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Abstract

Background: The “unhappy triad” injury includes tears of the anterior cruciate ligament, medial collateral ligament, and medial meniscus. There is limited research on the prevalence and outcome of this injury. The unique surgical repair consisting of lateral extra-articular tenodesis (LET) was utilized to reinforce the anterior cruciate ligament repair (ACLR) and to prevent rerupture. Due to this extensive surgery, the patient struggled to regain full range of motion and quadriceps activation. This case is a Level 2 case study that explores the different interventions used to address the aforementioned objective deficits and return him safely to play. Patient: The patient is an 18-year-old male soccer player that presents to physical therapy and the athletic training room for postoperative rehabilitation after ACLR, LET, MCL repair, and medial meniscus repair. The initial injury was non-contact and occurred while playing soccer; He reports planting his left leg and feeling his knee shift. He denies feeling or hearing a pop. Swelling in the knee was present and he was unable to continue playing. Upon examination, the knee was not tender to palpation, loss of range of motion was not significant, and Valgus and Varus stress tests were negative; Lachman’s was positive. Differential Diagnosis: The differential diagnosis of this injury was ACL tear with MCL and medial meniscus involvement; and ACL tear with concomitant chondral injury. The physician’s assessment, including MRI imaging, revealed a torn ACL with MCL sprain and medial meniscus tear. Treatment: Surgical repair was performed 2.5 weeks after the initial injury and consisted of bone-patellar tendon-bone ACL reconstruction with lateral extra-articular tenodesis, MCL and medial meniscus repairs. The patient began physical therapy 2 days post-op with treatment consisting of manual techniques to target range of motion and blood flow restriction to promote quadriceps strength and hypertrophy. Due to weight-bearing precautions, the Alter-G machine was utilized to aid in gait training. According to an ACLR study, the knee should have full range of motion at week 6. The patient still lacked 43 degrees at week 6. Outcomes: There are no specific guidelines for return to play after an ACLR, LET, MCL repair, and medial meniscus repair, therefore, a unique treatment plan was created by the treating physical therapist and athletic trainer to meet the patient’s needs. The patient achieved full extension and continues to lack 5 degrees of flexion at 7 months. Conclusions: The complexity of the surgical repair and the patient's response to the interventions created challenges. Recommendations for clinical practice include implementing early interventions of blood flow restriction to inhibit muscle atrophy, Alter-G to initiate early gait training and more manual techniques to improve range of motion. Clinical Bottom Line: This case stresses the importance of involving the entire medical team (physician, athletic trainer, physical therapist) in the care of the patient as well as the ability to find ways to be creative with rehabilitation when there are protocols inhibiting traditional interventions.

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