REHABILITATION

By Lynda Daley MCSP, English Institute of Sport (East Midlands), Loughborough University and Dr Nicola Phillips PhD, MSc, MCSP Director of Postgraduate Healthcare Studies, Cardiff University

INTRODUCTION Tennis is a popular racquet sport that presents a variety of physical challenges including speed, agility, power, endurance, strength, balance and tennis-specific skills. In order to gain success at the top level of this sport, tennis players frequently begin playing in childhood and may continue playing into late adulthood.

Like many other sports, tennis can place its participants at risk of injury. The purpose of this case study was to explore the diagnosis and subsequent conservative management and rehabilitation of a young elite male tennis player with osteochondri- tis dissecans.

A ten month phased evidence based rehabilitation programme was developed, that took into account the player’s fitness level, training goals and objectives in order to successfully return the player to competitive tennis.

Tennis is one of the most widespread and popular recreational sports in the world (1) with more than 200 countries affiliated with the International Tennis Federation (2). Despite its popularity, tennis can place its participants at risk of injury (3). Overuse injury risk factors in tennis have been reported as occurring due to intrinsic factors such as anatomical malalignment and poor muscle balance, or extrinsic factors such as training errors, improper

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footwear, variation of surfaces and unsuitable environmental conditions (1). The unpredictability of the sport, including shot selection, strategy, match duration, atmospheric conditions and the opponent, have all been shown to have an influence on complex physiological aspects involved in playing tennis (4).

There is a high incidence of lower limb injuries in tennis (3,5). The sprinting, stopping, starting, changes of direction and lunging nature of the game puts repetitive demands on the lower limb tissues as they absorb the shearing forces produced by such movements (6). Osteochondritis dissecans (OCD) of the knee is not, however, widely cited as a lower limb injury associated with the tennis playing population.

OCD

OCD is a localised bone-cartilage lesion characterised by separation and fragmenta- tion of the subchondral bone in association with disruption of the articular cartilage (7-9). Opinion is divided regarding the exact causes of OCD but proposed aetiolo- gies include genetic, traumatic and ischemic (10,11). OCD of the knee has a male predilection most often occurring between the ages of 10 to 20 years (12). Flynn et al (11) reported that approximate- ly 75% of lesions at the knee would be typically found on the lateral aspect of the medial femoral condyle with other common sites being the lateral femoral condyle, the femoral groove and the patella.

Reid (13) suggests that OCD at the knee may be confirmed with clinical examina- tion. In contrast, Agliette, De Baise,

Ponteggia and De Felice (14) suggest that diagnosis with clinical examination alone is difficult due to an absence of clear pathognomonic symptoms. There are, how- ever, some symptoms commonly associated with OCD at the knee, which include aching or diffuse pain and/or swelling with activ- ity (14), increased external rotation of the tibia and giving way of the knee (15,16).

DIAGNOSIS Diagnostic techniques commonly used in the detection of OCD appear to be primari- ly determined by the preference of the referring physician or orthopaedic surgeon and include arthrography, magnetic resonance imaging (MRI), bone scans and computed tomography (17). Plain radiographs are useful for revealing hyperlucency, joint deformities or loose bodies (18) and specific tunnel views detect the majority of OCD lesions of the femoral condyles (14) and provide the opportunity to visualise the intercondylar fossa for loose bodies (17).

MRI has been shown to detect occult injures of subchondral bone and cartilage that might escape identification with routine radiographic analysis (19, 20). In OCD this is mainly directed toward evaluat- ing stability of the lesion (19) and has shown a high degree of accuracy in evaluating the stage of the condition (21). However, correct diagnosis based on the results of MRI studies alone is dependent on their interpretation. Luhman, Schootman, Gordon and Wright (22) carried out a prospective study which evaluated the pre-arthroscopic diagnostic accuracy of specific knee pathology made by interpretation of MRI scans in isolation

sportEX medicine 2007:34(Oct):10-15