Injury details, surgical intervention, consultant summaries, physiotherapy care and MRI details throughout rehabilitation following semimembranosus reconstruction
| Injury 14 August 2017 | Surgical intervention 19 August 2017 (5 days post-injury) | Early physiotherapy care (Weeks 1–7) | Repeat MRI and consultant check-up (7 weeks post-op) | Physiotherapy care → sports science (Weeks 7–11) | Repeat MRI and rehabilitation update (11 weeks post-op) | Repeat MRI and consultant check-up (17 weeks post-op) |
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| Player felt a ‘sharp’ acute pain in posterior thigh (proximal) after stepping over the ball and stretching. Player immediately stopped and withdrew from the pitch—ice and compression applied (phase 1; rest, ice, compression and elevation (RICE). MRI performed 24 hours post-injury. MRI summary (A): acute high-grade partial tearing extending throughout a long craniocaudal dimension involving the proximal free extra muscular portion of the semimembranosus (SM) tendon, with longitudinal split tearing at the origin and partial transverse fibre disruption of the membranous portion of the tendon, which comprises approximately 50% disruption of the tendon fibres continuing into a long segment of minor partial tearing of the myotendinous junction (MTJ) representing a grade 3C injury. Associated laxity of the pelvic tendinous portion of the free tendon and mild distal retraction of the muscle belly are adverse imaging prognostic features. Extent of injury explained to player by medical team; consult with an orthopaedic surgeon—surgical repair advised. | Player underwent surgery at the Princess Grace Hospital, London. Both segments of the horsetail (ruptured end of the tendon) were mobilised and held with No. 5 Ethibond. Four sets of Kessler sutures were used to reconstitute and bring back the tensions to create a tubular tendon proximally. The membrane was recreated with No. 5 Ethibond and then with 1 Vicryl to cover the sutures. A strong repair obtained and tested with the knee back in extension, thorough washout performed. The neurovascular structures were seen clearly and protected—intact. Closure was affected in layers using 1 Vicryl, 2-0 Vicryl followed by 3-0 Monocryl to skin. Operation discharge plan: Tendon in a ‘shredded’ state—~8 weeks healing before progressing to strengthening programme. Post-check-up: 6–8 weeks post-op for clinical assessment and obtain updated MRI. Mobilise NWB with crutches, brace at 60–120°~4 weeks+gradual wean-off. Aspirin+TED anti-embolism stockings for VTE prophylaxis. | Wound care (cleaning/fresh dressings) Sciatic nerve mobilisation Minimise atrophy: combination of isometric knee extension+NMES (atrophy setting) (60°→90°) progressing to supported fundamental movement patterns such as squat (→ROM), isolated hip ab/adductor+ankle flexor/extensor strengthening. Isolated hamstring contraction on involved limb avoided. Hydrotherapy; walking in shallow end. Soft tissue; scar mobilisation. | MRI summary (B): Good post-op features following a long segment of surgical repair of the proximal extra muscular SM tendon and proximal region of MTJ. The majority of the tendon repair shows mature low signal fibrous tissue with a smaller volume of maturing fibrous tissue. Significantly, there is good restoration of the normal tension of the tendon repair site as well as the intramuscular tendon. There are no complicated features or concerning muscle atrophic change. Consultant summary: satisfactory progress. Slight neural tension apparent but notunexpected,scar a little distally thickened → progress soft tissue. Good hip+knee mobility/able to generate reasonable hamstring contraction+muscle bulk ‘far better’ than peers at this stage. MRI shows good healing response alongside good tension in the intramuscular tendon+distal muscle. Plan: progress to S&C programme → football-specific activity. Nb. Objective strength testing prior to RTS. | Phase 2: restore pain-free range of motion, FWB, integrate progressive optimal loading. (criterion: <2/10 NRS, <5% ILA SLR/PKE) Continue sciatic nerve mobilisation+soft tissue; scar mobilisation. Incorporate measurements of SLR+PKE. At Week 9: SLR: 87° each side PKE (gentle): 69° each side. Begin isolated hamstring contraction; including progression of isometrics (short → long lever)—combination of overcoming/yielding derivatives, progress intensity (% MVC) and volume targeting involved limb. Begin transition to stationary bike (concentric action; short-range). Gradually introduce exercise selection incorporating simultaneous hip and knee extension (intermuscular co-ordination). Introduce running mechanics (starting with walking derivatives alongside use of aerofloor to ↓ impact forces/’elastic’ demand when introducing dynamic movements that is, A-skips). Assess IPC strength/RFD (IPC at 90°: bias medial hamstring recruitment—starting at Week 8, evaluated weekly throughout the RTS process. | MRI summary (C): good post-op appearances following surgical repair of the proximal extra muscular SM tendon and proximal extent of the intramuscular portion of the tendon. Interval maturation of intratendinous maturing fibrous scar tissue is noted. Restoration of the normal tension of the tendon and muscle belly are again noted, with no concerning muscle volume reduction or MTJ fatty infiltration. Rehabilitation plan update following MRI: Continue sciatic nerve mobilisation+soft tissue; scar mobilisation. Initiate antigravity running when supported by objective measures/player confidence (criterion: <10% PF %ILA, full pain-free ROM <5% %ILA), MRI positive healing response, player pain-free <2/10 NRS). Assess ENF strength bi-weekly following return to on-pitch running. Assess CMJ performance compared to pre-injury data during on-pitch reconditioning. Phase 3: progress optimal loading (S&C)+transition to on-pitch sport-specific reconditioning using the ‘control–chaos continuum’ (pre-injury data). (criterion: <10% IPC-PF %ILA, <15% IPC-F at 100 ms %ILA, ENF <15% ILA plus trends in relation to pre-injury data, pain-free (<2/10 NRS) on anti-gravity treadmill running at 90% BW). | MRI summary (D): Continued maturation of fibrous scar tissue throughout the long segment of repair involving the extra muscular portion of the right SM tendon. This reflects uncomplicated post-op healing with good preservation of tendon tension proximal to and within the SM muscle belly. Mild residual remodelling related muscle oedema at proximal extent of MTJ and mild peritendinous oedema, both of which are expected postoperative findings Consultant summary: Excellent progress. Scar long but well healed; this outcome expected and explained to player prior to surgery due to extent over long tendinous portion of the staggered SM injury. Muscle mass ‘reasonable’ relative to visual inspection of the contralateral limb. No neural tension noted/SM shape similar on both sides. No 'red flags' displayed. Plan to reintegrate in team training (phase 4) with gradual progression of high loads and high-speed activity while monitoring for any symptoms of tiredness/neural features (criterion: <10% IPC-PF/F at 100 ms %ILA, <10%ENF %ILA plus trends in relation to preinjury data, GPS training load data (pre-injury), player pain free (<2/10 NRS, positive player feedback, surgeon discharge, MRI healing status). |
MRI scans are shown in figure 1.
BW, bodyweight; CMJ, countermovement jump; ~, Circa; ↓, Decrease; ENF, eccentric knee flexor; FWB, full-weight bearing; %ILA, % inter-limb asymmetry; IPC, Isometric posterior chain; IPC-PF, isometric posterior chain peak force; IPC-F at 100 ms, isometric posterior chain force at 100 ms; % MVC, % maximal voluntary contraction; Nb., note; NWB, non-weight bearing; NRS, numerical rating scale; PKE, post-op, post-operative; prone knee extension; ROM, range of motion; RFD, rate of force development; RTS, return to sport; S&C, strength and conditioning; SLR, straight-leg raise; TED, thrombo-embolus deterrent; VTE, venous thromboembolism; NMES, neuromuscular electrical stimulation.