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Case Study: Complete ACL Tear and LCL Sprain in a Male High School Football Player Emily Pevey Athletic Training Education Program Southeastern Louisiana University Emily Pevey Athletic Training Education Program Southeastern Louisiana University
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History Athlete is a 17 year old male football player. Athlete has no previous injury in the left knee. During a JV football game on 9/11/2013, the athlete was running down the field, planted, then was tackled with an opposing player landing on his left leg. The athlete’s leg twisted and he claimed to hear a “pop”. He could not get up from the ground and had to be carried off the field to be further evaluated by the athletic trainer. Athlete is a 17 year old male football player. Athlete has no previous injury in the left knee. During a JV football game on 9/11/2013, the athlete was running down the field, planted, then was tackled with an opposing player landing on his left leg. The athlete’s leg twisted and he claimed to hear a “pop”. He could not get up from the ground and had to be carried off the field to be further evaluated by the athletic trainer.
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Observation & Palpation The athlete complained of sharp left knee pain, was very point tender in the medial and lateral joint lines and in the anterior knee. Athlete could not put weight on his left leg. Effusion was present immediately. No bruising or bleeding. No obvious deformity. The athlete complained of sharp left knee pain, was very point tender in the medial and lateral joint lines and in the anterior knee. Athlete could not put weight on his left leg. Effusion was present immediately. No bruising or bleeding. No obvious deformity.
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Special Tests McMurray’s: medial (+); lateral (+) for pain Lachman’s: (+) Anterior Drawer: (+) Posterior Drawer: (-) Varus Stress: (-) Valgus Stress: (+) Pivot Shift: (+) Patellar Apprehension: (-) ROM: Right Leg: Extension- 0, Flexion- 130 Left Leg: Extension- 5, Flexion- 100 McMurray’s: medial (+); lateral (+) for pain Lachman’s: (+) Anterior Drawer: (+) Posterior Drawer: (-) Varus Stress: (-) Valgus Stress: (+) Pivot Shift: (+) Patellar Apprehension: (-) ROM: Right Leg: Extension- 0, Flexion- 130 Left Leg: Extension- 5, Flexion- 100
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Results of Diagnostic Imaging The x-ray showed no fractures. The MRI showed a complete tear of the ACL, along with a slight tear to the distal biceps femoris tendon. The LCL also showed slight damage. There were contusions on the distal femur and proximal tibia, most predominately on the medial femoral condyle. There is joint effusion present. The x-ray showed no fractures. The MRI showed a complete tear of the ACL, along with a slight tear to the distal biceps femoris tendon. The LCL also showed slight damage. There were contusions on the distal femur and proximal tibia, most predominately on the medial femoral condyle. There is joint effusion present.
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Clinical Plan and Protocol The athlete was scheduled for surgery on October 4 th. He was nonweightbearing for 4 weeks. After 4 weeks, he moved to weight bearing in a knee immobilizer. Rehabilitation began 10 days after surgery. The athlete was scheduled for surgery on October 4 th. He was nonweightbearing for 4 weeks. After 4 weeks, he moved to weight bearing in a knee immobilizer. Rehabilitation began 10 days after surgery.
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Rehabilitation Program Week 1 : Control Pain and Swelling Stem, ultrasound, ice, game ready, etc. Can work on some ROM Extension: have athlete lie prone on table with leg hanging off. 3 X 10-15min daily Flexion: passive flexion, towel pulls, or foot slides down the wall Other exercises: -Quad sets, Straight leg raises with knee immobilizer on, ankle pumps, etc. Week 1 : Control Pain and Swelling Stem, ultrasound, ice, game ready, etc. Can work on some ROM Extension: have athlete lie prone on table with leg hanging off. 3 X 10-15min daily Flexion: passive flexion, towel pulls, or foot slides down the wall Other exercises: -Quad sets, Straight leg raises with knee immobilizer on, ankle pumps, etc. Week 2 : Continue with modalities for pain and swelling. Cardiovascular training: bike or elliptical Exercises: Partial squats, SLRs without immobilizer, calf raises Goal should be to maintain extension and regain strength Week 2 : Continue with modalities for pain and swelling. Cardiovascular training: bike or elliptical Exercises: Partial squats, SLRs without immobilizer, calf raises Goal should be to maintain extension and regain strength
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Rehabilitation Program Weeks 3-6 : Should be working towards full ROM and strength Maintain cardio with bike or elliptical. Can also add aquatic therapy at this point. Full ROM, gait training, etc. Exercises: Wall squats/slides, seated leg curls, light leg press, SLRs, quad sets. Can add some balance exercises towards the end of the 6 weeks with a tilt board or balance board Weeks 3-6 : Should be working towards full ROM and strength Maintain cardio with bike or elliptical. Can also add aquatic therapy at this point. Full ROM, gait training, etc. Exercises: Wall squats/slides, seated leg curls, light leg press, SLRs, quad sets. Can add some balance exercises towards the end of the 6 weeks with a tilt board or balance board Weeks 6-12 : Can continue with same exercises as previous stage, just adding more resistance or repetitions. Can begin swimming for cardio. Exercises: Introduce treadmill- walking normally. Weeks 6-12 : Can continue with same exercises as previous stage, just adding more resistance or repetitions. Can begin swimming for cardio. Exercises: Introduce treadmill- walking normally.
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Rehabilitation Program Weeks 12-20 : Can begin working towards sport specific activity, so introduce jogging. Jog straights, walk curves S-curve jogging Jogging backwards Exercises: Same as prior, with continued increase in reps, intensity, weight, etc. Weeks 12-20 : Can begin working towards sport specific activity, so introduce jogging. Jog straights, walk curves S-curve jogging Jogging backwards Exercises: Same as prior, with continued increase in reps, intensity, weight, etc. 6 months post-op : Can begin evaluating for RTP Introduce agility drills and more sport specific activities Exercises: Agility drills Running/cutting/planting Running routes, catching and passing, etc 6 months post-op : Can begin evaluating for RTP Introduce agility drills and more sport specific activities Exercises: Agility drills Running/cutting/planting Running routes, catching and passing, etc
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Return to Play Criteria Cleared by physician Can complete sport specific demands pain free and without apprehension Has full ROM Has regained quad and hamstring strength Is confident to return to playing field Has a properly fitting knee brace and understands the importance of wearing it during all activity Cleared by physician Can complete sport specific demands pain free and without apprehension Has full ROM Has regained quad and hamstring strength Is confident to return to playing field Has a properly fitting knee brace and understands the importance of wearing it during all activity
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Summary of Research The research from the article “Bone–Patellar Tendon–Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate Ligament Reconstruction” suggests that patients who had ACL reconstruction surgery using an autograft were less likely to experience graft ruptures, laxity, loss of strength and knee pain when compared to other patients who received allograft reconstruction surgery. “Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy” is another research article that compared the effectiveness of an autograft versus an allograft acl reconstruction. This study found that patients with an allograft were 7.7 times more likely to experience graft failure. The authors of the article recommended autograft use in all acl reconstructions. The research from the article “Bone–Patellar Tendon–Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate Ligament Reconstruction” suggests that patients who had ACL reconstruction surgery using an autograft were less likely to experience graft ruptures, laxity, loss of strength and knee pain when compared to other patients who received allograft reconstruction surgery. “Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy” is another research article that compared the effectiveness of an autograft versus an allograft acl reconstruction. This study found that patients with an allograft were 7.7 times more likely to experience graft failure. The authors of the article recommended autograft use in all acl reconstructions.
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Works Cited Kraeutler, M.J., Bravman, J.T., & McCarty, E.C. (2013). Bone-Patellar Tendon-Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate Ligament Reconstruction: A Meta-analysis of 5182 Patients. American Journal Of Sports Medicine, 2439. April 12,2013. Pallis, M, Svoboda, S.J., Cameron, K.L., & Owens, B.D. (2012). Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy. American Journal of Sports Medicine, 1242. April 24, 2012. Kraeutler, M.J., Bravman, J.T., & McCarty, E.C. (2013). Bone-Patellar Tendon-Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate Ligament Reconstruction: A Meta-analysis of 5182 Patients. American Journal Of Sports Medicine, 2439. April 12,2013. Pallis, M, Svoboda, S.J., Cameron, K.L., & Owens, B.D. (2012). Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy. American Journal of Sports Medicine, 1242. April 24, 2012.
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