabilitation.
From the the second week after the operation the footballer attended the clinic twice per week for the first six weeks and worked on the programme below.
FIRST PROTOCOL (4/6 WEEKS)
1) Terminal extension must be achieved (you must be able to get leg straight yourself). You are given a series of prescribed exercises which must be done for a specific time and a specific routine.
2) The patellar must be mobilised three times per week by a clinican to ensure the knee cap is mobile and does not become bound down post surgery and thus potentially irritating the repair site.
3) The swelling must re-absorb via icing 20 mins on the hour every hour practically possible starting immediately by protecting inciscion site with waterproof covering (freezer bag).
4) The inflammation must re-absorb via prescribed oral anti–inflamatories.
The player was told the most important goal at this stage is to get the leg straight so that it is the same as the unaffected side (a specific protocol must be adhered to).
At around the six week stage the rehabilitation for the footballer becomes more interesting and numerous other prescribed activities can be introduced.
SECOND PROTOCOL (10/12 WEEKS)
1) Inner range quads control must be achieved to facilitate normal patellar tracking .You are given a series of prescribed exercises. Which must be done for a specific time and a specific routine.
2) Ongoing (as 1st Protocol above)
3) Ongoing (as 1st protocol above)
4) Introduction of Hydrotherapy sessions x 2/3 per week to facilitate running, inpool with water waist level. This is carried out for 20/30 minutes per session.
5) Introduction of static cycling sessions x2/3 per week for 20/30 minutes per session.
6) Introduce proprioceptive sessions to facilitate normal knee function.
7) Close chain mini circuits introduced.
Again at this stage of the rehabilitation programme we must introduce more physically stressful activities to the player and now the goal is to protect the graft as we increase activity
THIRD PROTOCOL (12-16 WEEKS)
1), 2), 3), 4), 5), 6), and 7) ongoing.
6) Speed, Agility and Quickness drills are introduced (see attached sheet).
7) Introduce stretching programme for thigh / anterior hip area.
Now at this stage post operation we must start and get the footballer to think about playing again and introduce sport specific activities as detailed below.
FOURTH PROTOCOL (20/22 WEEKS)
1) Gait re –education activities are introduced to prepare for running.
2) Muscle activation screening analysis is carried out to prevent movement
and neural abnormalities.
3) Commence running drills.
4) Open chain strength and conditioning commenced (using isokinetics to achieve objective measure).
5) Introduce rotation drills.
6) Introduce sport specific activities.
Having finished the rehabilitation programme the footballer started playing again in the November 07, he has now played with no problems for the last twelve months.
It is worth saying that in the later stages of the rehabilitation players tend to “pick up “ little “ niggles “ in other parts of their body and this footballer complained of a stiff back when his running was increased , these things will settle and it is the body reacting to unaccustomed activity
Obviously, this case study is about a footballer getting back to playing ,but it can be applied to any person sporting or not who has a similar injury.
