OCD

improved muscle function, endurance and co-ordination (6). A resisted exercise regime for the trunk and upper limbs was therefore provided using body weight, free weights, resisted cord and medicine balls. In consideration of the player’s relatively young age, the use of machine weights in the gym was postponed in favour of body weight exercises (29, 30). Care was taken that the degree of resistance selected for each exercise was appropriate and allowed good technique. Resisted exercises for the left leg were not prescribed to avoid development of a disparity between the injured and uninjured sides.

Activities in the swimming pool allowed the player to maintain both cardiovascular endurance (aerobic capacity) and many sports specific functional skills. By exercising in deep water (depth to mid chest/shoulder), the buoyancy effect of the water reduced compressive joint forces and ensured that the knee was non-load bearing.

Early non-weight bearing mobilisation was encouraged in an attempt to minimise the loss of functional range. As mentioned previously, there is a distinct lack of any evidence to support or refute this choice in the current literature, however the decision was based on a reasoned approach to risk management related to the needs analysis. Exercises consisted of knee flexion and extension in long sitting and prone lying as well as the use of a static bicycle. The cycling exercise was aimed at range of movement work rather than any cardio-vascular training effect and the 20 mins of low grade effort reflected this.

The enforced break from tennis specific training was also used as an opportunity to address some of the more recently recognised aspects of performance enhancement and injury prevention in developing athletes (5). Much of this work addressed core stability which could be continued relatively easily within the constraints of the pathology. This included gluteal control exercises; static quadriceps and hamstring exercises at multiple angles; VMO and SLR exercises plus tubing and band exercises to maintain calf and anterior tibial muscle strength.

Preadolescent and adolescent tennis players often demonstrate poor core stability, together with a lack of adequate

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muscular control necessary for the demands of the sport (5). During tennis activities, the spine, pelvic girdle and shoulder girdle must all be capable of supporting and controlling the effort and forces generated from both upper and lower limbs in order to allow muscles and joints to perform in their strongest and most effective positions. The critically appraised progression of exercises for the transversus abdominis, multifidus and gluteal muscles as developed by Sahrmann (31) was, therefore, implemented to improve trunk control and stability.

Data obtained from Lawn Tennis Association (LTA) musculo-skeletal profiling assessments (unpublished) has demonstrated that abnormal scapular posture and dynamic control is common in tennis players, with excessive scapular protraction and an increased range of gleno-humeral external rotation being the most usual findings. These findings are usually associated with overactivity of the upper fibres of trapezius with poor control in the lower fibres of trapezius and lower fibres of serratus anterior which reduces the dynamic control of the scapula (32). To improve scapular control, the player was taught a programme of scapular stabilising exercises (33). In addition, a recent musculo-skeletal profiling of this player had identified a relative weakness of the shoulder external rotators compared with the internal rotators - particularly on the dominant (racquet) side, therefore - scapular stabilising exercises were performed in conjunction with both concentric and eccentric exercises to strengthen the posterior components of the rotator cuff muscles. Tennis specific actions using resistance tubing were used to develop strength within the context of the player’s skill pattern.

The programme also included flexibility work (24). The effect of stretching, with reference to duration, remains controver- sial. Bandy and Irion (34) evaluated the effectiveness of hamstring stretches performed amongst healthy subjects and concluded that optimum lengthening of the contractile unit occurred when the stretch held was for 30 seconds duration. In comparison, Taylor, Dalton, Seaber and Garrett (35) concluded that maximum length gains occur within the first four stretches of a series conducted on rabbit muscle tissue. However, Taylor et al. (35)

concluded that each stretch repetition needed to be held for 20 seconds.

Based on the evidence on stretching as outlined above, the player was advised to perform four times 20-30 second sustained stretches to the quadriceps, hamstrings, ilio-tibial band and calf muscles immediately following lower limb activity in order to maintain and subsequently improve muscle length and flexibility of the muscles affecting the biomechanics of the knee joint.

Freestyle swimming was utilised for aerobic training purposes but interval swimming was also prescribed in an attempt to mimic the demands of the sport (24). Since tennis is a game that is 'stop ñ start' in nature, intensive but short burst exercising using an aqua jogger was also used in an attempt to reproduce the cardiovascular demands of the sport where the heart rate alternately increases and decreases over a period of time. The resistance of movement performed in water is significantly greater than in air, making it a very effective stimulus for muscular development (36). Resistance was further increased by the addition of paddles for upper limb exercises, with the player performing multi-plane tennis specific movement patterns within the water.

The negative emotional impact of the diagnosis was considerable for this player but physiotherapy intervention resulted in the development of a comprehensive maintenance programme that allowed the player some limited participation during all RTC training sessions. This avoided player isolation and ensured that he remained positive, focused and compliant during his time out of tennis. The importance of maintaining a positive mental attitude was not underestimated since athletes who have the feeling that they can control their situation themselves appear to complete their rehabilitation with greater success (37).

After six months, MRI showed the lesion to be almost completely healed and the bone marrow oedema almost fully resolved. The player's rehabilitation schedule was therefore progressed.

Low impact exercises A low impact lower limb programme of exercises was introduced, that included

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