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Simple treatments done well

Lateral tibial plateau bruise

I am a big advocate of keeping things simple, but doing those simple things as well as possible well. This case study is an illustration of when simple interventions needed to be taken to the next level. In this case an 18 year old professional soccer player sustained an unusual injury to his (L) knee. This settled slowly but steadily (with simple management), however, after a full return to competition, it recurred, and needed an extra push in its
subsequent management. The initial mechanism of injury was not entirely clear, though when knee pain was reported it presented clinically as lateral meniscus tear. The pain was located at the lateral joint line, which was tender on palpation and compression of the lateral joint space was painful.

Initial management
Radiology
As the presentation of the injury was not entirely typical, a MRI scan was performed. A MRI scan will image a number of different structures and is therefore very useful in differential diagnosis when the pathology is unclear (SIB67) , t h i s was therefore the investigation of choice. The MRI was able to show considerable bony oedema in the lateral tibial plateau, with no evidence of a fracture line. No other abnormality was seen.

Medical management
With a firm diagnosis of a tibial plateau bone bruise and no fracture identified, it was decided to rehabilitate the knee, free from pain, over 6-8 weeks. No medication was indicated. I've seen this injury in a professional soccer player only once previously, and it settled well with rest and simple rehabilitation.

Exercise prescription
During later stage rehab it was identified that his injured leg had noticeably greater ‘Frontal Plane Knee Excursion (FPKE) during triple flexion (Figure 3a). Excessive FPKE (or knee valgus) will lead to increased compression and loading of the lateral joint space (See Figure 2 ‘Valgus close up'). As uncontrolled valgus of the knee may well have been the mechanism of
injury here, it needed to be corrected, both to prevent excessive loading and therefore slowing healing and also to prevent recurrence in the future.
Accordingly he was prescribed single leg small knee bends, in the mirror, with cueing on controlling hip adduction and internal rotation and therefore FPKE. These progressed ultimately to high load lunges and unilateral step downs which he was eventually able to do both pain-free and with good hip and knee control. The player progressed through a good
number of pain-free high level outdoor rehab sessions and progressed to 71 minutes followed by two 90 minute games in the reserve team. At this point he felt confident he was fully fit and moving forward.

Recurrence management
Alas, after a tough training session, finishing with strength work and plyometrics, the dreaded pain returned. Though the severity of the relapse was not that of the initial injury, given the time already lost to the injury, the level of concern was high. A sense of scale had dictated the simplicity of his initial management, however, with this recurrence the increased
concern warranted pushing all of his management to the next level of complexity.

Radiology
In order to definitively rule out a tibial plateau fracture, a CT scan was obtained. The MRI had given us all the information we needed initially, and as he was to undergo a significant period of rest, with management being pain-free, there was no need for
a CT scan. However with the recurrence of pain, CT became the imaging of choice to rule a fine fracture, as CT is highly sensitive for detecting subtle fracture lines (see SIB67). Repeat MRI to show resolution of bony oedema was not an option as patients often improve functionally well before MRI shows the corresponding improvements.

Medical management
As well as an initial rest from training, it was decided that in order to enhance his bony healing he should have an infusion of IV Bisphosphonate. Widely used in bone diseases and postmenopausal women to prevent osteoporosis, Bisphosphonate has an inhibitory action on osteoclast-mediated bone re-absorption. So simply put, the action of
osteoclasts in breaking down bone is muted so the action of osteoblasts in building up the bone is more effective.[1] In athletes with stress reactions, stress fractures, severe bony oedema, it may be useful to enhance healing. There is anecdotal evidence of effective use of IV Bisphosphonate in a series of athletes with stress fractures[2], however there is no
conclusive evidence here. The reported common short-term side effects of bisphosphonates include; nausea, fatigue, arthralgias and myalgias[3], we have seen this consistently in our athletes who have undergone this therapy, though this usually improves over 72 hours.

Exercise prescription
Rationale
As this is not a common injury, it is not possible to know absolutely what the risk factors are and therefore what should be modified in order to enhance healing and prevent recurrence. In this case we needed to use basic clinical reasoning and borrow some evidence from another more common injury, in order to guide his management.
Video analysis studies by a group in Cincinatti, indicate that a frontal plane ‘valgus collapse' mechanism is seen in many ACL injuries[4]. Valgus collapse is a combination of; knee valgus, hip internal rotation and tibial rotation. So where is the link here you ask? Well, MRI studies, indicate that where this ‘valgus collapse' occurs during ACL injury, concurrent bone
bruises are often seen in, wait for it.... the lateral tibial plateau. Interestingly this concomitant tibial plateau bony bruise is seen most in the group with more valgus driven injury mechanisms (that is; female athletes). Another study by the same group of researchers[5] prospectively examined valgus loading during a jump landing task
in athletes. They found that athletes who subsequently went on to rupture their ACLs showed, on average, 8 degrees greater valgus at landing, with 2.5 times greater knee valgus moment and 20% greater ground reaction force at peak
contact, than the uninjured normals. So the theory here goes; this player's poorly controlled and excessive FPKE lead to excessive compression of his lateral joint space and a load great enough to bruise his lateral tibial plateau. So you ask; is there any evidence to back this theory up in this particular player? Sadly it is impossible to go back and measure these variables prior to the injury, we can only assess them retrospectively with a view to identifying factors which may over-load the knee subsequently and therefore slow
healing and increase re-injury risk. We knew that this player showed noticeably greater frontal plane knee excursion (FPKE) during standing triple flexion on his injured leg prior to the recurrence. However this was no longer a useful test as he had learned this test so well and performed a program specifically to train it. This is where his management
had to be taken to the next level. The ‘triple flexion test' is only ever meant as an elementary test, so a more specific and challenging test was needed here. The
aforementioned study used multiple cameras for 3-D kinematic analysis. Funnily enough we didn't have this set up in our treatment room, however, with this predicament in mind a recent study had described a similar test in 2-D to assess
‘drop jump landing valgus knee angle'[6]. We replicated one of their tests – a “step landing task” (figures 4a and 4b) where the player stepped off a 30cm high bench landing on the opposite foot, on a mark 30cm away and holding that position. 2-D
video was taken using a basic compact digital camera. We substituted the 30cm for 50cm due to the height and athletic ability of the individual making a 30cm bench unrevealing.
Figure 5a shows lowest point of landing phase (camera at knee height), using ASIS, centre of knee and ankle as points to measure knee valgus angle. Without measuring angles it was clear to both the player and myself that he was not controlling his knee well at all (by comparison with the other side). This clearly needed addressing. It was unclear
what role old or new motor patterns, fear avoidance and/or kinesiophobia were playing here. However, this was not hugely relevant, as a specific functional rehab program would improve all of these. What did need to be addressed was whether he had the basic ‘building blocks' in place to perform a specific dynamic training program. Two of these building
blocks are RoM at the hip and ankle. If there is not enough RoM in the joints above and below the knee to attenuate forces or allow good planes of movement, then the knee may have to increase its range to compensate. In a study of Soccer players, those with less ankle dorsi-flexion and hip external rotation exhibited higher FPKE during a drop landing task[7].
Fortunately in this player's case simple screening showed RoM was not an issue at these joints (figures 6 and 7), so suspicion moved elsewhere.
The next building block to examine was whether he had the strength in his hip to control hip internal rotation. In an ACL recurrence study[8], subjects generating lower hip external rotation moments were 8 times more likely to reinjure. In this case, a simple ‘Glut medius' test (Figure 8) convinced both myself and the player that his (L) abductors and external rotators were not working well at all. With patient in ‘side lying', non-tested hip flexed for stability and to relatively extend the tested hip. Top leg in abduction,
external rotation and extension, resistance is applied to the ankle by the tester.
Adding further credence to this theory, is the above study[8] (also from the Cincinatti group) showing that biomechanical measures associated with an initial injury, can also predict a recurrence of same said injury. Again a drop landing task (among other biomechanical measures) showed that athletes with greater FPKE were three times more like to suffer a second ACL injury after having a repair. Another measure that predicted a second rupture was ‘single leg postural stability' on the involved leg, with those getting poor scores being twice as likely to re-rupture. Interestingly this test on the ‘Biodex Balance System SD' had been recorded prior to our player's re-injury. His balance scores had placed him firmly in
the bottom quartile of players tested in the club. This lack of balance was another missing ‘building block' needed to improve his FPKE.

Prescription
Initial stage rehab was to target his 'building blocks'. Simple balance exercises on one leg were used to improve his postural stability and probably don't need further description.
To improve his hip strength in abduction/ external rotation a number of exercises were used, moving from isolated to more functional and non weight-bearing to weight-bearing. This progression also coincided with keeping the knee pain-free, as initially, functional weight-bearing exercises were painful. The first exercise was a modification of its test, (figure 9) which was ideal for education cueing and biofeedback.
A pressure biofeedback cuff is used to cue the athlete. Focus is on all movement coming through hip, and dissociating this from lumbar movement entirely.
Mid stage rehab consisted of improving his strength, balance and motor patterns during increasingly loaded triple flexion exercises (Figures 10a,10b,11a,11b), for example step downs, lunges and single leg squats, and what we call ‘lawn mowers'.
End stage gym based rehab consisted of varying plyometric exercises, focussed on form during landing, specifically; minimising FPKE, by focussing on alignment and attenuating forces through movement at the hip and knee. The first two stages of rehab, though probably essential, are really just a means to an end, that end being the ability to train
those movement which most closely mimic his needs on the football pitch. In order to do this, these end stage exercises must be full-load multi-directional landing exercises. Hopefully by ensuring he had the building blocks of the movement pattern, and progressively making exercise more functional, he would be able to incorporate the correct patterns unconsciously into his team football training. In this case the player needed to return to sport before his movement patterns were ideal. However, he was painfree, conditioned, and training fully, therefore he wanted to return, and the team was more than eager to have him as needs must in professional sport. In order to complete some of this end stage rehab, it needed to be continued after return to play (and to this day).

Conclusion
This player is now playing regularly and pain free, in the first team and at international level. This recurrence may well have settled by itself, without all our ‘stepped up' interventions. However, most of these interventions were made whilst the knee was too painful to train, so cost him no time. Regardless of effect on the injury, the exercise prescription should, at the least prove useful for force development and prevention of other injuries going forward (not the least his ACL).

Simple treatments done well