Use of Clinical Movement Screening Tests to Evaluate Return to Sport Readiness of Young Athlete with Multi-Ligament Knee Injury: A Case Report

Background: Hundreds of thousands of anterior cruciate ligament (ACL) injuries occur every year, thousands of which are combination injuries with damage to multiple ligaments. Despite advances in surgical and rehabilitative interventions the rate of reinjury in this patient population remains high. While there is a growing amount of return to sport guidelines being published in the literature, there lacks a consensus on which is best. The purpose of this case study was to investigate the use of clinical movement screening tests to assess the return to sport readiness of a patient with a multi-ligament knee injury. Case Description: The patient was a 17-year-old male soccer player who sustained ACL, medial collateral ligament (MCL) and meniscus tears due to a contact injury while playing football. The patient underwent surgery for ACL reconstruction, MCL reconstruction and meniscal repair. The patient worked with therapy for over 12 months with an extended return to sport phase focused on functional strengthening, plyometrics, agility and neuromuscular training. Outcome Assessments: The move2perform tool was utilized, which combines the results of the Functional Movement Screen, the Lower Quarter Y Balance Test and Functional Hop Testing to assess risk of future injury. A checklist developed by the clinic to test neuromuscular control was also used. Discussion: This case report describes the effectiveness of using a combination of multiple movement screening tests to assist with guiding interventions and return to sport decision making. Research studies evaluating the validity of these movement screens to assess the risk of future injury show mixed results. Future research studies should investigate the validity of movement screens to specifically assess risk of reinjury in patients with multi-ligament knee injuries. Clinical Movement Screening Tests © 2017 Harper, David 2 Background An ‘unhappy’ or ‘terrible’ triad injury, originally termed by O’Donoghue in the 1950’s, has traditionally been described as the combination of a ruptured anterior cruciate ligament (ACL), ruptured medical collateral ligament (MCL), and damage to the medial meniscus [1]. While it’s debated whether the medial or lateral meniscus is more often damaged with this combination injury [2], it is evident that injuries to one or more of these structures are common and costly. The MCL is the most commonly injured ligament of the knee and 78% of grade III MCL injuries have a concomitant ACL injury [3]. The ACL is the most commonly injured ligament that causes pathological changes in knee function, with approximately 350,000 people estimated to have ACL reconstruction (ACLR) surgery each year in the United States [4]. It is likely that at least 40% of ACL injuries have concomitant meniscal damage [5]. These combination injuries are not only debilitating in the short term, but can lead to significant increases in osteoarthritis in the long term [6]. These injuries are also a burden on the healthcare system, with ACL injuries costing over $625 million annually [7]. Despite appropriate surgical and rehabilitation efforts, there are high rates of reinjury with ACL tears. In a meta-analysis and systematic review, Wiggins et al found a 15% ACL reinjury rate (7% in the ipsilateral leg, 8% in the contralateral) in the general population and a 21% reinjury rate (10% ipsilateral, 11% contralateral) in those under 25 [7]. For young athletes under the age of 25 returning to high-risk sports the reinjury rate is as high as 23%, which would be approximately 30-40 times greater risk than uninjured young athletes [7]. While there is a lack of data on the reinjury rate of multi-ligament injuries, one study found that only 70.8% of NFL players returned to sport after a combination ACL/MCL injury [8]. While there is a growing amount of return to sport (RTS) guidelines being published in the literature, there lacks a consensus on which is best. Many physicians continue to clear patients for sport based purely on time from surgery or personal experience [7]. A recent review found that out of 260 studies discussing RTS, 40% only had post-operative time as a RTS criteria and only 13% focused on objective criteria [9]. Recent research suggests that successful RTS relies on many different criteria including time, objective and subjective benchmarks. One category of objective benchmarks used to predict risk of injury that has gained popularity includes movement screens such as the Y-balance test, the Functional Movement Screen and hop testing. These movement screens are clinician friendly, costeffective and can help detect neuromuscular deficits in patients. The reliability and effectiveness of such screens to predict sport injury has been debated. The purpose of this case study was to investigate the use of clinical movement screens to guide the RTS decision making in a patient with an ACL, MCL and meniscus repair. Case Description Patient History The patient was a 17-year-old adolescent male who sustained ACL, MCL and meniscus tears due to a contact injury while playing football. The patient underwent surgery 21 days after injury for ACL reconstruction (bone patellar bone graft), MCL reconstruction and meniscal repair. The patient presented to physical therapy 4 days after surgery. The patient was required to wear knee brace for 6 weeks after surgery. The knee brace was locked in full extension with weight bearing and could be opened to 90 degrees of flexion during open chain exercises. Prior to injury, the patient played multiple sports including football and soccer. The patient was in good health and had no co-morbidities. The patient had a supportive family and social group. The patient had a previous partial PCL tear that is now more damaged after current injury. He was instructed to stay in knee immobilizer at 0-90 degrees for first 6 weeks after surgery. He had a long-term goal of returning to competitive soccer in one year in order to play in college. Clinical Movement Screening Tests © 2017 Harper, David 3 Systems Review The patient’s musculoskeletal system was impaired due to gross range of motion (ROM) and strength impairment of R lower extremity (LE) post-surgery. The R quadriceps had atrophy and poor activation. The cardiovascular/pulmonary systems were not impaired. The neuromuscular system findings include mild decreased light touch around incision site and altered gait due to limited weightbearing and crutches. Integumentary system impaired due to swelling and ecchymosis in R LE. The incision site had no signs of infection and appeared clean and dry. The patient was pleasant, cooperative and spoke English. The patient was alert, oriented, his cognition was intact and he had no learning barriers. Clinical Impression 1 There were no differential diagnoses as the diagnosis was established prior to therapy and was consistent with the injury, imaging and surgical repair. His presentation of joint effusion, limited range of motion and reduced quadriceps strength was as expected for his surgical intervention. The patient was a good candidate for therapy because he was a healthy adolescent who was motivated. The patient was a good candidate for this case report and clinical movement screening because of his high risk of reinjury and his desire to return to a high risk competitive sport. Examination will focus on strength, balance and LE stability in order to determine when the patient will be safe to perform movement screens and if he has functional limitations that warrant their use. Examination During the initial examination, the patient completed a Lower Extremity Functional Scale (LEFS). The LEFS is a questionnaire containing 20 questions about a person’s ability to perform everyday tasks. The LEFS evaluates the level of impairment in patients with lower extremity musculoskeletal conditions and is scored from 0-80 with lower scores representing higher disability levels. For ACLR patients the MCID is 9, the test has excellent interrater/intrarater reliability (ICC = .90) as well as test/retest reliability [10]. The patient’s score was a 20. The patient reported moderate pain (4/10 on Numeric Rating Scale). The patient demonstrated a weak quad set and was unable to lift leg without assistance. The patient’s knee ROM was evaluated using goniometry, which has been shown to be reliable for knee flexion/extension [11]. The patient lacked 5 degrees of extension and only had 30 degrees of flexion. The patient’s presentation followed the pattern of most ACL-R cases, therefore it was assumed he would continue to demonstrate functional deficits that would warrant clinical movement screens in the later stages of his rehab. Three months after surgery the patient was re-examined to see if movement screening was still appropriate. At this point the patient demonstrated no pain at rest, but the patient would still get soreness after activity that could raise his pain level to 2/10. The patient’s LEFS score was a 62 (22.5% impaired). He was full weight bearing, but would still wear the brace during activity. The patient still lacked 1 degree of full active knee extension, but had 136 degrees of knee flexion. The patient still had low grade swelling in the R knee (2.5cm). The patient’s hip and knee strength was evaluated using dynamometry. Dynamometry has been shown to have good-excellent reliability, but results can be affected by the tester’s gender, body weight and grip strength [12-15]. Studies have suggested that less than a 10% difference in quadriceps strength should be the goal after ACLR [16]. The patient’s R hip abductors were 5lbs weaker than his L and the patient’s knee extensors were 25lbs weaker than L. The patient was safely able to perform single leg strengthening exercises and low level sagittal plyometric exercises with R leg. Clinical Impression 2 Based on the examination data, the patient was a good candidate for clinical movement screens 3 months post-s