Rehabilitation Program for a Person with Medial Ligament Sprain - Case Study Example

Rehabilitation Program for a person with Medial Ligament Sprain Introduction Medical Ligament Sprain or injury is referred to, a conditionwhen the ligament on the inside of the knee is damaged. The most common cause is twisting or an impact on the outer portion of the knee. These are the most common type of injuries sustained in games like football or rugby. It can also occur due to sudden falls or impact injuries. As per the severity of injury sustained they are graded as 1, 2 and 3. The symptoms of the MCL injury can be confirmed by the valgus stress test which puts a strain on the ligament by applying some force to the outside of the knee, stretching the ligament. If the pain and excess of laxity is felt then it will indicate that the medial ligament has been damaged. The grade 1 symptoms are marked by mild tenderness on inside of knee over the ligament. Swelling is normally not present. If the knee is bent to 30 degrees and outside force is applied to lower leg, in order to stress the ligament-pain will be perceived but no joint laxity will occur. During grade 2 symptoms the tenderness would be significant on the inside of the nee on the medial ligament. Swelling occurs and there is pain and mild to moderate laxity in the joint. The symptoms have specific endpoint- unable to bend the knees sideways completely. The grade 3 symptoms are marked by complete tear of the ligament. Pain sensations will vary and sometimes matches pain symptoms of grade 2 sprain. When the knee is stressed there is significant joint laxity. The athlete often complains about an unstable knee. MCL injury: Pathophysiology The medial collateral ligament connects the inner surfaces of the femur or the thigh bone to the tibia which is the larger shin bone. The function of the MCL is to resist the forces that are applied from the outside of the knee, and prevent the medial or inner part of the joint from widening out. The medial knee ligament is divided into two parts i. deep inner section which attaches to the cartilage meniscus and joint margins and ii. A superficial band which attaches from the higher part of the femur to an area which is lower down, that is on the inner surface of the tibia. The injury to the MCL is often caused by impact on the outer side of the knee, when the knee becomes bent slightly. Thus the MCL on the inner side of the knee becomes stretched and when this outside force is great, some of the fibers will tear apart. The deep parts of the ligament are prone to more damaged first and this will lead to the medial meniscal damage also. While repetitive valgus forces lead to the MCL sprain and lead to pain. If the pain in this area does not occur after a sudden injury then the likely cause may be of tendinopathy or bursitis and thus the pain is of the nature of fast pain as it is carried by Ad fibers. As already mentioned the MCL injury is categorized to grade 1,2 and 3 on the basis of the degree of damage sustained. Grade 1 damage signifies that around 10% of fibers are being torn while a grade 3 categorizes a complete rupture of the ligament and grade 2 falls between the above two categories. Thus it can be seen that grade 2 varies considerably in terms of symptoms. The pain is produced is produced by the Ad fibers and the nature is of excruciating pain since the theory of Meljack & Wall’s Gate Control Theory. It is postulated that from the damaged ligament the pain stimulus is carried by the Ad myelinated nerve fibres to the lamina of the spinal cord in the central transmission cells which ultimately sends pain sensation up the spinal cord into the cerebral cortex to cause the sensation of pain. Thus it acts as a gate and modifies the pain sensation that will reach the cerebral cortex. Being myelinated fibers the pain sensation travels quickly and fast from one node of ranvier to another and gives the sensation of fast pain. During the impulse transmission to the central transmission cells it also stimulates the substantia gelatinosa cells which will in fact inhibit the central transmission cells and hence inhibit the pain transmission further and hence the nature is of a fast pain following a high impact injury(grade 3) on the outside of the knee. By contrast the slow or chronic pain sensations are caused by the impulse in the C fibers or the unmyelinated fibres and the transmission is slow and chronic. On the other hand during the transmission in these fibers, the substantia gelatinosa cells are inhibited and hence the substantia cells cannot inhibit the central transmission cells, and the pain sensation persists and appears prolonged after an injury, and hence the chronic nature of pain. This happens in case of grade 1 injuries where mild tenderness and pain is felt. Assessment of MCL injury Observe & Palpate It is necessary to observe and palpate the joint for swelling, bruising and deformity and then the joint areas should be palpated for tenderness, warmth and swelling. In case of the MCL injury, the palpation will range from mild tenderness in grade 1 sprain to more acute pain in the case of more serious injuries. Checking for Range of Motions Then the range of motion of the knees would be checked. The person would be asked to bend and straighten the knee by own and then will be asked to relax again. In MCL injuries the range of motion is mainly affected by the severity of injuries and is mainly limited by a pain or a swelling. Resisted Muscle Test One would be asked to try to bend or straighten the knee against a certain resistance. This will cause the muscles to contract. If there is a pain on contraction a muscle injury can be inferred. Valgus Stress Testing The test is done when a MCL injury is being suspected. The limb of the person is hold ensuring the knee is slightly bent to around 30 degrees, The thigh is stabilized while applying an outward pressure on the lower leg. This causes the medial ligament to stretch. If there is pain in the inner side of the knee then it will indicate a positive test or specify that a person is having a MCL injury. The degree of damage may be speculated based on the movement or stability that is being present. Rehabilitation Plan for the grade 1 MCL Sprain For these type of injuries there may be mild tenderness on the inside of the knee over the ligament and normally swelling is absent. Specific soft tissue mobilization programs will be useful to manage this situation. Soft tissue mobilization signifies the movements of the soft tissues in the body. They include the muscles, skin, ligaments an d tendons. It can be done through direct and indirect technique. In the indirect technique includes moving into the tissues least resistance range to allow a relaxation of tissue tone. This will allow the tissue to move further when released causing improved range of motion and ease of movement. The direct technique involves moving a tissue into a plane of resistance or towards a tissue barrier with a gentle sustained hold. This will help collagen to unwind and increase pain free range of movement. Additionally these will cause to improve neurological reflexes of the body. These can reduce muscle tone and tightness and improve range and inhibit pain. For these type of injuries there may be mild tenderness on the inside of the knee over the ligament and normally swelling is absent. Rationale and Benefits of the Exercises to be initiated during the Rehab Program The Flexion Extension Exercises These exercises are important not only to improve the mobility of the injured knee but will also improve the flexibility of the quadriceps and hamstrings in the early phases of rehabilitation. These exercises will also reduce the swelling around the joint. The principle is tobend and straightens the knee as far as possible and comfortably. This is achieved under sitting, standing or while lying down on one’s front. There should be 3 sets of 10-20 repetitions and performed a minimum of 3 times a day depending upon the intensity of pain. The exercise should be progressed so as to hold the leg in its place at the end of the possible range, both in flexion and extension. This activity will help to strengthen the muscles. Passive Physiological Exercises These area set of movements which follows the body’s normal movement patterns. These can be used to regain the range of movements and decrease the intensity of pain. The affected limb is moved through the pain free range and sometimes into the painful range. This will indicate the quality of movement and will help to assess the areas where restrictions still occur. Also, the range of oscillations at the end of the range performed will increase the range of mobility. Passive Accessory Exercises This exercise will involve moving the joint into positions that cannot be attained by muscular contractions. The soft tissue structures will be passively stretched which caused restricted movements. These exercises are performed in an oscillatory manner which will be conducted in a grading fashion. The Plan Immediately Following Injury: Till day 7 The duration for this rehab would be one week and the aim would be to reduce the swelling if it is present ensuring that the knee can be straightened fully and bent to more than 90 degrees and the objective would be to begin the pain free strengthening exercises. The person should be advised to take rest and refrain from activities that will cause pain. Cold therapy and Compression support should be aimed to reduce the swelling. Ice should be applied for 15 minutes every two hours for the first day. The frequency can be gradually reduced to 3-4 times a day over the next few days depending upon the condition of swelling. While putting ice it should be cloth wrapped preventing freezing of body parts and causing further injury like cold burns. Sports massaging techniques will be initiated from day 2 onwards specifically to the ligament. Ultrasound will also be applied on the affected area of the ligament to reduce the pain and inflammation. The person should be encouraged and motivated to maintain aerobic fitness by stationary cycling exercises. There will also be a recommendation for pain free stretching exercises for the quadriceps and the hamstrings muscles and also the flexion and extension mobility exercises will be carried out. Depending on the subsiding of the pain static strengthening exercises will be recommended. This will include the isometric quadriceps exercises, hip abductors and hip extensions and adduction will be discouraged as it will stress the medial ligament. Hip Abduction Exercises The person should stand on the uninjured leg and shift the leg towards sideways as far as possible. Then the leg should be slowly brought towards the centre. Ankle weights and resistance bands should be incorporated to increase the difficulty levels. There will be 3 sets of 10-12 repetitions. Hip Extension Exercises The person should face the anchor point and with the band on , the leg should be pulled against the band’s resistance. The Static Quad Contraction Exercises This exercise may be performed when pain subsides and be done on a daily basis following injury. This exercise can even be performed when the affected person is in plaster cast. The quadriceps muscles should be contracted at the front of the thigh. This should be hold for 10 seconds. Rest and relaxation to be done for next 3 seconds. The exercise is to be repeated for 10- 20 times. After 2 weeks from day 21 The duration will be of 2 weeks and will aim to maintain the full range of motion, return of equal strength on both the legs, return to running and application of sports specific skills and training. Cold therapy should be continued after the training sessions and sports massaging techniques will be carried out every 3 days along with stretching. Dynamic exercises like leg curls and extension exercises along with squats to horizontal and lunges to be continued. The intensity of weight lifted and the number of repetitions will be increased. Running sideways and backwards with agility drills and plyometric exercises to be initiated. There should at least 10-20 repetitions. Plyometric Exercises These will include rapid hopping and jumping movements which will increase the power of the muscles. Agility drills These will involve agility exercises involving the change in direction, by using the small hurdles and agility ladders. The ultimate aim is to bridge the gap between normal running and will be fit for the actual sports activity. Calf Raises Exercise The person to stand on the feet and the shoulder should be wide apart and closed to latch on to a balance. The heels should be lifted as high as possible off the floor. During early stages of the exercise it should be performed with both the legs and at the same time. The back should be lowered slowly towards the floor. There will be 2-3 sets of 15-20 repetitions. Leg Curl Exercises The person should lie on the front and the knee should be bent against the resistance of ankle weights. The hips should be hold firmly. There will be 3 sets of 10-20 repetitions initially and when the strength improves the resistance will be increased to achieve 3 sets of 8-10 till failure. Half Squats One will stand with the feet just wider than the shoulder width with the back straight. The person should squat down half the way to horizontal or about 45 degrees and return to standing. Aiming for 3 sets of 10-20 repetitions. The Lunges The back knee is to be bent towards the floor but should not touch the floor. The back should be upright and the front knee should not move forward ahead of the toes. There should be 2 sets of 10 repetitions with the injured leg in the front and with 2 sets of 10 repetitions with the injured leg behind. It should be increased gradually to 3 sets of 15 repetitions. Leg Press Exercise The legs to be straightened from sitting with ankle placed at 90 degrees. Read More