Description of Injury and Treatment Plan
Anterior Cruciate Ligament Injury
The anterior cruciate ligament (ACL) is an important ligament of the knee in regards to stabilization (Friedberg, 2013). The ACL originates from the later femoral condyle in the distal femur; it traverses in an antero-medial direction to insert onto the antero-medial part of the tibia, in between the condyles. (Friedberg, 2013) The function of the ACL is to resist anterior movement and medial rotation of the tibia in relation to the femur (Markolf, Mensch, & Amstutz, 1976). A Non-contact mechanism of injury involves a running or jumping athlete with a sudden change in direction. A contact mechanism of injury, are those that are usually caused by a direct blow to the knee, which causes hyperextension of the knee.
Severity:
Signs and Symptoms:
- “Popping” sensation
- Swelling
- Joint Instability
- Effusion (form hemarthrosis)
Treatment:
Treatment of ACL tears may require surgery or may be treated conservatively in the case of partial tears; regardless of whether or not the injured needs to have surgery to repair the torn ligament, extensive physical therapy is needed to increase the range of motion of the knee and to increase stability of the knee.
Stage 1: ROM
- Straight leg raises
- Active extension (sits on edge of a chair)
- Knee extension while supine
Stage 2:
In week 2, closed kinetic chain exercises should be initiated first (Wright, Preston, Fleming, Amendola, Andrish, Bergfeld, Dunn, Kaeding, Kuhn, Marx, McCarty, Parker, Spindler, Wolcott, Wolf, & Williams, 2008).
Some examples:
- Squats
- Lunges
- Dead lifts
The purpose of these exercises is to strengthen the quadriceps, hamstrings, and hip flexors. Swimming and cycling are added as the patient has less pain and swelling. As the weeks progress more resistance can be added to each of the exercises to increase power and strength. In the following weeks, week 2-9 postoperatively, exercises that increase balance, proprioception, and increase core strength should be added into the rehabilitation routine. Full recovery time takes anywhere between 6-12 months depending on the patient and the rehabilitation program.
Patello-Femoral Syndrome
Patello-Femoral Syndrome is a multifactorial problem, which results do to interactions between the intrinsic anatomy of the knee and extrinsic training factors. Overuse, malalignment, and trauma are the most most common causative factors, with overuse being the most common
(Aminaka & Gribble, 2008).
Significance of Research:
Patello – femoral syndrome is a common complaint in patients due to its etiology in being a disorder due to overuse of the joint. It is also a multifactorial condition and therefore there are many approaches to its treatment. Patellar taping is a commonly used adjunctive therapy to the concurrent rehabilitation program. In an article by Jessee, Gourley, and McLeod (2012) they reviewed evidence of different taping techniques to see if an effective one existed to treat pain associated with patello-femoral syndrome. The following studies showed clinical significance in their study, protonics orthosis, McConnel taping, and Couman Taping. In this article, it was suggested that taping be considered in clinical practice, even though little scientific evidence proved its usefulness, because in combination with a proper rehabilitation program, it decreased pain and increased functional improvement in the patient. This research is significant, because this “injury” is fairly common. Patients may be in too much pain to do the required rehabilitation program, and therefore not follow through; this just perpetuates the injury. The use of taping can realign the patella making the pain decrease, and increase functional improvement, and therefore allow the patients to preform the exercises to strengthen the muscles. As the muscles strengthen they counteract the forces that cause patella-femoral syndrome.
Signs and Symptoms
Knee pain is either acute or gradual and may be associated with previous trauma. Pain in localized to the region of the patella, and is worse when doing exercises such as squatting or running. The feeling of instability is also a common complaint, but is due to pain inhibiting the proper contraction of the quadriceps rather then true instability (Jessee, Gourley, & McLeod, 2012).
Severity:
The severity of patello-femoral syndrome is based on the anterior knee pain scale. It consists of a 13-item knee specific questionnaire. The questions asked are designed around six activated that are thought to result in anterior knee pain; these include: walking, running, jumping, climbing stairs, sitting for long periods of time with the knees bent, and squatting. The maximum score on the questionnaire is 100, and a lower score indicates more severe pain and instability. Categories for the response to the questions range from no difficulty in the activity difficulty do the activity and no pain severe pain.
Treatment
The conservative approach, meaning non operative, for patellofemoral syndrome includes, patellar taping, stretching, strengthening of the vastus medialis muscle, training modification, neuromuscular electric stimulation, bracing and foot orthotics (Aminaka & Gribble, 2008) (Jessee, Gourley, & McLeod, 2012). Operative interventions include, patellar alignment, patellar resurfacing, and patellar arthroplasty.
Stage 1: Activity modification is very important; due to the fact the overload plays an important role in its mechanism.
Stage 2: Exercises include:
- Stretching
- hip abductor strengthening
- quadriceps strengthening
- core stability.
Open and closed chain kinetic exercises seem to have equal affectivity on quadriceps strengthening in patella-femoral syndrome. Open kinetic chain exercises are those in which the foot is not fixed; exercises in this category include leg curls and leg extension. For an explanation on closed kinetic chain exercises, see above: Treatment of ACL injuries.
Mid core strength effects pelvic stability and in turn can cause lower extremity injuries. Exercises involve trunk rotation and flexion of the knee and hip joints; for example; crunches with rotation and the knees flexed at 90 degrees in the air.
Return to sports follows the same rules as any other overuse injury; the degree of motion of the joint should be equal to the unaffected side, and strength should be approximately 80%.
Asthma:
Asthma is a disease of the pulmonary system and is a result of chronic inflammation, which leads to the airway hyper-responsiveness of the airways. It is characterized by reversible airflow obstruction and bronchospasm. Asthma can be triggered by, allergens, pollutants, respiratory infections, inhaled irritants, and exposure to cold and exercise (Miller, Weiler, Baker, Collins, & D’Alonzo, 2005). Many athletes have difficulty breathing and it is most often due to undiagnosed or uncontrolled asthma.
Signs and Symptoms:
- Chest tightness
- Coughing
- Dyspnea
- Wheezing
- Inability to catch ones breath
- Personal history of atopy
- Family history.
Classification of Severity:
Classification of asthma is based on the clinical features present before treatment. Differences are based on the number of symptoms, which can occur daily, weekly, or even continuously.
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
Treatment:
There are different pharmacological approaches to the treatment of asthma, depending on whether or not the patient needs only a short acting agent or may need a combination of short and long-term acting agents. Short acting drugs are known as bronchodilators and are use to reverse bronchoconstriction in asthma. Short-term acting drugs have no effect on the inflammatory reaction associated with asthma, and therefore the long-term acting or “controlling” drugs are used. Patients with exercise induced asthma benefit from the use of short term and long-term beta-agonists. Short-term drugs work within seconds and can be used as prophylaxis in practice or during competition; or for rescue during an acute attack. Long-term beta agonists are usually used in combination with steroids for control. Non-pharmacological treatment of asthma include, limiting exposure to irritants, and proper warm up; which has shown to decrease the reliance of medication in some athletes.
Education of the athlete, the coaches, and the referees, is important and they should know the signs and symptoms, the method of us of spirometry, and the methods of limiting exposure. The increased use of a rescue inhaler is a signal that a better treatment plan is in order.
Works Cited
Friedberg, R. (2013) Anterior Cruciate Ligament Injury. UpToDate. Waltham, MA: UpToDate
Markolf, KL., Mensch, JS., and Amstutz, HC. (1976) Stiffness and laxity of the knee--the contributions of the supporting structures. A quantitative in vitro study. J Bone Joint Surg Am. 58(5):583
Wright, Rw., Preston, E., Fleming, BC., Amdendola, A., Andrish, JT., Dunn, WR., Kaeding, C., Kuhn, JE., Marx, RG., McCarthy, EC., Parker, RC., Spindler, KP., Wolcott, M., Wolf, BR., Williams, GN. (2008) A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008;21(3):225
Aminaka, N. & Gribble, P. (2008) Patellar Taping, Patellofemoral Pain Syndrome, Lower Extremity Kinematics, and Dynamic Postural Control. Journal of Athletic Training. 43(1): 21-28
Jessee, A., Gourley, M., & Mcleod, T. (2012) Bracing and Taping Techniques and Patellofemoral Pain Syndrome. Journal of Athletic Training. 47(3): 358-359
Miller, M., Weiler, J., Baker, R., Collins, J., & D’Alonzo, G. (2005) National Athletic Trainers’ Association Position Statement: Management of Asthma in Athletes. Journal of Athletic Trainin. 40(3) 224-225
