Assessing key treatment options in sports chiropractic to help patients minimize risks and avoid knee surgery
Knee injuries in athletes is a common complaint in chiropractic and physical therapy offices. No matter the level of play, the potential exists for an injury event to occur. Helping patients avoid knee surgery in the presence of this potential risk requires a health care professional who understands the intrinsic and extrinsic factors that may contribute to an injury.
Avoid knee surgery: understanding risk factors
Extrinsic factors of injury include things like equipment, playing surface and weather conditions. The extent to which a practitioner may influence these factors is often limited; however, knowledge of these conditions may be helpful in understanding the risk for injury, guiding treatment or making recommendations.
For example, understanding the relative risk of injury when playing on turf as opposed to natural grass may help a clinician understand the patient’s risk for injury. Likewise, information about playing surface may provide context when considering overuse injuries. If the patient is a competitive gymnast, have they recently spent time tumbling on a “dead floor?” Has a track athlete been spending more time running on asphalt as opposed to a more forgiving surface?
Intrinsic risk factors are inherent to the athlete and may be modifiable or non-modifiable.
Modifiable factors may include skill level, level of fitness and even body composition, while some inherent risk factors are non-modifiable, such as a patient’s anatomy. Knowledge of inherent risk factors is important in directing how clinicians examine patients and can guide a clinician in making the most appropriate treatment, conditioning and rehabilitation recommendations.
Risk factors and gender
Some of the most researched inherent risk factors that pertain to knee injury are gender differences. Literature on this topic generally identifies two predominant factors in contributing to knee injury, particularly in female athletes.
First, gender differences in Q-angle — a measure describing the relationship between the width of the pelvis as it relates to specific points on the knee — have been identified as contributing to greater risk of knee injury in female athletes, who typically exhibit a greater Q-angle than their male counterparts (Almeida et al., 2016). Second, the relative strength between the quadriceps and hamstrings is frequently implicated as a predictive risk factor for serious knee injuries, such as ACL tear, and should be evaluated in female athletes who may experience this injury at a rate two times their male counterparts (Walden et al., 2012).
Assessment and treatment of the athlete
Understanding that certain risk factors exist in the proliferation of knee injury in sport means that functional assessment of the athlete is critical for identifying and addressing those modifiable factors.
Functional movement assessment of the athlete can be undertaken in a variety of ways and can take place before an injury event occurs or after a patient has presented to your office. Several methods and protocols exist for screening movement patterns and identifying potential problem areas. One strength of these protocols is that they often package a group of specific movements, giving the clinician a streamlined tool for pinpointing and addressing faulty motor patterns.
When working with a team, these movement screens can be performed prior to the beginning of a competitive season as a way to spot systemic issues that can then be addressed with an appropriate strength and conditioning program. In office, it may be appropriate to perform a brief whole-body movement screen.
More often, however, it is important to take the time to learn the demands of an athlete’s sport and understand what movements or tasks they are repeating over and over again. In working with adolescent athletes, I have learned that everything is recorded, and watching a cell phone video of someone tumbling, sprinting or swinging a bat has often guided me in my assessment and treatment.
Consider the entire body
Importantly, assessment and treatment of any athlete should consider movement of the entire body. Though the focus here is preventing knee injury, an injury to the knee is so often simply a symptom of dysfunction elsewhere.
As practitioners, we understand that the body presents as a pattern of relative stability to mobility. Every day, I explain to patients that when motion is not present in one joint, it is often created at the expense of another joint, which is supposed to be more stable. In this way, an injury to the knee may be the result of dysfunction at the hip or elsewhere.
It would be unreasonable to expect the knee complaint to resolve — or not to recur — if the other dysfunction is not addressed. Targeted, dynamic mobility exercises should be incorporated as a component of any corrective exercise program so that an athlete may learn to move and control joints through their full range of motion.
Strength and stability for injury prevention
Moreover, injury prevention relies upon the appropriate balance of strength across muscle groups and adequate stability training. As noted above, injury risk to the knee is increased when the ratio of strength between eccentric hamstring contraction and concentric quadriceps contraction is decreased (El-Ashker, 2017).
Acknowledging this disparity through targeted strength and conditioning, or “pre-habilitation,” may reduce knee injury risk. Stability and proprioceptive training are critical in preparing the athlete for the demands of any sport. While knee injury may certainly be the result of direct trauma, it frequently occurs as a result of poor cutting, planting or landing mechanics. These issues may be appropriately addressed by focusing on core strength, hip stability and balance training.
Finally, helping a patient avoid knee surgery or significant injury is often about knowing when to remove a patient from sport and when to return to sport following injury. In this instance, to rest an injury does not mean to stop movement.
Overuse injuries respond well to breaking from sport and devoting time to both passive therapy and targeted rehabilitation that focuses on the above-mentioned principles of mobility, strength and balance. When making a return-to-play decision, the practitioner should consider whether the patient has full range of motion, full strength, sufficient balance and the ability to perform sport-specific tasks without pain.
Though aiding an athlete in avoiding surgery following a knee injury is the ultimate goal, it is the responsibility of the provider to acknowledge when treatment has plateaued or failed, or the injury is not otherwise within their scope of care. In this case, the provider should rely on their care network, making the appropriate referral in the best interest of the patient and offering support when the athlete is ready to move again.
LESLIE REECE, DC, MS, CCSP is an assistant professor and clinician at Logan University. She earned her Doctor of Chiropractic degree from Cleveland University in 2017 and her M.S. in Sports Science and Rehabilitation from Logan University in 2019. She is a Certified Chiropractic Sports Practitioner and a member of the American Chiropractic Association.