Application Of The Cross Bracing Protocol For A Knee Injury In A Soccer Player

HISTORY: A 23-year-old soccer player sustained a non-contact knee injury while warming up. He unintentionally misplaced his right leg on the ground instead of the ball for an L-turn maneuver. As he landed his foot on the ground, he fell on the ground and felt a popping sensation with an audible popping sound. He reported swelling of the right knee without pain immediately after the injury. PHYSICAL EXAMINATION: Examination in the clinic revealed moderate swelling and moderate tenderness over the lateral aspect of the knee. Lachman’s test and pivot shift test of the right knee were positive. Active and passive ROM was within the normal limits. Manual muscle testing of the right knee extensor score was 4+ from sitting position. DIFFERENTIAL DIAGNOSIS: 1. Anterior cruciate ligament (ACL) tear. 2. Meniscal tear. 3. Medial collateral ligament tear. TEST AND RESULTS: Axial, sagittal, and coronal planes T1- and T2-weighted MRI scans of the right knee: - Complete tear of the ACL with partial tear of the lateral collateral ligament (LCL). - Anterior Cruciate Ligament Osteoarthritis Score (ACLOAS) MRI grading system (Grade 3: complete discontinuity). FINAL WORKING DIAGNOSIS: Complete ACL rupture with partial LCL tear. TREATMENT AND OUTCOMES: 1. Immobilization of the right knee in 90° flexion for 12 weeks started 3 weeks post-injury. 2. Daily 10 mg of Rivaroxaban started upon bracing for 12 weeks to minimize the risk of deep vein thrombosis. 3. During the first 4 weeks of immobilization, manual therapy and an exercise program were performed twice a week, including quadriceps and hamstring co-contraction, calf Theraband plantarflexion, hip abduction and extension exercises, contralateral leg strengthening, and upper body strengthening. 4. From week 5 until week 10 post bracing, gradual movement of the injured leg was applied while restricting ROM in the knee extension until full ROM was achieved. 5. Additional gait retraining, ROM exercise, and strengthening exercise of the injured leg started at week 7 post-bracing. 6. Repeat MRI of the right knee at 12 weeks post-bracing revealed evidence of spontaneous healing of the ACL determined by thickened ligament and high intraligamentous signal with normal course and continuity (ACLOAS Grade 1). 7. Lachman’s test and pivot shift test of the right knee at 12 weeks post-bracing were negative.