While on my musculo placement I treated Mark* who came in with knee pain after hyperextending his knee as a result of a tackle during a game of soccer four weeks ago. Initial examination lead to a diagnosis of a lateral meniscus tear/sprain with possible strain of popliteus, Mark also demonstrated general ligamentous laxity throughout (including both knees). Initial treatment consisted of mainly RICE to remove swelling, VMO exercises, taping and hamstring/quad co-contraction to prevent further damage and promote stability. Mark was seen for the next two weeks with treatment consisting of progressing HEP and further taping, he was progressing well and had an important game to play in the following Sunday. Mark was advised that his knee would most likely be okay to play but should probably take this game off if able.
Mark returned the following week in a bad way. Mark reported falling with his knee collapsing laterally while running in a straight line without being tackled, mark reported hearing a pop. Assessment revealed further damage to lateral meniscus, laxity and pain over LCL and possible damage to ACL/PCL. Mark was thus referred on to an orthopaedic surgeon.
This situation lead me to reflect on whether I should have advised Mark not to play soccer, I talked to my supervisor regarding this situation and she concluded that this event was unavoidable and it was highly likely that it was going to happen at some point due to Mark’s generally lax ligaments, this was further evident by the untraumatic and seemingly trivial mechanism of injury. With this information in mind I still can’t help but think that if we had worked on his ability to co-contract for a couple of weeks more Mark may have been able to avoid such an injury
If I was to be confronted with this situation again I think I would try to convince my patient to avoid sport for a longer period explaining to them the possible detrimental effects of returning to sport too early. This situation has taught me the importance explaining the big picture and giving a detailed timeline of likely progress etc to patients so they are fully aware of the situation at hand and they can make informed decisions.
*Fictitious names used
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4 comments:
Don't worry Trav, it certainly wasn't your fault the patient re-injured his knee. One thing I am beginning to learn is that we have to get used to the fact that patients are not always going to listen to our advice. Whether it be advising someone to use a walking aid at home when you know they won't, or in your case, advising a player to not return to sport- all we can do is offer our advice as health professionals, educate the patient as to why we are giving that particular advice, inform them of the possible consequences of not following our advice, as well as giving them a rough guideline as to the length of time such a restriction may apply for (so the patient has a goal in mind).
I think your patient has also highlighted the importance of documenting when we have given a patient particular advice- that way, if the patient returns and blames you for a worsening condition, you are covered from a legal point of view because you can prove the patient went against your advice.
You did all you could do in this situation. Being hypermobile, his joints are less stable and therefore he will be more susceptible to injury. Nicole makes a good point, you can give patients advice but not all of them will follow it. You should definately document any advice you give as an intervention so as to cover yourself.
Trav
I suspect that there was a high degree of inevitability with this injury, particularly given the fairly harmless manner in which it occurred. He may have had a partial tear from the previous trauma.
Don't be too hard on yourself however. I have witnessed this situation with elite athletes under excellent medical supervision.
Regards
John
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