RSSACL Pathology & Functional Impairment
September 1, 2010 by David Fitzgerald
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Filed under Physiotherapy Blog
Recent media reports reminded me of the necessity for vigilance and clinical reasoning when assessing for potential ACL deficiency. It was highlighted from a recent sporting event – the all Ireland hurling semi-final when star player Henry Shefflin suffered a suspected ACL rupture. For those of you unfamiliar with Gaelic games there are two codes played in Ireland; Gaelic football and Hurling. If you have never seen hurling played I would highly recommend you check it out on YouTube. We have discussed ACL rehabilitation protocols previously here.
Now back to the story. The player collapsed following an incident in which he reported feeling a ‘popping’ and was unable to continue but walked from the field. He had a prior history of ACL disruption on the contra-lateral side two years previously and had verbalised to the medical staff that it felt like the same injury. The treating physiotherapist observed that the clinical signs were relatively modest but in view of the history an MRI scan was conducted confirming an ACL disruption. However, as the patient’s clinical signs were very modest and his functional impairment at this stage post injury was very modest it begged the question of whether it would be possible to play in the All-Ireland Hurling final in three weeks time. There is a historic element to this as the team in question – Kilkenny, are seeking five Titles in a row which would be an unprecedented achievement and this player has played all matches.
The events that unfolded were surprising to say the least. Within ten days of the injury eight thousand people turned up to watch the Kilkenny hurling team train and to watch Henry Shefflin participate fully in the training session without any supportive device – part-taking in all the skill elements required for a game situation. Apparently there had been no adverse reaction subsequently. With the final looming in one week’s time it remains to be seen whether the player will play active roll but the story reminds me of the constant surprises we observe clinically between known pathology, clinical signs and functional impairment.
The literature would have us believe that approximately 30% of ACL disruption cases can return to competitive field sports activity without requiring surgical intervention. Unfortunately the clinical challenge is that we cannot detect which patients are in this 30% sub-group and therefore only know by taking them through a sequential rehabilitation regime and observing achievement of milestones. What is particularly surprising in this case was the speed of return to high level function even if the deadline is ultimately lost. We’ll watch with interest…
There were some parallels with this example and a case of a twenty-five year old lady I had seen six weeks previously. She presented with a spontaneous collapse of the right knee, again playing Gaelic football but this time presented with significant signs of joint effusion and functional impairment. However, apart from the ominous signs of joint effusion I could not detect demonstrable laxity on anterior drawer, Lachman’s or pivot-shift tests. As her functional capacity steadily improved over a number of weeks she progressed to jogging which unfortunately exacerbated her effusion. On this basis and my suspicion of significant trauma initially (despite the absence of a full spectrum of confirmatory clinical signs) we arranged for surgical evaluation and MRI. Again the Orthopaedic Surgeon’s physical examination was inconclusive and MRI scan confirmed a complete tear. Surgery has subsequently being scheduled.
So take home messages from today’s discussion is the necessity for clinical reasoning when evaluating suspected ACL pathology or indeed any intra-articular pathology. All may not be as it seems from clinical examination. The observation of suspicious features in the absence of positive definitive tests cannot always be fully relied upon. In reality “function is king”, suspected pathology is secondary unless it is sinister or life threatening. That is what makes the work of physiotherapist so exciting. How frequently do you see patients who fit the classic descriptions? Are there many exceptions to the rule? Let us know.
Enjoy the clinical challenge.
David.
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