Case Study

A grade II medial collateral knee ligament sprain in a professional football player

Lee Nobes, Robert Ryles and Kevin Foreman
Introduction
A 4 week placement at a Nationwide Second Division Football Club highlighted a wide variety of injuries of which a grade II medial collateral ligament sprain of the right knee was the most intriguing. A plan of treatment was devised and carried out up until the player regained full tness. The aim of this study is to review relevant literature concerning this injury, underline the treatment plan devised and provide the appropriate rationale for their inclusion. movement changes in a 90 min game which includes jogging, sprinting, jumping, getting up off the ground, competing for the ball, accelerating, decelerating and changes in direction, which highlights why so many injuries occur in the game (Yamanaka et al. 1988; cited in Tumilty 1993; Bangsbo 1994; Inklaar 1994; Bangsbo 1997). Chan et al. (1993) supported by Inklaar et al. (1996), highlights this problem by identifying that knee injuries constitute the most common injury sites (50.47%) in soccer with sprains comprising the most common type of injuries (51.41%). A sprain is dened as `an injury to a joint in which some of the bres of the supporting ligament are stretched or ruptured beyond its normal limits' (Romansky 1989; Platt 1999). MCL sprains may be dened as tension injuries to the medial structures of the knee. These injuries may be isolated to the supercial bres or extended to include the deep capsular and posterior oblique ligaments (Reider 1996), and are usually classied as grades, according to clinical examination (Table 1). Injuries to the MCL are most commonly caused by a blow to the lateral aspect of knee or leg while the foot is in contact with the ground, resulting in valgus, external rotation and sometimes hyperextension stresses which tenses the MCL to the point of micro and macroscopic injury to its structure (Hastings 1984; Key et al. 1989; Woo et al. 1991; Norris 1993; Moore & Frank 1994; Reider 1996). Stress strain curves show that the MCL has very little elasticity. As force increases, the ligament lengthens less than 10% and then disrupts with further force (Alicea & Tria 1995). This type of disruption usually leads to pain over the medial epicondyle of the femur, the middle third of the

Lee Nobes BA (Combined Hons) in Sports Science and French, currently in nal year of BSc (Hons) in Sports Rehabilitation, Department of Rehabilitation, University of Salford, Salford, Manchester, UK Robert Ryles Grad Dip Phys, MCSP, Stoke City FC, Stoke-on-Trent, Staffordshire, UK Kevin Foreman PhD, BSc (Hons), Grad Dip Phys, MCSP, Faculty of Health and Social Care, University of the West of England, Bristol, UK Correspondence to: Lee Nobes, J14, Flat 1B John Lester Court, Meyrick Road, Salford, Manchester, M6 5HE, UK. E-mail: 1.nobes@rehab. salford.ac.uk

Review of literature
The medial (tibial) collateral ligament (MCL) is a broad, at band about 8 or 9 cm long. It attaches from the medial femoral condyle, immediately distal to the adductor tubercle, with the deep bres extending to the medial meniscus, and the supercial bres fanning out to the tibial condyle and adjacent shaft just below the pes anserinus (Trickey 1982; Key et al. 1989; Williams et al. 1989; Hertling & Kessler 1990; Lefters 1992; Norris 1993; Alicea & Tria 1995). The supercial MCL ligament, which is the primary static stabilizer medially, and the deep medial collateral ligament, along with the posterior oblique ligament, stabilize the knee against excessive rotation of the tibia as well as valgus instability (James 1980; Lefters et al. 1992). The most frequently injured ligament, the MCL is damaged at all levels of sports related activity (Woo et al. 1991; Shapiro et al. 1991; Alicea & Tria 1995). This is especially true in soccer, which imposes such demands upon its participants. Soccer involves up to 1000

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Table 1 Gradings of ligaments injuries (Macnicol 1998) First degree sprain: there may be micro-tears within the structure of the ligament, but the strength of the ligament is clinically unimpaired. Second degree sprain: there is a partial tear of the bres composing the ligament, such that some lengthening and subsequent laxity is evident (4510 mm than the opposite side). Third degree sprain: the ligament is torn across completely and offers no stability to the knee (410 mm of excess laxity, and with no feeling of an `end point').

joint line, or the tibial insertion of the ligament (Norris 1993). Despite the MCL being the primary stabiliser of the medial aspect of the knee (Indelicato 1983; Alicea & Tria 1995), there is general agreement that an isolated injury of the MCL in active athletes heals satisfactorily without operative intervention and has a good short to medium term prognosis concerning knee function and the patient's return to their previous level of sporting participation (Shapiro et al. 1991; Woo et al. 1992; Hillard-Sembell et al. 1996; Lundberg & Messner 1996). The capsule and the ligaments surrounding the knee joint form a exible, dynamic cup embracing the femoral condyles, providing not only stability in the frontal plane but also rotational stability in the horizontal plane (James 1980). Functional stability is provided by the passive restraints of the ligaments and joint geometry and by active restraints generated by the muscles (Noyes et al. 1980; Woo et al. 1992). These ligaments, although simple in appearance, are highly specialized structures with complex biomechanical properties (Frank et al. 1983; Claes & Neugebauer 1985; cited in Zarnett et al. 1991). In addition to their stabilizing properties, ligaments provide an important neurosensory role, supplying important proprioceptive information, or serving as important transducers of dynamic information to the muscles (Woo et al. 1991). When these ligaments are injured, the ligaments heal by scar tissue formation and the biochemical and biomechanical properties of this scar tissue are very different from those of a normal ligament (Zarnett et al. 1991). When operative treatment is not indicated, various conservative treatment methods have been, and are used to try to improve the healing process. A variety of these measures were used in the treatment of this grade II MCL injury, with the aim of the treatment being a safe, quick and effective return to match tness.

Clinical examination
Observation

. Face, gait, posture: subject walked with a

limp, appearing to have difculty putting weight through the right leg. Player's expression indicated pain when weightbearing.

History

. Age: 25 years. Occupation: Professional . Site and spread: medial side of right knee. . Onset and duration: sudden, traumatic onset.
Pain was localized to this area. As player went to block pass the ball, he was tackled straight on. The player tried to pull out of the tackle but was too late, and a valgus strain was applied to the knee. Pain was not immediately severe, and player continued for approximately 5 min. A burning sensation was felt and pain worsened, player stopped playing. . Behaviour and symptoms: pain increases on weightbearing causing the player to alter his gait accordingly. Knee has the feeling of being `weak'. . Past medical history: September 1994, Arthroscopy right knee nothing abnormal detected (NAD). Footballer/Centre Forward.

Inspection

. Slight swelling observed on medial aspect of

right knee. No deformity, colour changes or muscle wastage was observed.

Initial palpation

. As well as swelling, injured area was

palpably warm.

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Objective examination

Diagnosis
Due to ndings from clinical examination, a diagnosis of a MCL sprain was made. The sprain was classied as a grade II due to the slight ligamentous laxity observed (Macnicol 1998).

. Active movements: Player A showed slight

apprehension on knee exion. Active range of movements were noted as 108 extension, and 258 of exion. . Passive movements: pain, range, end feel (inert tissues). Extension: 48 h post injury player A had a 108 loss of extension (1708) which was due to pain and swelling. Flexion: 48 h post injury player had a 158 loss of exion (1208), again due to pain and swelling. Valgus (208 exion): positive, slight laxity, very painful. Valgus ( full extension): positive, stable but very painful. Varus: negative (NAD). Lat rot: positive (very painful). Med rot: negative (NAD). Ant draw: negative (NAD). Post draw: negative (NAD). Lachmann test: negative (NAD). McMurray's test and Apley's test: negative (NAD). . Resisted movements: pain and power (contractile tissues). Flexion: positive, sharp pain was felt on the medial side of the knee, more so at the femoral attachment at the end of available range. Extension: positive, a similar pain was felt in the same place again at the end of available range.

Problem list
1. Loss of exion (258 active and 158 passive) and extension (108 active and passive). 2. Slight swelling on medial aspect of right knee. 3. Severe pain on valgus stress tests. 4. Slight ligamentous laxity on valgus stress test in 208 of exion. 5. Severe pain on lateral rotation of the tibia. 6. Pain on resisted exion and extension. This has been noted as being due to swelling and damage to the MCL (which is stressed during these movements) and not due to any damage to the contractile tissues. 7. Severe tenderness on palpation. This tenderness was localized to the anterior ad posterior superior sites at the attachment to the medial femoral epicondyle. 8. Slight antalgic gait.

Site of injury
It was decided due to palpation and localizing the injury that the MCL tear occurred at the femoral attachment at the adductor tubercle. Alicea and Tria (1995), indicated that MCL tears occur 65% of the time on the femoral side, 25% on the tibial side and 10% on the joint lines (Fig. 1).

Associated joints
Hip: In supine, ve passive tests for pain, range and end feel and four resisted tests for pain and power identied (NAD). In prone, two passive tests and four resisted tests found NAD. Due to the ndings of the examination, any associated injuries to the hip were eliminated. Ankle: Passive and resisted ankle tests, passive ligament tests ( pain and laxity) for the ankle and sub-talar joint found NAD. Due to the ndings of the examination, any associated injuries to the ankle were eliminated.

Management plan . . . . . . . . . . . .
Up to 48 h post injury. Management of pain. Restore full range of movement. Increase tensile strength of ligament. Restore proprioception. Maintain cardiorespiratory tness. Maintain strength/power. Maintain/increase exibility. Functional progression. Full match tness. Functional testing. GOAL return to competition in 56 weeks (Fevre 1998).

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Fig. 1 Examples of stretching exercises.

Treatment: rationale for inclusion

Week 1 (2630 January 1999)
Up to 48 h post injury: rest/ice/compression/ elevation It is imperative that some form of cryotherapy was applied to the injured area as soon as possible to lower the temperature of the injured tissue that, in turn, reduces the tissue's metabolic rate. The slowing of the metabolic

rate helps to reduce the tissue to survive the period of hypoxia following the injury. It is also well known that local application of cold causes vasoconstriction mediated by the autonomic nervous system with a concomitant decrease in skin temperature and cutaneous analgesia and a reduction in pain (Edwards et al. 1990; Zenke et al. 1998; Fevre 1998). Ice was applied for 25 min every 34 h (Sherwin et al. 1995).

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Compression was applied to reduce the physiological and functional effects of any effusion that may develop (Fevre 1998) and provide counter pressure to the bleeding developing within the injured area so that the body's own haemostatic functions take effect more easily (Peterson & Renstrom 1995). Although swelling is the natural response of the body to injury, it often complicates the injury situation by producing pain and encouraging muscle atrophy and joint stiffness (Wilkerson 1985; cited in Fevre 1998). Elevation helped reduce the blood ow and enable expelled blood to be transported away more easily, thus reducing swelling (Peterson & Renstrom 1995). Ultrasound therapy 5H , 3 MHz, 0.5 W/cm2, 1 : 2, R MCL, lesion, long sitt Ultrasound is one of the modalities most frequently used for the treatment of pain (Kitchen & Partridge 1990; Prentice 1994; Partridge 1987 and Holmes & Rudland 1991; cited in Mardiman et al. 1995). Clinicians have claimed that early ultrasonic treatment of soft tissue injuries is desirable (Patrick 1978), as it can induce physiological changes which increase the rate of tissue repair and reduce pain (Dyson 1987; ter Haar 1987). Increased blood ow to the area is frequently listed as a physiological effect and this is often given as a mechanism for hastening repair (Dyson 1987; cited in Maxwell 1992). In addition, during the acute stage of injury, the effects of stable cavitation and acoustic streaming appear to increase the calcium ion diffusion across the cell membrane (Low & Reed 1997). With the release of histamine, which causes arteriolar dilation, constriction of venules and increased vascular permeability, ultrasound has the potential to accelerate normal resolution of inammation and enhance phagocytosis by neutrophils and macrophages (Maxwell 1992). This acceleration could also be due to the gentle agitation of the tissue uid which may increase the rate of phagocytosis and the movement of particles and cells (Dyson 1987; Evans 1980; cited in Low & Reed 1997). Three MHz was the chosen frequency due to the supercial nature of the MCL and the 0.5 W/cm2 intensity was chosen due to the acute nature of the injury (Prentice 1994).

Weeks 23 (112 February 1999)

Ultrasound therapy, 5H , 3 MHz, 0.5 W/cm2, 1 : 2, R MCL, lesion, long sitt; 6H , 3 MHz, 0.8 W/cm2, 1 : 2, R MCL, post jt line, supine In addition to the treatment of pain, ultrasound is reputed to reduce oedema, accelerate tissue repair and modify scar formation (Maxwell 1992). Connective tissue framework is laid down by broblasts for new blood vessels as early as 3 days post injury. From this time, the aim is to stimulate broblasts to produce more collagen, as it has been shown that ultrasound can produce collagen synthesis. This is thought to be due to increased cell membrane permeability allowing the entry of calcium ions which control cellular activity (Dyson 1987; cited in Low & Reed 1997). An increase in intensity from 0.5 0.8 W/cm2 was chosen to try to accelerate healing of the injury by increasing the ultrasound intensity. Deep transverse frictions (DTFs), 15H , R MCL (Fem attach), in end of range (EOR) F, long sitt Following injury, the tensile strength of the tissue is reduced, and a major role of the healing process lies in the restoration of the tensile strength of the healing tissue to `normal' values (Forrester et al. 1970; cited in Hunter 1994). This restoration is accelerated by DTFs which are given across the bres of the affected structure, penetrating deep enough to bring about the desired effect. This effect is a controlled re-injury of the tissue introducing a small amount of inammation and traumatic hyperaemia to the area. The result is restructuring of the connective tissues, increasing circulation to the area, temporary analgesia (Lehn & Prentice 1994; Fritz 1995) and realignment of bres without detaching them from their origins in order to prevent adherence at abnormal sites (Schwellnus 1992).

Weeks 46 (15 February6 March 1999)

Ultrasound therapy, 6H , 3 MHz, 1/1.2 W/cm2, 1 : 2, Fem attachment R MCL, long sitt The maturation phase of healing begins 2 weeks or so after injury with a gradual decrease in number of broblasts. There is no further increase in collagen content but the bres are

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remodelled and reoriented along the lines of tension. In tissues rich in collagen, there is a pronounced increase in mechanical strength, a decrease in vascularity as a result of this remodelling and eventually scar will form which may taken many months (Maxwell 1992). In order to inuence scar tissue formation, higher surface intensities of the order of 1 W/cm2 are required (Wadsworth & Chanmugan 1980; cited in Low & Reed 1997). In addition to this, although pulsed ultrasound largely eliminates a rise in temperature within the tissues (Binder et al. 1985), it has been identied that heating can occur with pulsed ultrasound if the intensity is towards the upper end of the available range (Prentice 1994). This has the effect of increasing the extensibility of collagen bres, decreasing joint stiffness, reducing pain, increasing blood ow and producing a mild inammatory response (Dyson 1987; Kitchen & Partidge 1990; Prentice 1994), which was the reasoning for increasing the ultrasonic intensity to 1 and 1.2 W/cm. Ultrasound therapy placebo effect While the physiological effects of ultrasound have been discussed, it can also have signicant therapeutic psychological effects. A number of studies have demonstrated a placebo effect in patients receiving sham ultrasound (El Hag et al. 1985 and Hashish et al. 1986, cited in Prentice 1994; Lundeberg et al. 1988; Kitchen & Partridge 1990). Many patients nd their exposure to ultrasonic therapy pleasant, soothing and relaxing and can therefore be considered as an additional bonus to the physiological effects (Dyson 1987). Passive movements (mobilization) F/E, 5H Maitland grade IV passive oscillatory movements were performed well into resistance of knee exion and extension. These techniques can be applied in the treatment of a number of structures including spinal and peripheral joints and soft tissues (Austin et al. 1995). Graded mobilizations applied at and beyond the available arthrokinematic range are intended to elongate connective tissue (Threlkeld 1992) and reduce the tendency toward the adaptive shortening of connective tissues about joints (Twomey 1992).

Rehabilitation: rationale for inclusion

Aerobic session
Throughout the duration of the player's injury, it was imperative to maintain and hopefully improve his cardiorespiratory tness. Up until week 3/4, this type of exercise was carried out on a cycle ergometer, rowing machine and in a swimming pool. This was because weightbearing was too painful and the risk of further injury was too high to undertake this type of rehabilitation when weight bearing. Although these sessions constantly changed to add variety, a typical aerobic session consisted of: Bike session: 2030 min ( polar heart rate monitor 140160 bpm) 2030 min (min 1 30 rpm, min 2 45 rpm) Rowing session: 5000 m row (140160 bpm) or (time limit 20 min) Pool session: warm up 8 25 m ( freestyle) 8 25 m ( freestyle legs 4/arms 4) 4 25 m ( freestyle legs, breaststroke arms) 4 25 m (buttery arms 2/ freestyle arms 2) 2 3 25 m (individual medley) Treading water 5H Target HR: 140160 bpm The importance of maintaining and even improving the aerobic energy system is essential to successful performance especially within professional soccer. Throughout a game, players of a mean VO2 max of 55 65 ml kg 1 min 1 have been estimated to be working at 7075% VO2 max (Bangsbo 1994; Maughan & Leiper 1994; Faina et al. 1988; Bangsbo 1994; Wisloff et al. 1998; cited in Wilkinson et al. 1997; Bangsbo 1997). Top players travel from 917 km during a 90 min match (Mayhew & Wenger 1985; Apor 1988; Van Gool et al. 1988; Kuzon et al. 1990; Kirkendall 1993; Nagahama et al. 1993; Tumilty 1993; Bangsbo 1994; Wilkinson et al. 1997; Wisloff et al. 1998) and 88% of the activities undertaken during this period are said to be aerobic in nature (Mayhew et al. 1985). The

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energy required for such a work rate (75% VO2 max) is produced primarily by the complete oxidation of glucose ( from liver and muscle glycogen) and to a lesser extent fatty acids from both intramuscular stores and mobilized in the blood from extramuscular stores (Snell 1990), which highlights the importance of training and maintaining this energy system.

with a mean duration of 2 s, highlighting the importance of maintaining and improving this energy system.

Leg/upper body strength session

Mesocycle 6 weeks. Although the leg strength sessions were constantly changed to add variety and prevent the effects of Seyle's `general adaptation syndrome' (Kraemer et al. 1988), a typical session consisted of: Identify one repetition maximum (RM) for each exercise (this is done by trial and error). Week 1 60% 1 RM, Week 2 65% 1 RM, Week 3 70% 1 RM, Week 4 75% 1 RM, Week 5 80% 1 RM, Week 6 90% 1 RM. (This principle was followed for both upper and lower body strength exercises.) Technique: strict form is essential to ensure the exercise is performed correctly and to prevent further injury. As a rough guideline the following principles were followed. Even if these durations are halved, it is still forcing the subject to concentrate on form and perform the exercise correctly. Raise weight duration 2 s Lower weight duration 4 s (McRobert 1999) Breathing: this is again an essential part of the exercise to ensure correct form, help support the spine and ensure blood pressure does not rise substantially. Excessively holding one's breath with a closed glottis (Valsalva manoeuvre) during performance of resistance training is not recommended due to dangerous uctuations in blood pressure (Fleck et al. 1997; Zumerchik 1997). Therefore, the following principles were followed. Ascending part of lift breathe out Descending part of lift breathe in Example of session, Week 4 Each exercise weight 75% 1 RM (8 RM) Exercise 1. Leg extension 2. Hamstring curl 3. 45% leg press Sets 4 4 4 Reps 12 12 12

Anaerobic session
Although the anaerobic sessions constantly changed to add variety, a typical anaerobic session consisted of: Bike session: Sprints: 10, 20, 30, 40, 50, 60, 50, 40, 30, 20, 10 s sprint 10, rest 10, sprint 20, rest 20 etc. (Target HR 220age) Rowing session: 100, 200, 300, 400, 500, 400, 300, 200, 100 m (sprint time rest time) Target HR 220age Pool session: Warm-up 8 25 m ( freestyle) Sprints 4 2 25 m ( y, back, breast, free) Sprints 4 4 25 m ( y, back, breast, free) Sprints 10 25 m (30 s per 25 m) Deep end sprints 15 10 m (buoyancy aid) Deep end static sprints 15, 30, 45, 60, 45, 30, 15 s (rest time sprint time) Treading water 5H In addition to the maintenance and improvement of the aerobic energy system is the maintenance of the anaerobic system. Football involves intense anaerobic periods superimposed on a background of endurance running (Mayhew & Wenger 1985; Van Gool et al. 1988; Kuzon et al. 1990; Bangsbo 1994; Wilkinson et al. 1997). Football involves true high power and explosive type activities such as jumping and sprinting (Holmyard et al. 1997), which constitute 1215% of activities involved in a match (Mayhew & Wenger 1985; Kuzon et al. 1990; Ohashi et al. 1993; Wilkinson et al. 1997). Bangsbo (1991; cited in Bangsbo 1994) identied that the total duration of high intensity exercise during a soccer match is about 7 min which includes about 19 sprints

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4. 5. 6. 7. 8. 9.

Dumbell lunges Standing calf raises Mini squat One legged mini squat Dumbell step ups Spinner (bike)

4 4 4 4 4 20/40/60 s Sets 4 4 4 4 4 4 4 4

12 12 12 12 12 sprints Reps 12 12 12 12 12 12 12 12

Exercise 1. Chins (wide grip) 2. Chins (close grip) 3. Dips 4. Bench press 5. Incline bench press 6. Shoulder press 7. Lat pull down 8. Seated rows

the training program 1520 min was set aside each day to try to improve lower-limb exibility. Although the exibility of the player was not a cause of the injury, it was noted that the player was very inexible and this type of program may reduce any likelihood of injury in the future. A typical session consisted of: Static stretching which developed into proprioceptive neuromuscular facilitation (PNF) and ballistic type techniques. Contract relax PNF techniques were performed on the player by the trainer. Stretching 3060 s duration (Fleck et al. 1997). Flexibility is an important component of physical tness and needs to be addressed in a rehabilitation program (Fleck et al. 1997). Within the 90 min soccer match, players complete approximately 1000 changes in playing activities (Bangsbo 1997). In addition to running, players are engaged in many other explosive bursts of activity, such as tackling, jumping, kicking, accelerating, turning and sustained forceful contractions to maintain balance and control of the ball against defensive pressure (Bangsbo 1994; Wisloff et al. 1997). These activities are often performed at the very end of ranges of movement. Flexibility training was felt to be necessary as when static, ballistic and PNF type stretching is tailored to the individual's muscle structure, exibility and varying tension levels it results in the elongating soft tissue, an increase in circulation and ultimately improving an athlete's exercise tolerance and decreasing the likelihood of further injury by increasing full range of movement (Anderson 1991; Beck 1994; Wajswelner & Webb 1995) (Fig. 2).

A variety of different training principles were employed in order to introduce variety to the sessions. These principles involved (Yates 1999):

. Pyramids (lightheavy) or (heavylight) . Stripping (heavylight) (`running the rack') . Supersets (two exercises with little rest
between) Support and stability provided by active muscle strength is an important ingredient in the recovery of any injured player. In the majority of rehabilitation programmes designed for players, strengthening ligamentous and relative muscle groups has become an important component in order to reduce the risk of reinjury to the concerned area by strengthening the soft tissues surrounding the knee joint (Zumerchik 1997; Fevre 1998). Leg strength is especially important in the rehabilitation of injured soccer players especially as leg strength is an important factor in playing soccer (Togari et al. 1988). All round upper body strength is also an important component when playing football. This is especially important for this particular player's style of play. The player is known to be a `traditional type' centre forward, and a lot of his play involves holding the ball up and holding defenders off. This highlights the importance of a general upper body strength training programme for this individual player.

Proprioception session
Up until the end of week 4, general proprioception circuits were organized. After this period, when more functional activities were undertaken in the rehabilitation programme, a lot of the activities incorporated proprioceptive type tasks, reducing the need for separate proprioception sessions.

Flexibility session
In addition to the general stretching undertaken as part of the warm-up/cool down, throughout

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A typical session involved: 1. Leg balance. Development shut eyes/ introduce ball pass against a wall/pass and catch with therapist/trampette/cliniband to upset balance. 2. Slide boards to perform lateral slides/ intro ball for various exercises. 3. Wobble boards use variable weights to upset balance/intro ball. 4. Bench balance walks intro various exercises on bench/intro ball(medicine)/ intro incline. Session time 30 min approx Proprioceptors are responsible for providing afferent information regarding change in position and angular velocity of a joint. When this information is processed via specic reex arcs, it facilitates and adjusts motor activity in various muscle groups (Matthews 1988; cited in Beard et al. 1994). It has been identied that during a soccer match, a player can make approximately 1000 changes in playing activity (Bangsbo 1997), obviously involving many changes in position and direction. It is therefore vital to include proprioception in the

rehabilitation of this type of injury (Wajswelner et al. 1995). Failure to rehabilitate the balance strategies of the injured player will result in a poor functional recovery, increase the possibility of re-injury or produce another injury situation (Fevre 1988).

Hydrotherapy session
Hydrotherapy, which in its broadest sense encompasses any therapeutic use of water, is now an accepted component in the treatment and rehabilitation of many conditions (Whitelock 1990). Pool sessions were used frequently, and were extremely useful as it is possible to combine aerobic and anaerobic sessions as well as upper and lower body strength sessions. These sessions also provided the player with some variety in the rehabilitation programme which does become essential to maintain the player's morale.

Discussion
Despite the fact that the player did not return to action in record time, he was back ready for normal training and competition within the time frame of 6 weeks which was set at the early stages of treatment. Fevre (1998) has given a time frame for grade I and II injuries as varying from 26 weeks and due to the nature and severity of this injury, this was quite satisfying. It could be argued that the use of other modalities and methods of rehabilitation may have further accelerated healing. Instead of simply using ultrasound everyday, other modalities could have been used, such as pulsed short wave therapy (PSWT) to try and bring about other associated physiological effects. This may not have been the case if the injury was progressing continuously in an upward spiral; however, there were times when the injury seemed to be reaching a plateau. Pulsed short wave therapy is now used widely and many claims are made regarding its clinical effectiveness (Goats 1989). It is believed that PSWT affects tissues by improving the rate of oedema dispersion, reducing inammation and encouraging collagen layering at an early stage. This prompts a more rapid rate of brin bre orientation and collagen deposition and stimulates osteogenesis (Golden et al. 1980;

Site of injury

Tibial collateral ligament

Semitendinosus Gracilis Sartorius

Fig. 2 Medial aspect of the right knee showing the MCL and where the lesion was localised to. Reproduced with kind permission from Sanders Manual of Physical Therapy Practice.

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cited in Hayne 1984), which theoretically would have helped the healing of this injury. It could also be argued that later on in the rehabilitation, when a sound strength base had been achieved through leg strength sessions especially, more power type activities could be introduced to attempt to mimic the high intensity burst type activities involved in soccer. The importance of this aspect of the game was highlighted by Reilly and Thomas (1976; cited in Tumilty 1993) who found a mean of 15.5 jumps in a game, and Withers et al. (1982; cited in Tumilty 1993) who counted 9.4 jumps, 13.1 tackles and 49.9 turns in a game. Strength is the foundation upon which power can be developed (Sale 1991), and power is an important component upon which many of the intense anaerobic activities involved in soccer are based (Bangsbo 1994). This component of the game could have been introduced to the programme through either more Olympic style weight lifting activities or plyometrics. Plymetrics mimics this normal functional activity in soccer where muscular contraction involves different stages of accelerating, concentric muscle activity coupled with decelerating, eccentric activity (Fevre 1998). It may have been benecial to reproduce, in the functional stage of rehabilitation, these types of activities via the use of depth jumps, bounding, lateral jumps, alternate push offs and multiple hops (Chy 1992). Despite this, the late stage, functional part of the rehabilitation was excellent and incorporated the aerobic and anaerobic energy systems, and it blended proprioceptive, skill type activities with the normal activity patterns and contact work. This was the essence of the whole program, but the late stage, functional type rehabilitation in particular. It was necessary to analyse the demands of the game, the activities involved and the main activity patterns of the particular position that the player played. Once this was done, these activities needed to be reproduced throughout the programme to ensure a safe return to competition.

frame that one had set oneself (5 weeks and 3 days). This goal setting is an essential part of the treatment and rehabilitation, not only for when the athlete is going to return to competition, but right throughout the programme (Crossman 1997). There has been a plethora of information supporting the value of effective goal setting that include setting specic, relevant, measurable and performanceoutcome goals that are both challenging and realistic (Crossman 1997) and this seemed to help in keeping the player motivated. Despite minor adjustments, which could be made to similar future cases of this injury, it was felt that the treatment and rehabilitation progressed very well. This is supported by the fact that the player in question returned to rst team action on 20 March, 2 weeks after returning to full training, and opened the scoring in a 32 win.

References
Alicea J A, Tria A J 1995 Medial collateral ligament. In: Tria A J Jr (ed). Ligaments of the knee. Churchill Livingstone, USA Anderson B 1991 Stretching. Penguin Books, USA Apor P 1988 Successful formulae for tness training. In: Reilly T, Lees A, Davids K, Murphy W J (eds). Science and football 1. E and F N Spon, London Austin L, Magarey M, Maitland G D 1995 Manual therapy: when and why? In: Zuluaga M , Briggs C, Carlisle J et al. . (eds). Sports Physiotherapy. Churchill Livingstone, Edinburgh Bangsbo J 1994 Energy demands in competitive soccer. Journal of Sports Sciences 12: S5S12 Bangsbo J 1997 The physiology of intermittent acivity in football. In: Reilly T, Bangsbo J, Hughes M (eds). Science and football 3, 1st edn. E and F N Spon, London Beard D J, Dodd C A F, Trundle H R, Hamish A, Simpson R W 1994 Proprioception enhancement for anterior cruciate ligament deciency. Journal of Bone and Joint Surgery 76B: 654659 Beck M F 1994 Milady's theory and practice of therapeutic massage, 2nd edn. Milady Publishing Co., USA Binder A, Hodge G, Greenwood A M, Hazleman B L, Page Thomas D P 1985 Is therapeutic ultrasound effective in the treatment of soft tissue lesions? British . Medical Journal 290: 512514 Chan K M, Yuan Y, Li C K, Chien P, Tsang G 1993 Sports causing most injuries in Hong Kong. British Journal of Sports Medicine 27 (4): 263267 Chy D A 1992 Jumping into plyometrics. Leisure Press, USA Crossman J 1997 Psychological rehabilitation from sports injuries. Sports Medicine 23 (5): 333339 Dyson M 1987 Mechanisms involved in therapeutic ultrasound. Physiotherapy 73 (3): 116120

Conclusion
The most pleasing aspect of the treatment and rehabilitation of the injury was that the player was back into competition within the time

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