Conservative management of a traumatic meniscal injury utilising osteopathy and exercise rehabilitation: A case report

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Abstract

Meniscal injury is one of the most common knee soft tissue injuries, commonly affecting young athletes and an older, degenerative population. Treatment largely depends on the type and extent of the injury with arthroscopic repair or meniscectomy being mainstays. Although non-surgical approaches have been described, there is no published literature regarding a combination of indirect osteopathic techniques and rehabilitation in the management of these injuries. The current case report follows a 20-year-old male presenting with a 5-day history of acute knee pain, following trauma during an Australian Rules Football (AFL) match. An 8-week management plan of indirect osteopathic techniques and a tailored rehabilitation program was implemented. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lower Extremity Functional Scale (LEFS) questionnaires were utilised to measure outcomes. After the 8-week treatment and rehabilitation program, the patient had exceeded the minimum detectable change score for all outcome measures. This case report suggests that osteopathic manipulative treatment and rehabilitation may be an alternative, non-surgical approach in the management of post-traumatic meniscal injuries.

Introduction

Meniscal injuries are a common occurrence in young athletes, particularly in contact sports such as football and rugby.1, 2 Due to the unique vascular anatomy of the meniscus, with only the outer third of the tissue having a ready blood supply,3 treatment outcomes of these injuries can vary, based on the individual tear pattern. The type of treatment used varies and is largely dependent on the extent and location of the injury. Typically treatment is arthroscopic repair or meniscectomy.4 Appropriate management of these injuries is vital, as meniscal injury can significantly increase the risk of osteoarthritis development in later life.5 Conservative management of meniscal injuries is the preferred method of treatment, particularly in the case of stable meniscal tears, as arthroscopic repair or meniscectomy also increases risk of OA development.6 Current guidelines recommend acute inflammation management (rest, ice, compression and elevation), anti-inflammatory medications and physiotherapy7 in the early stages, prior to potential surgical intervention. There are examples of conservative manual therapy management of meniscal pathologies 8, 9, 10, 11 however where studies have been undertaken they have usually been in degenerative rather than acute meniscal presentations. 10, 11 The current case report explores the application of indirect osteopathy manual therapy techniques combined with exercise rehabilitation as an alternative strategy for the management of an acute knee meniscal pathology.

Section snippets

Patient information

A 20-year-old male patient presented to a metropolitan-based student-led osteopathy clinic (Melbourne, Australia) complaining of left knee pain with associated joint effusion and bruising. The patient reported diffuse, constant aching pain over the entire knee, with regular sharp exacerbations localized to the anteromedial aspect. Major functional limitations were identified by the patient, and a self-rated pain level of 7/10 on a visual analogue scale. The functional limitations identified by

Clinical findings

The physical examination findings are summarised in Table 1 below. The examination of the patient was guided by the clinical history and informed by the literature with regard to examination of acute knee complaints.12, 13, 14, 15, 16, 17, 18

Diagnostic assessment

Based on the patient’s history and physical examination, a working diagnosis of an acute left medial meniscus injury was made.9 This diagnosis was based on the mechanism of injury, positive orthopaedic testing (Apley’s, McMurray’s and Thessaly’s), pain on palpation of the medial joint line, and pain with passive knee flexion and extension at end-range.18 Differential diagnoses were pathologies affecting the knee cruciate and collateral ligaments. Ligament stress testing (Table 1) did not

Timeline

The planned and executed treatment regimen was spread over 5 treatments in eight weeks (Fig. 1).

Intervention

Each treatment session was divided into three components: 1) 15- min for re-examination and history taking; 2) a 15-min session of osteopathic manual therapy (OMT) aimed at symptom reduction and assisting in tissue healing; and, 3) a 15-min exercise rehabilitation session including teaching and monitoring the patients’ at home exercise and care.

Follow-up and outcomes

After the eight-week treatment regimen, the patient-reported outcome measures were re-evaluated (Table 3). The patient showed improvement greater than the minimum detectable change score for all KOOS subscales and for the LEFS. Additionally, the patients’ self-reported pain score had reduced by 6 on a 10-point VAS. Clinically, the patient showed almost complete functional resolution, being able to run, hop and jump without pain and disability, and had complete restoration of both active and

Discussion

The case report presents the conservative, non-surgical management of an acute knee meniscus pathology. A combination of manual therapy, in the form of indirect osteopathy manual techniques,26 and exercise rehabilitation, allowed the patient to return to performing a range of functional movements that were impaired following injury. The improvement in these functional movements is supported by the change in the KOOS and LEFS scores above their respective MDC score. 23, 25 Further, the number of

Patient perspective

The patient was contacted several months after their treatment had concluded to provide their perspective about the treatment. The patient identified an initial “disbelief” that the gentle treatment techniques used would be effective, as they were unlike any that they had previously experienced with manual therapy care. After the initial few treatments however, the patient began to feel more positive toward the methods used as their symptoms improved, finding the use of indirect osteopathic

Conflict of interest

The authors identify no competing interests in relation to the manuscript.

Informed consent

The patient agreed to the publication of the case study, and provided written informed consent.

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