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REHABILITATION

resisted band exercises and controlled closed kinetic chain (CKC) exercises - static bike, dips, lunges and calf raises. CKC exercises demonstrate a major reduction in the tibio-femoral shear forces due to the force being exerted more axially in conjunction with co-contraction of the quadriceps and hamstrings (38). The authors considered this reduction in antero-posterior translation to be a desirable effect of CKC exercises during rehabilitation.

The exercises were made progressively more difficult by gradually increasing the resistance and speed of the movement (39). Performing CKC activities also helped to restore proprioceptive input and improve coordination (40) but additionally, wobble board activities and balance and co-ordination exercises were included for both lower limbs.

General stretching exercises were continued as part of a daily routine. At this stage, low intensity racquet and ball work - mainly hitting against a wall - was introduced and supervised by the coach.

Higher impact exercises Once both MRI and x-rays reported the knee as having normal appearances, final stage rehabilitation was commenced.

Lower limb exercises that had previously been performed in a controlled manner were progressed to become faster high impact exercises (39) and more sport specific exercises such as step ups, squats, multidirectional lunges, trampette work and jogging and hopping on grass were introduced. This led to a graduated progression of running activities that included sprinting, bounding, jumping activities, changes of direction, turns and zig zag moves - all intended to replicate the on-court movements associated with tennis. In general, rehabilitation exercises were intensified in accordance with the player's functional condition.

Specific on court tennis activities, were gradually increased until there was full resumption of tennis training. One month later, the player returned to competitive tennis.

CONCLUSION The onset of OCD is not usually related to any specific trauma but it is typically due

14

to repetitive overload. It is most common in male adolescents - being 2-3 times more common in males than females (14).

Musculoskeletal conditions commonly present as complex pathological and aetiological processes. Resolution is dependant on early and precise diagnosis and sports medicine practitioners must be vigilant in recognising potential symp- toms, often before the patient complains of any significant pain or problems. Therefore, when a young, male patient who participates regularly in sporting activities is found to have vague knee symptoms and the clinical picture is unclear, a diagnosis of OCD of the knee must be considered and diagnostic x-rays should immediately be requested.

Once a diagnosis of OCD has been made, treatment of the condition will ultimately depend on the size and location of the lesion, together with the radiographic appearance of the fragment and articular cartilage (24), but early diagnosis and investigation of OCD is vital in order that surgery may be avoided. In this particular case, the player appears to have made a full recovery and has returned to his pre-injury competitive level. However, given the high predicted percentage of the development of early degenerate changes following OCD, there is a clear need for early diagnosis and appropriate treatment.

This case study demonstrates that even with conservative treatment of OCD, a prolonged period of relative inactivity will be necessary. Rehabilitation should be goal-orientated but during this time, the player's physiological and psychological needs must be carefully monitored and maintained.

This study also illustrates that following conservative treatment; evaluation with x- ray and MRI should always be performed before any sporting activities are resumed.

References 1. Kraemer WJ, Triplett NT, Fry AC, Koziris LP, Bauer JE, Lynch JM, McConnell T, Newton RU, Gordon SE, Nelson RC, Khuttgen HG. An in-depth sports medicine profile of women college tennis players. Journal of Sports Rehabilitation 1995;4:79-98 2. Wood T. Medical care of tennis players by country. British Journal of Sports Medicine 2006;40(5):377-486 3. Pluim BM, Staal JB, Windler EE, Jayanthi N.

Tennis injuries: occurrence, aetiology, and prevention. British Journal of Sports Medicine 2006;40(5):381-385 4. Kovacs MS Applied physiology of tennis performance. British Journal of Sports Medicine 2006;40(5):381-5 5. Bylak J. Hutchinson MR. Common sports injuries in young tennis players. Clinics in Sports Medicine 1998;2:119-132 6. Chandler TJ. Exercise training for tennis. Clinics in Sports Medicine 1995;14:33-46 7. Peterson L, Minas T, Britberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplanta- tion: results at two to ten years. Journal of Bone and Joint Surgery (Am) 2003;85-A: Supp 2:17-24 8. Yoshida S, Kkata T, Takai H, Kashiwaguchi S, Katoh S, Takeda Y. Osteochondritis dissecans of the femoral condyle in the growth stage. Clinical Orthopaedics and Related Research 1998;346:162-170 9. Pill SG, Ganley TJ, Milam RA, Lou JE, Meyer JS, Flynn JM. Role of magnetic resonanace imaging and clinical critera in predicting successful nonoperative treatment of osteochn- dritis dissecans in children. Journal of Pediatric Orthopaedics 2003;23:102-108 10. Wright RW, McLean M, Matava MJ, Shively RA. Osteochoncritis dissecans of the knee. Clinical Orthopaedics and Related Research 2004;424:239-243 11. Flynn JM, Kocher MS, Ganley TJ. Osteochondritis dissecans of the knee. Journal of Pediatric Orthopedics 2004;24(4):434- 443 12. Cameron JC. Osteochondritis dissecans, osteochondral fractures and osteoarthritis of the knee. Current therapy in sports medicine. Mosby 1985. ISBN 0941158330 13. Reid DC. Sports injury assessment and rehabilitation. Churchill Livingstone 1992. ISBN 04443086625 14. Aglietti P, De Biase P, Ponteggia F, De Felice R. Osteochondritis dissecans of the knee; arthroscopic evaluation and treatment. Sports Exercise and Injury 1996;1:152-161. 15. Birk GT, DeLee JC. Osteochondral injuries: clinical findings. Clinics in Sports Medicine 2001;20(2):279-285 16. Braemer JAM, Maas M, Dallinga RJ, te Slaa RL, Vergroesen DA.

Increased external tibial

torsion and ostochondritis dissecans of the knee. Clinical Orthopaedics and Related Research 2004;422:175-179 17. Tatum R. Osteochondritis dissecans of the knee: a radiology case report. Journal of Manipulative & Physiological Therapies 2000;23(5):347-351 18. Anderson SJ. Lower extremity injuries in youth sports. Pediatric Clinics of North America 2002;49:627-641 19. Loredo R, Sanders TG. Imaging of osteo- chondral injuries. Clinics in Sports Medicine 2001;20(2):249-278 20. Ranger C, Klestil T, Kathrein A, Inderster A, Hamid L. Influence of Magnetic Resonance Imaging on Indications for Arthroscopy of the Knee. Clinical Orthopaedics and Related Research 1996;330:133-142 21. O’Connor MA, Palaniappan M, Khan N, Bruce CE. Osteochondritis dissecans of the knee

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

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