REHABILITATION

no pain or subjective reports of instability, locking or blocking. There was however an awareness of slight stiffness in the right knee following play that had been apparent for several weeks but which usually settled within 24 hours.

Initial findings A follow up clinical examination was carried out one week after the initial report of the problem, which had been made during a tournament situation.

Table 1 outlines the clinical findings at this stage.

Range of movement was measured using a long arm goniometer and muscle strength was recorded using Oxford Grading. It is appreciated that a detectable difference in strength at near normal muscle power using this method can be difficult and unreliable (25). However, in the absence of any means of more objective strength measures, this was regarded as an appro- priate option. Knee ligament stress testing was unremarkable. Palpation revealed a thickened area over the lateral quadriceps tendon just proximal to the patella, with associated swelling in the suprapatellar region. There was no tenderness on palpation of the joint but fine crepitus was noted to exist over the area of thickening. The left knee was asymptomatic and the player was otherwise fit and well.

The clinical findings were discussed with the RTC doctor and a decision was made to allow the player to continue with tennis activities whilst further investigations were arranged and completed. An MRI scan performed three weeks later identified an effusion that was suggestive of bone

bruise/bone marrow oedema at the posterior aspect of the femoral condyle. However, the RTC doctor considered the MRI results to be inconclusive and followed up with plain x-rays. Anterior- posterior (AP) views appeared normal but tunnel view films were suggestive of OCD at the medial femoral condyle. It was concluded that the x-ray appearances, in conjunction with the previous MRI scan, were highly suggestive of OCD. As there was no bone fragmentation and the overlying cartilage appeared to be intact, the OCD was assumed to be at an early stage.

At this stage, the player was asked to immediately refrain from all tennis training and high impact/loading activities to avoid stressing the knee. He was also advised that an extended period of relative rest over several months might be necessary to ensure complete resolution of the problem.

Table 1 details the clinical findings on assessment one month later.

Further tunnel view x-rays demonstrated a similar lesion to that noted on previous films, but it now appeared larger, with some joint line opacity and sclerotic changes. The most recent x-rays indicated that the lesion was worsening and that it was more severe than the initial impression. A second MRI scan confirmed that the OCD had progressed slightly, but that there were no signs of a loose or potentially unstable osteochondral fragment. The decision of non-surgical management was concurred by an orthopaedic surgeon at this stage. Therefore, the player continued resting

from all tennis and impact activities.

On reflection, initial examination findings of minimal swelling together with full and pain free joint range and no other significant findings were not suggestive of serious pathology. However, given the common occurrence of OCD in adolescent males and that the patient was participat- ing in a sport that can place significant shearing forces at the knee joints, perhaps a potential diagnosis of OCD should have been given more consideration, earlier on. This might have prompted an earlier request for tunnel view x-rays along with orthopaedic specialist opinion that may have resulted in more prompt diagnosis with appropriate treatment.

Rehabilitation A rehabilitation programme was devised, based on the available evidence of the management of juvenile OCD and a needs analysis of the physical requirements of the sport at this level of competition. A focus on maintenance of fitness was begun and continued during the initial six months following diagnosis. Whilst rest from high impact activities was necessary, a conditioning programme was devised to allow the player to maintain and/or improve all parameters of fitness necessary for tennis - ie. mobility, strength, power/speed, endurance and skill /co-ordi- nation (24).

Success at an elite level requires commitment to a systematic and intensive programme of training (26), with young competitive tennis players often engaging in intense, professional participation including long daily training sessions (27). It was therefore considered important to maintain this level of commitment to training whilst minimising any adverse effects on the knee. Development of the programme involved working with other members of the multi-disciplinary team, including strength and conditioning coaches and a sports psychologist. Maintenance of normal muscle strength and endurance was considered an important part of the rehabilitation programme as trained athletes have been shown to demonstrate more atrophy than untrained subjects during breaks from training (28).

In young tennis players, resistance exercises have many benefits, including

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