TABLE 1: OUTCOME MEASUREMENT & METHODOLOGY USED Methodology

Outcome Measure

Pain intensity (at rest)

Range of movement (ROM) (active)

Range of movement (ROM) (passive)

Limb girth bi- lateral (thigh)

Limb girth bi- lateral (calf)

Figure 1: Swelling and bruising

Muscular strength (lower limb)

Proprioception

Muscular strength (lower limb & upper body)

Figure 2: Pitting oedema of the shin bleeding inflammation proliferation hours

remodelling days

weeks months

Figure 3: The basic response to tissue unjury

cyclist was examined to identify functional deficits, base-line measures, and establish diagnosis. As the x-rays and ligament stability tests proved to be negative, the amount of bruising was indicative of muscle tissue damage. Base-line measures were recorded for pain, range of movement (ROM), limb girth, and muscular strength using the MRC scale. Base-line bilateral comparisons for proprioception were recorded upon reaching weight- bearing capabilities. For practical reasons measurement in muscular

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strength for evaluating bilateral lower- limb comparisons were reviewed on reaching phase III, the remodelling phase. Interim assessments, outcome measurement, and photographs continued throughout the rehabilitation process. This arrangement enabled monitoring of sensitive changes in patient status and evaluation of interventions which contributed towards making informed-decisions. Additionally, outcome measurement can have positive motivational benefits. Table 1 lists the outcome measures and associated methodology used in the case study. Figures 5a, b, c, highlight the extent of trauma and bruising exhibited at 10 days post-injury ie. first visit.

TREATMENT AND REHABILITATION

The short, medium and long term rehabilitation plan was briefly outlined to the cyclist and a simple SWOT analysis was introduced to assist in patient

education. The cyclist was informed of what to expect, the typical time frames for healing, and encouraged to work within the healing tissue’s capabilities to avoid exacerbating symptoms. The importance of avoiding a perpetuating chronic inflammatory cycle was specifically emphasised. Throughout, following each exercise session, the cyclist was instructed to monitor for adverse effects and apply cryotherapy as necessary.

PHASE I: INFLAMMATORY PHASE Acute inflammation Following injury, damaged blood vessels bleed causing hypoxia, so the injured tissue contains dead cells and extravasated blood (6). This triggers a natural but essential inflammatory reaction, involving a vascular and cellular response with fluid exudate, resulting in oedema and phagocytic activity (17). To prevent further bleeding a short period of

sportEX dynamics 2008;17(Jul):11-17

The patient was asked to indicate pain intensity at rest using the Visual Analogue Scale (VAS) on a scale 0 - 10. Where 0 = no pain, and 10 = the worst possible pain.

A long arm goniometer was used to measure knee flexion and extension - within the ‘limits of pain’. With patient supine, the centre of the goniometer was placed over the lateral epicondyle of the femur, the proximal arm pointing towards the greater trochanter, the distal arm pointing towards the lateral malleolus.

Upon reaching weight-bearing status, with patient standing, an inclinometer was used to measure ankle dorsi-flexion. This method provided a reliable repeatable comparison, bilaterally. Refer to figures 9a,b, c.

Girth measurements were taken to monitor swelling and muscle atrophy of the thigh. With the limbs extended within pain-free limits, a tape measure was passed around the girth to measure the circumference at 3 locations i.e. 8cm, 15cm, and 23cm above base of patella.

Girth measurements were taken to monitor swelling and muscle atrophy of the calf. As above, the circumference was measured at 2 locations i.e. 10cm and 20cm above tip of medial malleolus.

Initial base-line strength measurements were graded on a scale of 0-5 accordingly to the Medical ResearchCouncil (MRC) scale 1976. This included the main muscle groups, hamstrings, quads & calf.

Base-line bilateral comparisons for proprioception were recorded upon reaching weight-bearing capabilities using the one leg (stork-test) while situated between two uprights for safety reasons.

Base-line measurement for evaluating bilateral lower-limb comparisons and upper body strength were reviewed upon reaching phase III, the remodelling phase as the tissue became more capable of handling increased resistance. Different method of measurement were employed dependent upon type of equipment used e.g. isokinetic devices, repetition maximum (RM) and cable tensiometry.