Issue 31 Spring 2012 - Bases

Case study
The interdisciplinary approach to the
management of chronic knee pain in the
elite athlete – a case study
Experts from the Intensive Rehabilitation Unit (IRU) based at Bisham Abbey National Sports Centre provide
an insight into the interdisciplinary approach taken to providing optimal injury rehabilitation to elite athletes.
Introduction
The performance of an athlete is supported by input from a
large number of professionals from a wide range of disciplines,
and the recovery of an athlete from injury is no different. The
effectiveness of interaction between the professionals involved in
an athlete’s rehabilitation can make the difference between optimal
and delayed recovery. A truly interdisciplinary approach has been
shown to optimise medical rehabilitation when compared to that
of a multidisciplinary team (Korner, 2010). By identifying objective
markers, the effectiveness of the team in improving function and
effecting change in the injured site can be monitored.
History
This case study involves a 21 year old male, elite-level weightlifter
with severe left anterior knee pain, which came on whilst squatting
an empty bar following a period of rest for another injury. A
diagnostic ultrasound scan showed collagen degeneration and he
underwent plasma rich platelet (PRP) injections at the left patella
tendon insertion and proximal patella. His pain improved, as did
the appearance of the tendon on ultrasound, and he commenced
an eccentric squat programme for six minutes each day, which was
governed by a visual analogue scale (VAS) with a pain score of 4-5
out of 10 during exercise.
His pain returned and he underwent a steroid injection to
the tibial tuberosity three weeks before his admission to the IRU.
Once again there was improvement in his pain but he continued to
complain of anterior knee pain, which was aggravated by training
and on stairs. The weightlifting support team subsequently referred
this athlete to the IRU for a one-week block of investigation and
intensive treatment as part of his overall rehabilitation strategy.
Clinical examination
On assessment the athlete presented with reduced muscle tone
and definition around his left knee compared to the right, as well
as reduced strength on manual muscle testing. He had full range of
movement of his knee with no pain or tenderness but significant
laxity of the medial collateral and anterior cruciate ligaments, with
excessive tibial rotation bilaterally, worse on the left. Around the
pelvis he had poor gluteal function on the left with poor control of
his sacroiliac joint; radiculopathy signs at L2-L4; paraspinal muscle
tenderness and stiffness of his thoracic spine. Of relevance was a
history of three previous bone stress injuries in the right tibia (see
Table 1).
Management
The management of this athlete necessitated an interdisciplinary
approach that involved integration of medical, physiotherapy,
psychology, nutrition, strength and conditioning and physiology
support. The physiotherapy approach involved the integration of
two theoretical models. The application of this intervention was
based on objective and repeatable clinical markers.
The neuropathic pain and dysfunction model (Gunn, 2002)
This model looks at disturbed function and super sensitivity in
the peripheral nervous system, which is often apparent in chronic
conditions such as this (Loeser, 2001). His key clinical markers
of prone hip extension off the end of a plinth showed very poor
inner range gluteal strength with excessive trunk rotation at
L2/3 lumbar levels. This test reproduced his knee pain. Using this
marker, treatment focused on the lumbar spine using intensive
intramuscular stimulation to impact on the referred pain. Dry
needling, a form of acupuncture was also performed on the
quadratus lumborum, iliocostalis and quadriceps muscles. Following
this treatment the hip extension test improved and his knee pain
decreased.
The load transfer model
The next element of clinical intervention involved addressing
the athlete’s load transfer dysfunction. The fundamentals of his
kinetic chain were examined and objective markers obtained.
Scientific measures are essential in underpinning clinical decisions.
Table 1 shows those of relevance in this case. All of these factors
contributed to a decreased ability to transfer load effectively, placing
the left knee under greater load and leading to pathological changes.
A programme was put in place to address these dysfunctions (see
Table 2) and was performed daily as part of preparation before
strength training.
Table 1. Relevant clinical findings
Anterior Posterior proprioceptive deficit on sway test
External rotation left hip restricted greater than 50%
Extension in standing shear at L2/3
Stiff lumbar flexion and thoracic stiffness
Side holds showed a 47% discrepancy – left greater than right
Table 2. Rehabilitation programme
Hip and trunk programme
Prone bench gluteal extension (3 x 10 reps)
Bird dog with theraband alternate arm /leg extensions (3 x 10 reps)
Static theraband side step outs (3 x 12 reps)
Wide arm pushups (3 x 10 reps)
Standing theraband leg pulses (3 x 12 reps)
Gluteal and oblique force couple in side lying (3 x 8 reps)
Knee stability drill
Single leg anterior – posterior direction proprioception drills (3 x 60 sec)
Reverse lunge (3 x 8 reps)
Assisted squat (3 x 10 reps)
Load transfer capacity was greatly assisted by targeted manual
mobilisation and self mobilisation to the thoracic spine. Pre- and
post-exercise dynamic thoracic extension and rotation exercises
were completed. Soft tissue massage, especially deep facial release
to the spiral line and superficial back line was performed by the soft
tissue therapist. Specific points to mid thoracic area/tensor fascia
lata and abdominal aponeuroses made a significant impact in trunk
control strategies.
6 The Sport and Exercise Scientist n Issue 31 n Spring 2012 n www.bases.org.uk