accelerated rehabilitation | meniscal rehabilitation

The 2004 Olympics were marked by outstanding performances and remarkable displays of dedication, determination, skill and athleticism. From a sports medicine viewpoint, however, the Jana Pittman story stands out. For sports therapists treating athletes at all levels, this case provides food for thought in terms of re-evaluating present rehabilitation programmes.

Jana Pittman, the reigning world champion in the 400m hurdles, was Australia’s best hope for a track and field athletics gold medal. Her training was going superbly until the Zurich Weltclasse meeting two weeks before the start of the track and field part of the Olympics. During the warm-up that evening Jana felt something go in her right knee and was clinically diagnosed with a lateral meniscal tear. This was rapidly confirmed on MRI scan and her Olympic hopes were effectively dashed there and then. She consulted local surgeons who felt that she had no hope of recovering and recommended that she should go back home for treatment.

The Australians have a remarkable depth of sports medicine talent and a superb team that surrounded her and rallied around her at this time. The decision was made that she should at least be assessed elsewhere for another opinion and that any possibility of her arriving in Athens to compete should be pursued. She therefore travelled to London less than 36 hours after her injury.

She had spent the period after injury elevating, compressing and icing her knee assiduously. She had maintained her muscle control. Clinically she had lateral joint line pain and clicking with restriction of end-of-range flexion and difficulty with hyper-extension in that compartment. Her knee was otherwise stable. Her MRI scan confirmed a degenerative lateral meniscus with a significant tear in its main body. In young athletes (Jana is 21 years old) such scans often appear dramatic but with the history that she described and the clinical signs she demonstrated, it was likely that this was a radial tear and that there was a possibility that with minimal intervention she might recover.

In collaboration with her coach, her support team and her doctors, she made the decision to proceed to an urgent knee arthroscopy, which was carried out on 8 August. In order to maximise her chances the procedure was undertaken with a very short tourniquet time (to minimise interruption of blood supply to the leg and muscles). The tear in the lateral meniscus, which was not repairable, was cut back to a stable rim. High doses of antiinflammatory medication were used and icing was begun immediately.

By the next day Jana had regained almost full movement of her knee and continued to compress and ice assiduously. She subsequently received treatment that included hyperbaric oxygen, a vigorous rehab regime to maintain muscle bulk and an injection of hyaluronic acid substitute into her knee (this joint fluid supplement provides a nutrition boost and additional shock absorption to the cartilage). Within a week she was capable of running and within 10 days she was ready to hurdle.

A number of measures were then put in place to facilitate her recovery from the arthroscopy. It would take most patients six weeks to be running comfortably and in some cases considerably longer to be performing manoeuvres such as hurdling, let alone competing at the very highest level. In this case, working with an extremely fit and motivated athlete with a support network of doctors and physiotherapists available at all times, it was possible to get her back to running within a week and to hurdling in an Olympic heat in 13 days.

Lessons for future rehab

There are minor lessons to be learned in terms of the care of most athletes with similar knee injuries who require arthroscopy. These are particularly in relation to the rigorous use of ice, compression, elevation, the use of hyaluronic acid supplementation and the use of anti-inflammatory medications. Provided athletes are carefully monitored with these measures, an early return to sport can be expected in many cases.

The literature has not ignored these phenomenal recovery rates in the past; however such cases are scarce. Almost 20 years ago Rand⁽¹⁾ suggested that arthroscopy was invaluable for diagnosis and treatment of knee injuries in athletes.

However, in a series of 63 meniscal injuries this author reported an average of four weeks before return to competitive activity. Two studies^(2,3) have advocated accelerated rehabilitation in athletes with meniscal injuries, even if meniscal repair has been carried out, thereby questioning the need for activity restrictions that seem so established after meniscal surgery.

All these studies make important reference to decreasing inflammation, restoring motion as early as possible, increasing strength in a phased manner and allowing the athlete to participate in goal setting advancement. We stress, however, that at no point should the rehabilitation activity compromise the athlete’s safety, particularly with regard to reinjury.

The caveat remains that not all athletes will be successful in such accelerated programmes and early recognition of this is vital to prioritise safety and avoid chances of reinjury. To ensure success, it is essential to determine carefully which athletes are suitable for this type of rehabilitation, based on the athlete’s psychological as well as physical attributes.

Jana’s ultimate performance of fifth place in a final that she could potentially have won based on her previous training milestones is somewhat disappointing and perhaps reflects the one thing that was unavoidable, which is the loss of the very important final two weeks of training and, in particular, speed work.

Jana Pittman’s somewhat unusual and rapid recovery is a testament to the vision of the Australian medical team who felt that it might be possible for her to rehabilitate in time to compete well in her event.

It is also a testament to a highly committed athlete who understood the need to protect her knee and to avoid further damage, but nevertheless was able to gauge her own recovery and gradually progress through her goals in the postoperative period, with the singular vision of achieving her lifetime athletics dream.

Mechanical injuries such as those to the meniscus require surgical management. If that surgical management is appropriately and carefully undertaken by the right people with the right support network, an expeditious recovery is possible. Fares Haddad carried out Jana Pittman’s arthroscopy on 8 August

References

Rand JA, ‘The role of arthroscopy in the management of knee injuries in the athlete’. Mayo Clin Proc. 1984 Feb; 59(2): 77-82.
Barber FA, ‘Accelerated rehabilitation for meniscus repairs’. Arthroscopy. 1994 Apr; 10(2): 206-10.
Wheatley WB, Krome J, Martin DF, ‘Rehabilitation programmes following arthroscopic menisectomy in athletes’. Sports Med. 1996 Jun; 21(6): 447-56.