M14 - again...sorry its late guys

Musculoskeletal case study 14


Karen Patton is a 21 year old club footballer who has recently pulled a muscle at the front of her right thigh. The injury occurred whilst kicking a ball 5 days ago. She attended the local walk-in centre where a diagnosis of grade 2 rectus femoris strain was made and she was referred to physiotherapy. Karen walks on elbow crutches and is partial weight bearing through her right leg. She is off work from her job as postal worker. Apart from a previous similar injury 8 months ago she is otherwise fit and well.


Notes on this case:

Pathology: Muscle strains-
A muscle strain is damage caused by over-stretching of muscle tissue. In football, this is thought to occur most frequently when movements such as sprinting, stretching for the ball or kicking the ball are carried out in an uncoordinated manner. The muscle tissue becomes overloaded and reaches a breaking point where a tear or partial tear occurs. The player will experience pain that will persist if he or she attempts to stretch or contract the muscle. Depending on their severity, muscle strains are categorised into Grades 1, 2 or 3:
Grade 1 strainThere is damage to individual muscle fibres (less than 5% of fibres). This is a mild strain which requires 2 to 3 weeks rest.
Grade 2 strainThere is more extensive damage, with more muscle fibres involved, but the muscle is not completely ruptured. The rest period required is usually between 3 and 6 weeks.
Grade 3 strainThis is a complete rupture of a muscle. In a sports person this will usually require surgery to repair the muscle. The rehabilitation time is around 3 months.
All muscle strains should be rested and allowed to heal. If the patient continues to play, the condition will worsen. If ignored, a grade one strain has the potential to become a grade two strain or even a complete rupture.

Anatomy-
Rectus femoris muscle
Function > hip flexion and knee extension
Location > origin at the anterior inferior illiac spine and the illum above the acetabulum.insertion at the quadriceps tendon to the base of the patella and onto tibial tuberosity via the patellar ligament.


Subjective

History – occurred whilst kicking a ball 5days ago (the mechanism of injury and the aetiology/cause of the pathology)
Otherwise fit and healthy
no mention of any medication or any social history

Symptom profile - pain in rectus femoris muscle, the level of pain would be determined by the patient and they should be asked to rate the pain on a scale of 1-10

Pain behaviour – you would expect there to be pain upon stretching and contracting
patient is walking on crutches and partial weight bearing so pain might be considerable and the patient should not be asked to fully weight bear on this leg during the objective examination
also patient is current off her job as a postal worker, which would indicate a certain level of disability

Variable factors (aggravating/easing factors)
- the pain should be eased when the PRICE principles are applied I.e. protection of the area, rest, ice, compression and elevation. The pain would be made worse on increased action of the muscle

Functional loss – the patient will have pain going up and down stairs, walking and standing up/sitting down, due to the stretch and contraction that this puts onto the rectus femoris

Special questions – these would be to exclude OA and RA, referred pain from the lower back and a fracture

Ask the patients opinion and also see what you can observe without asking, I.e. patient walking, the patient's standing still posture and sitting down
Expected observations, signs and symptoms would be abnormal gait due to partial weight bearing on the affected side, pain upon weight bearing and stretching the muscle into flexion at the knee or on extension of the hip also upon contraction of the muscle by extending the knee or flexing the hip

Main problems of patient?
What is their opinion?
possibly the fact that she is off work, or that she cannot play football
The areas affected is the anterior thigh and the structures involved would be the quadriceps muscles along with the knee and hip as these are the two joints that the rectus femoris works across


Objective
Gain consent!

Likely observations
other than posture and gait changes there are not normally any visual observations with a muscle strain I.e. no swelling, deformity or skin colour change

Assessment of movement, looking at the responses to function
I.e. ask the patient to actively move the muscle and then passively move the patients limb through the end range of movement (think about the patient's positioning)
do movements that would be less painful first:
adduction
abduction
medial rotation
lateral rotation
then movements that you would expect to be painful:
extension of knee
flexion of knee
flexion of hip
extension of hip (patient on side or supine)

Assessment of contractile tissues
I.e. Resisted tests
do movements that would be less painful first:
adduction
abduction
medial rotation
lateral rotation
the following movements may be too painful to do a resisted test with the patient and possibly unwise due to the muscle strain and making the pain worse and lowering function:
extension of knee
flexion of knee
flexion of hip
extension of hip

Assessment of function
I.e. ADL's and Gait
These can be observed as the patient enters the room and sits down/ stands up and walks across the waiting room and testing them will probably cause unnecessary pain as it is already known that the patient is partial weight bearing and using crutches

Special tests
Thomas's (rectus femoris contracture test) - this would be painful and positive
Trendelenberg – this test would require weight bearing and would be unnecessary so should not be attempted
Fabers test – this requires knee flexion and hip abduction/ external rotation and so would be painful and positive due to knee flexion
Ober's sign – abduction and extension of the hip with flexion of the knee, this test would have to be administered with extreme care as both the extension of the hip and flexion of the knee would be painful for the patient

Palpation for tenderness should be done

You would need to warn the patient of increased pain/symptoms for the next 24-48hrs following the examination

Goniometric measurement of movements could be taken
I.e. measurements of extension of knee
flexion of knee
flexion of hip
extension of hip
these could then be used throughout treatment to check for improvement of the patients ability to stretch/contract the affected muscle

This patient has experienced a previous muscle strain so advice should be given to prevent further strains, including:
Warm up prior to matches and training.
Performing a cool down after matches and training, including stretching.
Maintaining good muscle strength and flexibility.
Having a diet high in carbohydrate in the 48 hours before a match, so there will be an adequate supply of the energy which is necessary for muscle contractions.