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CASE REPORT
Year : 2017  |  Volume : 17  |  Issue : 3  |  Page : 174-177

Footballer's knee: Postoperative rehabilitation and return to play - A case study


1 Department of Physiotherapy, Gleneagles Global Health City, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Date of Web Publication4-Oct-2017

Correspondence Address:
Hariharasudhan Ravichandran
Global Hospitals and Health City, 439, Cheran Nagar, Perumbakkam, Sholinganallur, Chennai - 600 100, Tamil Nadu
India
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DOI: 10.4103/sjsm.sjsm_12_17

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  Abstract 


Rehabilitation of athlete in competitive contact sports such as football targets safe and early return to play. Accelerated rehabilitation programs are constantly updated in research literature, but they are limited to isolated ligament injuries. In this case study, rehabilitation of Dhanpal Ganesh, 24-year-old footballer of Indian National Team, who underwent right knee arthroscopic anterior cruciate ligament reconstruction, anterolateral ligament reconstruction, iliotibial band tenodesis, lateral meniscectomy, has been outlined. To describe the characteristics of complex soft tissue injuries, operated arthroscopically, and report on player's rehabilitation program and clinical outcome. Dhanpal Ganesh was rehabilitated postoperatively up to 3 months. Data collected include a range of motion (ROM), manual muscle testing grades, and functional tests. At 8-week postoperative period, Dhanpal Ganesh had nearly full ROM, normal gait, and trained to run safely. By 10th week, he started to perform all sports specific drills. He was rehabilitated and set fit to play after 4 months from the date of surgery. Accelerated and injury-specific postoperative rehabilitation program is found to be effective in returning the footballer to sports.

Keywords: Anterior cruciate ligament, anterolateral ligament, medial collateral ligament, meniscus, rehabilitation, tenodesis


How to cite this article:
Ravichandran H, Janakiraman B. Footballer's knee: Postoperative rehabilitation and return to play - A case study. Saudi J Sports Med 2017;17:174-7

How to cite this URL:
Ravichandran H, Janakiraman B. Footballer's knee: Postoperative rehabilitation and return to play - A case study. Saudi J Sports Med [serial online] 2017 [cited 2019 Jul 19];17:174-7. Available from: http://www.sjosm.org/text.asp?2017/17/3/174/215914




  Introduction Top


Football is one of the most popular sports played by young athletes; the way in which the game is played predisposes the individual to certain potential injuries.[1] Knee joint is composed of incongruent articular surfaces; therefore, it relies on other structures to provide both static and dynamic stability: anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, the menisci, the capsule, and the muscles crossing the joint.[2] Knee injuries are the most commonly sustained musculoskeletal injuries among footballers.

Many different rehabilitation guidelines are described in the literature, and the progression of activities allowed after surgery varies greatly. Clinicians have gradually changed their approach from immobilization and no muscle activity to minimal range of motion (ROM) with immediate muscle activation following surgery.[3]

As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. The purpose of this case report is to present the outcomes and rehabilitation strategies used for a 24-year-old male soccer player who underwent right knee arthroscopic lateral meniscectomy, iliotibial band (ITB) tenodesis, anterolateral ligament (ALL), and anterior cruciate ligament (ACL) reconstruction with semitendinosus (ST) graft.


  Case Report Top


Mr. Dhanpal Ganesh, 24-year-old defensive midfielder of Indian National Team and was playing soccer from the age of 10 years. He sustained injury on his right knee while playing an international match against Iran National Team on September 8, 2015. During tackle, a player from opposing team fell on his right knee. He had pain and inability to stand and walk on right leg immediately after the tackle and came out of the field. The team physio assessed him, and he was found to have instability of knee, gradually swelling developed, after the injury. He was managed with analgesic spray, cryotherapy, and compression taping of the right knee joint. Magnetic resonance imaging right knee was done which revealed Grade II Medial collateral ligament (MCL) tear, Grade II tear of femoral attachment of lateral collateral ligament and popliteus, Grade III tear of ALL and ACL, and flap tear of posterior horn of lateral meniscus. He was managed with cryotherapy, knee immobilization with brace and isometric exercises of knee after the injury. On October 15, 2015, he had undergone right knee arthroscopic ACL reconstruction using ST graft, Lemaire ITB tenodesis, and lateral meniscectomy. MCL was managed conservatively as per the surgeon's opinion. During the stay in hospital, he was mobilized with weight-bearing as tolerated in the right lower limb and taught to do isometrics for quadriceps, gluteus, and hamstrings. His knee was immobilized for a week. Following discharge, he returned to his club Chennaiyin FC on October 26, 2015 (11th postoperative day), to continue rehabilitation.

Physical findings

He was tall with a mesomorphic build. He had no history of previous hospitalization. He had mild swelling in the operated right knee. Surgical incisions are healing and healthy. In supine position, the resting position of knee was in flexed posture (15°). On palpation, warmth present all over the knee joint, except in the posterior aspect. There was no medial or lateral joint line tenderness. He had 40° of passive knee flexion and 10° of extensor lag in high sitting. Actively, he was able to do 30° of knee flexion. Patellar mobility was restricted in superior and inferior planes. There are no ROM deficits in the adjacent joints and contralateral limb. He walks slowly with a limping gait due to loss of terminal knee extension during stance phase. His muscle power was 3/5 in right hamstrings and gluteus medius. Quadriceps group was not checked with manual resistant to prevent strain in the healing ACL graft. Hamstrings muscle flexibility was poor. His muscle girth was measured and found to have 41.5 cm in right quadriceps compared to 45 cm in the left, 34.5 cm in the right calf compared to 36 cm in the left. He was able to perceive joint position sense with eyes closed. There was no distal neurovascular deficit on the operated limb.

Physiotherapy rehabilitation

He was explained and educated about his operative procedures and the importance of his dedication to participate in an accelerated rehabilitation program. To reduce swelling and pain, cryotherapy 4–5 times a day was provided through Cryo-Cuff modality. He was taught to perform isometric quadriceps, gluteal exercises which he performs himself in his room. Our physiotherapy session was focused on achieving full knee extension, improving knee flexion, and activating muscles around the knee to improve stability by the end of 4 weeks. Posterior capsule and hamstrings were stretched to normalize gait pattern of knee. Supine knee hangs and prone knee hangs were taught to him and advised to do most of the time in his room as much as tolerable for him. Straight leg raise (SLR) in three planes (supine, side lying, and prone) with knee brace was performed. The reason for using brace is to perform SLR without knee flexion. By 3rd week, he could able to do SLR with straight knee without a brace. A different method of vastus medialis oblique strengthening exercises was performed; he was advised to hold a football between both ankles and asked to do bilateral SLR. By 3rd week, rehabilitation sessions were divided into three parts every day which consist of physiotherapy, gym, and pool therapy sessions. Physiotherapy session comprises techniques to improve full knee extension/hyperextension compared to that of normal knee: stretchings to improve hamstring, adductor, and gastroc-soleus flexibility, strengthening of muscles of adjacent joints using activation loop band, proprioception, and strategies to improve gait pattern were performed. Strengthening exercises for hip musculatures using activation loop band were done, in which the loop band was placed above the knee joint to prevent strain to the operated knee. Strengthening of ankle plantar flexors and dorsiflexors was also done using loop band at the level of feet. Proprioception of knee was performed through following exercises: standing on nonoperated leg and performing hamstring curls, heel to toe activities in standing, performing high sitting knee ROM exercises, wall squats with a physioball between back and wall, and supine wall slides, all these exercises were performed initially with eyes open and then with eyes closed, and Mr. Ganesh was asked to feel his knee and its position while doing these activities. Gait training was done with an emphasis on knee extension and weight-bearing during stance phase. Walking backward, sideways walking, and forward walking with long steps were trained. Hot fermentation before physio session to relax the muscles and ice packs following the physio exercises was provided for pain. In gym, he was advised to do leg press (5 kg resistance with flexion not more than 30°, 30 repetition × 3 sets twice a day), cycling with increasing the seat height to prevent knee strain (15 min duration with level 2 resistance, twice a day), and workouts for upper limb and abdomen without straining the operated knee. In pool session (3½–4 feet level), forward walking, backward walking, sideways walking, walking on high knees, and active movements of hip and knee were encouraged. Pool session followed after physiotherapy and gym session. The purpose is that pool session acts as a cool down and recovery program. By the end of 15th postoperative day, his knee flexion was 90° and able to extend actively to 0° in high sitting. On 3rd week, single leg (operated leg) toe – heel raise, single limb stand, single leg wall squat (<30° knee flexion), and weight shifting activities for right lower limb helped him to promote weight-bearing in right knee which further improved his gait. Single leg (operated leg) mini squat with physioball at back was used to improve proprioception. Gradually in gym, he was advanced to hamstring curls (5 kg resistance, 20 repetitions × 3 sets, twice a day), elliptical trainer, and cycling was performed with normal seat height with resistance level increased to 4 from 2. By 28th postoperative day, he achieved 110° of knee flexion and passive hyperextension compared to left knee, and his gait pattern was improved. Warmth in the knee is present only after exercises and subsides with cryotherapy. Swelling is minimal. Moreover, he has pain at the end range of knee extension or flexion due to stretch of soft tissues.

After 4 weeks, the next level of rehabilitation focused on the advanced strengthening of hamstrings. Mr. Ganesh performed prone hamstring curls using loop band resistance, hamstring eccentric workout with 2 kg weight cuff in prone and in standing. He was trained to do half kneeling to standing for 2 weeks (15 repetitions × 2 sets, twice a day), and by around 6 weeks, forward lunges and side lunges were trained. Balancing activities were performed in wobble board with bipedal stance with eyes opened by seeing his posture on a mirror and then with eyes closed. This improved his joint position sense and proprioception. Around 8th week, balance activities were performed in single leg standing on operated leg. Now, SLR with resistance band was initiated in all planes with band placed at the level of leg above the ankle joint. In gym, treadmill walking (with taping on right knee) at 3 mph speed was initiated and he could able to walk around 2 km distance continuously without any discomfort. By 5th week, jogging in treadmill at 6 mph speed was initiated. By 8th week, knee extension in gym with 5 kg resistance was initiated for quadriceps muscle within the range of 90°–30° (15 reps × 2 sets, twice a day). This range is set because terminal knee extension from 30° to 0° will put strain on the ACL graft if the quadriceps muscle power and recruitment are poor. At the same time, he performed planks and side planks up to his tolerance. Pool jogging and running on high knees were initiated. By around 8 weeks, he achieved 125° flexion and full hyperextension of right knee compared to the left knee. From 6th week, he gradually reduced the cryotherapy session and does only twice a day by around 8th week after exercise sessions.

After 8 weeks, continuation of previous week rehabilitation program was encouraged. In field, Mr. Ganesh was trained to jog forward and backward in a level surface. His quadriceps recruitment and muscle power seem to be improving and hence in gym isotonic exercises for quadriceps were progressed at terminal knee extension (30°–0°) with low level resistance of 5 kg (20 repetitions × 2 sets, twice a day). Muscle girth was measured at thigh and calf level. Mr. Ganesh had 44.3 cm in right thigh compared to 45.8 cm in the left thigh and 35.8 cm in the right calf compared to 36.9 cm in the left calf.

By 9th week, full right knee flexion ROM of 135° was achieved compared to that of left knee. Hamstrings, quadriceps, and gluteus medius power was 5/5 in manual muscle testing grade. Strengthening with resistance band with level 4 was started for gluteus medius, gluteus maximus, quadriceps, and hamstrings. By around 10th week, running was initiated in the field. To return to play, the athlete had to perform sports activities without pain and discomfort, while maintaining proper technique. For example, the athlete had to be able to perform a sprint at 100% intensity and be able to kick or dribble a ball without pain. Mr. Ganesh underwent functional tests of Yo-Yo intermittent recovery test, repeated sprint shuttle ability test, eccentric knee drop, broad jump test, single leg hop test, and vertical jump assessment to participate in sports-specific drills. He was comfortable, and his performance was good in the functional tests. Sports and conditioning coach taught him sports-specific drill activities which include lunge walking, shuttle running, diagonal running, bounding, scissor running, high knee running forward-backward, Zorba running, single leg hopping, single leg diagonal hopping, hopscotch with side steps, fast feet – step and slide, and zig-zag running. He performed all sports-specific drills with Kinesio tape to enhance proprioception. Tackling is a major concern for all athletes after any injury. Psychological fear of sustaining reinjury while going for a tackle exists. Even after a perfect high-intensity sports-specific drills or agility drills, this fear exists. In Mr. Ganesh's situation, medical and technical staffs - physiotherapist, strength and conditioning coach, and coach are all involved in getting out of this fear factor. The method of returning Mr. Ganesh to play without tackling fear progressed from technical practice (such as shooting, passes, and dribbles) [Figure 1], playing practice match with division soccer team and with teammates, and then return to play the main match as a substitute. This prepares his mind to overcome the fear of tackle and makes him to deliver his 100% effort in the main match after return to play. Mr. Ganesh was able to compete in these training practices without pain and discomfort, got himself in the squad for the main match, and played first match as a substitute player for 20 min at the second half and then played full 90 min in the next match.
Figure 1: Dhanpal Ganesh in technical practice

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  Discussion Top


Injuries are a major adverse event in a soccer player's career. The unique nature of this case study is the aggressive rehabilitation of young soccer athlete who underwent arthroscopic procedures of lateral meniscal repair, ITB tenodesis, and ACL and ALL reconstruction in the right knee. Aggressive rehabilitation protocol uses knee function as the predictor rather than suspected graft strength. The purpose of any knee surgery following an injury is to restore knee stability and full function without any complications. In general, rehabilitation of athlete differs from rehabilitating a nonathlete. Athlete tends to cope up perfectly with the exercises, and their progression will be much faster than the nonathlete. In the past few years, injury prevention programs for soccer players have been developed and their effectiveness scientifically confirmed.[4] The sports physiotherapist plays an important role in monitoring a closely supervised criteria-based program and in guiding the athlete during the rehabilitation and training process.[5] Several evidence-based and empirical criteria are needed to plan and monitor the efficient return to competitive soccer. Two performance tests considered the best, in terms of validity and reliability in healthy soccer players, are the Yo-Yo intermittent recovery (Yo-Yo) test [6] and the repeated shuttle sprint ability test.[7] A carefully planned rehabilitation program that addresses all aspects of the game is vital to return the player to maximum function while minimizing the risk of re-injury.


  Conclusion Top


Researches on postoperative outcomes and the rehabilitation after arthroscopic concomitant ACL reconstruction, ALL reconstruction, lateral meniscal repair, and ITB tenodesis are very rarely overcome in clinical field, and rehabilitation outcomes are lacking for such soft tissue procedures in the literature. This is the first case study reporting rehabilitation guidelines after this procedure. The rehabilitation program of this case study was based on the therapist clinical experience with this type of injury.

Acknowledgment

We would like to express our gratitude to all the staffs of Global Health City, Chennai, Tamil Nadu, India, for their guidance and support throughout this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Charles TC, Karen G, Jack S, Sourav KP, Jonathan TB. On-the field management of American football injuries. Sports Injuries. 2nd ed. USA: Springer; 2015. p. 2703-19.  Back to cited text no. 1
    
2.
Frizziero A, Ferrari R, Giannotti E, Ferroni C, Poli P, Masiero S. The meniscus tear. State of the art of rehabilitation protocols related to surgical procedures. Muscles Ligaments Tendons J 2013;2:295-301.  Back to cited text no. 2
    
3.
Biggs A, Jenkins WL, Urch SE, Shelbourne KD. Rehabilitation for patients following ACL reconstruction: A knee symmetry model. N Am J Sports Phys Ther 2009;4:2-12.  Back to cited text no. 3
    
4.
Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: A review of prevention programs aimed to modify risk factors and to reduce injury rates. Knee Surg Sports Traumatol Arthrosc 2009;17:859-79.  Back to cited text no. 4
    
5.
Bizzini M, Hancock D, Impellizzeri F. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: Soccer. J Orthop Sports Phys Ther 2012;42:304-12.  Back to cited text no. 5
    
6.
Bangsbo J, Iaia FM, Krustrup P. The Yo-Yo intermittent recovery test: A useful tool for evaluation of physical performance in intermittent sports. Sports Med 2008;38:37-51.  Back to cited text no. 6
    
7.
Impellizzeri FM, Rampinini E, Castagna C, Bishop D, Ferrari Bravo D, Tibaudi A, et al. Validity of a repeated-sprint test for football. Int J Sports Med 2008;29:899-905.  Back to cited text no. 7
    


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Discussion
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