Jan 29, 2015Ready to Rebound
A third ACL tear, tibial plateau fracture with severe ligament damage, iliotibial band syndrome. Knee injuries are one of the most common issues faced by athletes, but no two rehabs are ever the same. In this three-part article, athletic trainers share their treatment plans.
By Nicole Alexander
Nicole Alexander, MS, ATC, is Staff Athletic Trainer at the University of North Carolina, where she works with women’s basketball and men’s tennis. She can be reached at: [email protected]
When I was hired at the University of North Carolina in August 2013, one of my first tasks was familiarizing myself with our student-athletes’ medical histories. Megan Buckland, a redshirt sophomore on the women’s basketball team at the time, stood out because she had returned the previous season from her second ACL tear in her left knee to have a breakout year.
But during the second game of the 2013-14 season, Megan drove to the basket for a layup and felt a pop–this time, in her right knee. The diagnosis was an isolated ACL tear, which meant Megan was facing her third ACL rehabilitation in as many years. As she was assisted off the court, all she could say was, “I can’t believe this is happening again.”
Megan and I discussed her two treatment options shortly after the injury: surgical ACL reconstruction or playing in a brace for the rest of the season. Due to the cutting required in basketball and that there were so many games remaining, surgery became the go-to option.
Once we landed on that decision, we had to determine what type of graft to use for the procedure. Megan’s first ACL reconstruction in April 2010 was a bone patellar tendon bone autograft, but she had used an allograft after her re-tear in 2011. The surgeon explained both options in detail, discussing the pros and cons of each. Because of the unsuccessful reconstruction using an autograft for her first ACL surgery, Megan decided to go with the allograft.
In the three weeks prior to surgery, I put Megan through a prehab focused on swelling control, active range of motion, and general quad activation. A compression bandage worn throughout daily activity helped manage her swelling, and she regained full active range of motion using active assisted and passive stretching. To increase her quad activation, we utilized Russian e-stim in conjunction with quad sets and straight-leg raises.
Following a successful surgery, Megan’s rehab process began the next day with a visit to one of the athletic department’s physical therapists. This initial session provided the athletic training staff with valuable girth and goniometric measurements. In addition to daily work with our athletic training staff, Megan continued weekly meetings with the physical therapist for the first two months of rehab.
Due to Megan’s history of ACL injuries, I chose to put her through a conventional rehab program rather than an accelerated one. I thought it would be smart to take advantage of the ample time we had for recovery before the beginning of the 2014-15 season.
Here’s a breakdown of what we focused on month-to-month in Megan’s rehab:
Month 1: Swelling and pain control, increase active range of motion, quad activation, return to full weight bearing, hip strengthening exercises
Month 2: Full range of motion, general strength gains (closed kinetic chain exercises), increase proprioception
Month 3: Add open kinetic chain exercises, begin cardio on stair-climber
Month 4: Plyometrics Month 5: Running progression on basketball court, stationary shooting
Month 6: Agility drills, non-contact basketball drills.
At approximately eight weeks into the rehab, Megan began working with the women’s basketball strength and conditioning coach on uninvolved leg strengthening. By 16 weeks, she was cleared to lift fully with the team. Working closely with the strength coach ensured a smooth transition into basketball-related activities.
UNC athletics offers many resources that were valuable during Megan’s rehab. For example, as soon as her wounds healed and the risk of infection was minimized, she got to work on the underwater treadmill. Initially, it was used to encourage normal gait. Megan responded well to this modality, so at week 18, we started a running progression on the machine that combined walking and jogging. As Megan continued to improve, we increased the jogging time and resistance.
We also often utilized an isokinetic rehab machine to gauge Megan’s quad and hamstring strength in her right leg compared to her left, using the percent deficits at three speeds in flexion and extension. In addition, this work helped us examine the changes in peak torque output in her right leg before and after injury.
Our goal as an athletic training staff throughout Megan’s rehab was to not only manage the injury, but the athlete as well. We encouraged her physical and mental progress, so her input was valuable from the beginning. We made a habit of asking her why she thought she couldn’t do a certain exercise and addressed where she was coming from, rather than assuming it was due to fatigue or because she wasn’t ready to progress to the next step.
It was also helpful for Megan to tell us what exercises she enjoyed and which ones she had struggled with during her previous rehabs. We found that there was a limit to the number of single-leg balance exercises she would put up with, which forced us to get creative while improving her strength and neuromuscular control. We recreated basketball-specific drills as much as possible and allowed Megan to occasionally participate in passing and dribbling drills during practice.
Part of focusing on Megan as a person meant tuning into how the injury was affecting her daily life. For example, at one game, she expressed discomfort when walking down a ramp to get to the court. So we added extra focus on eccentric control at her next rehab session.
Having a patient who had gone through two previous ACL rehabs was both advantageous and detrimental. While it helped that Megan knew what it took to get back on the court and understood the aches and pains that came along with it, an obstacle we faced as an athletic training staff was having to frequently reassure her that she was progressing on the right path throughout the rehab.
Perhaps the biggest challenge with multiple ACL rehabs is that, eventually, you have to discuss whether or not the athlete should return to their sport. Megan was most vocal about this during her second month of recovery. Her concern was not about how her knee would handle coming back, but about her mentality. She was not confident she could be the same fearless player after a third ACL tear. After careful deliberation, she chose to return to basketball and brought the same passion and drive to get back to the game as she had in her two previous rehabs.
Before Megan began contact drills, we had her fitted for a brace. During her first few practices back, she participated both with and without the brace so we could see which option she was more comfortable with. As a sports medicine staff, and with Megan’s input, we decided she would wear a brace on both knees during the preseason. Whether or not she will wear braces during the season is still to be determined.
Overall, Megan’s progression has exceeded expectations. A full preseason of practice allowed us to see if there were any areas of concern, giving us the chance to get Megan 100 percent ready for the team’s first game on Nov. 14.
Long Road Back
By Meredith Pope
Meredith Pope, MEd, ATC, is the Health Coordinator for The Masters School in Dobbs Ferry, N.Y. She was the Head Athletic Trainer at Mercy College from 2010 to 2014, where she worked directly with women’s soccer and men’s lacrosse and also served as the Vice President for the East Coast Conference Sports Medicine Committee. She can be reached at: [email protected].
While making a play for a 50/50 ball during a soccer game in October 2010, Mercy College defender Jackie Karras’s only concern was winning the tackle. But as the freshman stepped into the ball, she felt her right knee shift back and hyperextend and heard a pop followed by immediate pain. In that instant, Jackie had torn her MCL, LCL, and PCL; endured a lateral meniscus tear; and sustained a tibial plateau fracture. It would take three years, a complicated rehab, and overcoming a spate of subsequent injuries before she would play a full season of soccer again.
An initial assessment by the athletic trainer at the game was exceedingly difficult due to the intense pain Jackie was experiencing and the extreme swelling of her knee. Physically, she presented with no visible deformity, but she had a large joint effusion and palpable tenderness over the medial femoral condyle, medial tibial plateau, patellar tendon, patella, medial joint line, and popliteal space. Those observations, coupled with a positive valgus stress test, led me to believe Jackie had sustained an injury to her ACL and/or MCL.
It wasn’t until the next day when Jackie met with James Penna, MD, Chief of the Sports Medicine Division of Stony Brook Orthopedic Associates and Team Physician for Mercy athletics, that we realized the full extent of the damage. Neither our athletic training staff nor Dr. Penna had ever seen this set of injuries occur as a result of sports trauma.
Because of the severity of Jackie’s injury, surgical intervention was the only treatment option. We were unable to do any of the prehab that typically occurs before knee reconstruction because we were concerned that the tibial plateau fracture would displace and cause secondary injury to Jackie’s circulatory structures, nerves, and essential soft tissues.
Instead, her knee was immobilized following her first appointment with Dr. Penna, and she was instructed to not put any weight on it before the procedure. Two weeks after the injury, Dr. Penna surgically repaired the torn MCL and lateral meniscus, inserted a synthetic bone graft to promote healing and fill in the bone fragments that had been fractured, and stabilized the break in the tibial plateau with a metal plate and four screws.
The surgery was a success, and we started the rehab process two weeks later. Going into it, I knew the biggest challenge would be the multi-layered nature of Jackie’s injury. With so many elements to consider, we made the rehab more manageable by breaking it down into individual pieces. This resulted in a slower progression than usual, but we found Jackie responded well to this approach.
Typically, the first goal in knee rehabs is to restore full range of motion in both flexion and extension. However, to protect the healing of the fracture, Jackie’s movement was severely limited by Dr. Penna for the first few weeks after surgery. Therefore, we shifted our initial focus to decreasing the periarticular swelling and working around the injury by doing ankle dorsiflexion and plantarflexion exercises, hip range-of-motion work with the knee locked in extension, and building Jackie’s core strength. We also incorporated functional upper-body training to prevent the postural changes that can come with being on crutches for a long time.
Two weeks into the rehab, we were cleared to start work on the continuous passive motion (CPM) machine. We began by gradually progressing from zero to 60 degrees. The CPM machine also helped us increase Jackie’s brace motion. By the third week, we added open kinetic chain (OKC) hip abductor and adductor exercises.
At one month following surgery, we were given permission from Dr. Penna to begin implementing active range-of-motion exercises into the rehab. This ended up being one of our greatest challenges. Danielle DeLay, MS, ATC, CES, Mercy’s Assistant Athletic Trainer at the time, describes the day she had to passively bring Jackie’s knee to 45 degrees of flexion as the “worst day of her athletic training career thus far.”
Through weeks eight to 12, Jackie was allowed to begin crutch-assisted weight-bearing movements in her brace and could remove it for non-weight-bearing activities. Our new goals for this time period were to achieve 110 degrees of flexion, have Jackie perform a straight-leg raise with full strength against full manual resistance, discontinue use of crutches, and return to reasonable gait mechanics. At this point, we also began active OKC quad exercises and seated biomechanical ankle platform systems.
Month four was a pivotal stage in Jackie’s rehab. Dr. Penna indicated that enough healing had occurred, including in the tibial plateau fracture, to allow us to incorporate strength and functional movement activities. The months of immobilization in the brace caused severe atrophy in Jackie’s right quadriceps and gastrocnemius muscles, so strengthening activities were much-needed. We began with step-up, squat, and lunge progressions and added work on the elliptical, closed-chain rehabs, balance work, and eccentric training as tolerated. Being able to incorporate some of the strength training Jackie was used to doing for soccer really invigorated her.
After turning that corner, we worked on improving her aerobic tolerance during months five and six. We started with light jogging on the treadmill and gradually included plyometric work, with Jackie continuing to wear a brace for both activities.
Our aim was to get Jackie back on the field for the fall of 2011, so we worked on return to full activity while wearing a brace in months seven to nine. We started doing all weight-bearing activities in the brace, added agility drills, and eventually incorporated soccer-related exercises, such as a single-leg balance on a Bosu ball while kicking a soccer ball when tossed, light touches on a soccer ball, and alternating toe-touch hops onto the ball. Our athletic training staff was eager to implement soccer-specific movements, knowing it would further motivate Jackie and keep her engaged through the final weeks of her rehab.
We met our goal, and Jackie was eventually cleared to return to the field for the 2011 season, but additional setbacks would prevent her from seeing much playing time over the next two years. In October, a metatarsal foot fracture forced her to miss the rest of the season. Then, a right knee injury suffered in March 2012–unrelated to her 2010 injury–and a subsequent microfracture of the left femoral condyle in the fall of 2012 kept her out for that season, as well.
At this point, many athletes would consider hanging up their cleats. When I broached this subject with Jackie by asking, “What do you think about this option?” she shot the idea down before I could finish the question. After Dr. Penna brought it up with her again, she considered it, but ultimately decided to return to the sport she loved.
By Jackie’s senior year in fall 2013, she finally had the opportunity to play her first full season for Mercy without injury. She started every game and helped lead the team to its first-ever bid into the NCAA Division II tournament. Despite missing so much time, she finished her career ranked among the top eight players in program history for both goals and points. And to top it all off, in May of 2014, Jackie received the East Coast Conference’s John Smillie Jr. Award, which is presented each year to a student-athlete who has come back from personal or physical challenges.
By Joanne Brewster
Joanne Brewster, MS, ATC, LAT, is Athletic Trainer at Sheridan (Wyo.) High School. She can be reached at: [email protected].
Multisport athlete Maddy McClure went through most of her senior year at Sheridan (Wyo.) High School just as she had previous ones–excelling on the basketball court in the winter and looking to take the state by storm during the spring 2014 track and field season. A few weeks into track practice, however, she began experiencing knee pain. Diagnosed as iliotibial (IT) band syndrome, the rest of the season became a delicate balance of minimizing her symptoms so she could maximize her time on the track.
Because she had no previous history of knee injury, Maddy’s setback came as a surprise. As someone who suffers from IT band syndrome himself, Sheridan’s Head Track and Field and Cross Country Coach Art Baures first recognized Maddy’s symptoms, which manifested as lateral knee pain centralized over the lateral femoral epicondyle. It developed from and increased with running, typically starting to bother Maddy three to five minutes into a workout. Coach Baures sent her to me to see if I could give her some relief.
Once I officially diagnosed her malady as IT band syndrome, I set about determining the best treatment in collaboration with the track and field coaches and Maddy. Because of the coaches’ desire to keep Maddy competing in all her events–the 200, 400, 800, 4×100 relay, and 4×400 relay–our strategy was to treat her symptomatically and with modified practices and rest.
My work with Maddy in the athletic training room involved a combination of modalities and stretching techniques paired with strengthening exercises. We began our daily sessions by using moist heat packs to increase Maddy’s circulation and tissue elasticity prior to stretching. On days when her symptoms were bad, we used thermal ultrasound.
Following the application of heat, Maddy moved on to foam rolling and stretching, which helped relieve the tightness of the IT band and friction caused by its movement. Maddy used a high-density foam roller to address the tightness in her hip flexors and IT band, and I instructed her to roll her quads from the anterior superior iliac spine to the patella and her IT band from the iliac crest to the lateral femoral condyle. After rolling, Maddy stretched her hip flexor, quad, and IT band. The two movements we primarily used were the kneeling hip flexor stretch and side-lying IT band stretch. I felt the latter action was pivotal because it focused the stretch distally, which helped with Maddy’s IT band knee pain.
Rolling and stretching were successful because Maddy was great about doing them every day, multiple times a day. And her track coaches told me she would spend extra time stretching before competitions. Her diligent attitude toward therapy played a key role in keeping her on the track all season long.
Over my years at Sheridan, I have seen several cases of IT band syndrome, but Maddy’s was the first case where I focused on the strength component during treatment. IT band syndrome is often the result of poor hip strength, which often manifests as the Trendelenburg gait, where the hips “drop” toward the unsupported side while running. This gait increases the strain on the IT band.
Therefore, the strengthening component of Maddy’s rehab was aimed at developing her hip abductors. I used four specific exercises to accomplish this: clamshells, side-lying hip abductions, bridges, and single-leg squats. The strengthening work was so beneficial to Maddy that Coach Baures implemented a similar hip-strengthening program with Sheridan’s cross country team this fall.
The work I did with Maddy in the athletic training room helped complement the activity modification Coach Baures was doing on the track. On “good” days where she wasn’t having symptoms and there weren’t any upcoming meets, Maddy worked out with the rest of the team, keeping the exercises under three minutes to reduce fatigue and pain. When her IT band syndrome started to manifest, Maddy took a break to stretch before resuming activity.
On “bad” days when Maddy was symptomatic, she did warm-ups with the rest of the team and then completed a workout on the elliptical. The mechanics of the elliptical reduced the Trendelenburg gait, which allowed her to train without increasing her symptoms.
When it was time for competitions, Coach Baures and Maddy discussed which events she would run based on how she was feeling. Because most of her events were short to middle distance, they often did not last long enough to aggravate the pain of her IT band syndrome. As such, Maddy was able to compete in most of her races, paving the way for her appearance in the state track meet last May.
Our diligent and attentive treatment for Maddy’s IT band syndrome paid off. She participated in all her events at states, placing seventh in the 400, ninth in the 800, third in the 4×100 relay, and seventh in the 4×400 relay.
Maddy’s symptoms resolved with rest following the spring track season. Now a freshman at the University of Wyoming, she plans to walk on to the track and field team. She began the offseason strength and conditioning plan over the summer and has already been in contact with the athletic training staff, letting them know about her history of IT band syndrome and the way in which she was able to manage it during her successful senior year at Sheridan.