Knee Injury In A Collegiate Football Athlete

Personal Data/Medical History: A 22-year-old Division I collegiate football player injured his left knee during a football practice. Analysis of the practice video revealed a position of external tibial rotation with knee flexion beyond 90 degree while he was engaged in a block. He complained of sharp pain on the medial aspect of the knee and also pain stemming from within the knee joint. No bony deformities or other abnormalities were presented. Physical Signs and Symptoms: Upon initial evaluation laxity in the knee was found with a (+) posterior drawer test with an end point, (+) valgus stress test at 0 degree and 30 degree , and minor laxity with a Lachman's test and anterior drawer test. Differential Diagnosis: Anterior Cruciate Ligament Sprain, Posterior Cruciate Ligament Sprain, Medial Collateral Ligament Sprain, Medial Meniscus Tear. Diagnostic Imaging: Radiographs were negative for bony involvement of the tibial plateau or femoral condyles. A MRI scan revealed a grade-2 injury to the MCL with residual fiber continuity from the femur to the tibia, indicating an incomplete tear. The MRI also revealed a grade-2 injury to the PCL with residual fibers intact, indicating an incomplete tear. Remaining structures surrounding the knee were unaffected. A diagnosis was made of a grade-2 injury to both the PCL and MCL of the left knee. Clinical Course: Based on the presence of intact fibers in both the PCL and MCL a decision was made to treat this injury non-operatively. Conservative treatment involved the utilization of TENS to decrease pain and galvanic stimulation to delay muscular atrophy. Diclofenac (VERMED, Bellows Falls, VT) was applied via phonophoresis to decrease inflammation and to increase fibroblastic activity. Initially, range of motion was controlled by straight leg immobilization. Strength protocol was based on standard guidelines established for non-operative rehabilitation of posterior cruciate ligament and medial collateral ligament sprains. Isometric, isokinetic and isotonic strengthening began at 0 degree -60 degree of knee flexion then progressed to 90 degree of knee flexion. At 8 weeks hamstring strengthening from 0 degree -30 degree of knee flexion was initiated. Gastrocnemius contraction during hamstring strengthening decreased the amount of posterior tibial translation. A progression of treadmill walking to light jogging was also initiated at that time. Deviation from the Expected: The mechanism of injury described by the athlete and