CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector Alonso et al: Predicting recovery time from the initial assessment of a quadriceps contusion injury Predicting recovery time from the initial assessment of a quadriceps contusion injury Albert Alonso1, Phillip Hekeik2 and Roger Adams3 1Canterbury Bulldogs Rugby League Club, Sydney 2Private practice, Sydney 3The University of Sydney Six quadriceps contusion tests were evaluated for inter-rater reliability and ability to predict the recovery time of 100 injured rugby players. All subjects were treated with a standardised and disciplined treatment program incorporating cryokinetics and modified training. Muscle firmness ratings, thigh circumference and passive knee flexion range of movement (ROM) measurements, and the unilateral palpation, brush-swipe and tap tests were all found to have substantial to excellent reliability (range: 0.66-1.00). Multiple regression analysis demonstrated that 64 per cent of the variance in the time taken to return to full training could be accounted for by an equation involving the uninjured-injured difference in knee range, relative firmness rating of the injured muscle, difference in circumferences at the suprapatellar border, being able to play on following injury and the time delay before starting treatment. [Alonso A, Hekeik P and Adams R (2000): Predicting recovery time from the initial assessment of a quadriceps contusion injury. Australian Journal of Physiotherapy 46: 167-177] Key words: Contusions; Myositis; Predictive Value of Tests; Thigh Introduction horse injuries, are the result of a direct blow to the anterior thigh with high velocity compressive forces which are excessive (Young et al 1993, Zarins and Starkey and Ryan (1996) note that obtaining Ciullo 1983). Extremely high forces, exacerbation of successful management and rehabilitation of sports the injury during continued play (Bull 1995) and injuries depends on an accurate initial assessment of delays in treatment may result in the formation of the condition. Therefore, sports physiotherapists myositis ossificans and in prolongation of the time in require efficient and reliable evaluation tools, for both which the athlete is unable to play. diagnosis and reassessment, to facilitate the earliest possible return of the athlete to the sporting arena (Hutchison and Oxley 1995). The best techniques for measuring the extent of soft tissue damage and for identifying any complications arising from the initial injury are magnetic resonance Studies examining assessment procedures relevant to imaging (MRI), and diagnostic ultrasound, both of the sports physiotherapy clinic have been conducted which have been found highly sensitive to oedema since the early 1980s. The reliability of tests and and haemorrhage. Lehto and Alanen (1987) have also equipment commonly used to evaluate range of noted that MRI can provide accurate information motion (Gogia et al 1987, Rothstein et al 1983), the about the early phases of healing and can therefore generation of muscle torques (Kues et al 1992), spinal aid in optimising treatment. However, access to these motion (Gauvin et al 1990), patellofemoral alignment diagnostic tools is limited for most physiotherapists, (Fitzgerald and McClure 1995) and ligamentous so reliable and valid clinical tests are required which integrity (Cooperman et al 1990, McClure et al 1989) can accurately grade injury severity and direct have separately been determined. Although treatment without the need for soft tissue imaging. quadriceps contusions are a common injury in contact sports (Orchard and Seward 1994, Seward et al 1993), Assessment of quadriceps contusions has been no studies to examine the reliability and predictive described previously via the following clinical tests: validity of tests used in their assessment and direct palpation (Brukner and Khan 1995); muscle management have been conducted thus far. firmness ratings (Bull 1995); assessment of passive knee flexion ROM (Jackson and Feagin 1973); thigh Quadriceps contusions, often referred to in Australia circumference measurements (Bull 1995); and the as corked thighs, but in the United States as charley brush-swipe and tap tests to determine the presence of Australian Journal of Physiotherapy 2000 Vol. 46 167 Alonso et al: Predicting recovery time from the initial assessment of a quadriceps contusion injury Figure 1. Thigh circumference testing. Figure 2. Measurement of passive knee flexion ROM with the Baseline® digital inclinometer. knee effusion (Ryan et al 1991). Only the reliability Subjects All athletes with a quadriceps contusion of thigh circumference measures has been verified who were seen by the physiotherapists over a previously (Whitney et al 1995), with the intraclass 12-month period were invited to participate in this correlation coefficients between testers at the study. Athletes were excluded from the study if: there suprapatellar border and 20 centimetres proximal to was an open wound in the thigh area; there was a this site being 0.98 and 0.99 respectively. fracture of the femur or patella; they sustained other injuries to the hip and/or knee which could confound the test results; or if the thigh pain was non- The study described here was designed to investigate mechanical in origin. the reliability of a series of clinical tests for assessing quadriceps contusion injuries, and to examine the predictive validity of the tests, by noting the recovery Following the athlete’s consent being obtained, the times of subjects. first tester, who was the treating physiotherapist, filled in the data sheet with the subject’s age, the Methods mechanism of injury and the dates of injury and presentation. Playing time following the injury was also recorded, to identify subjects who were unable to This study was conducted through two private continue playing beyond five minutes in a match due physiotherapy clinics, both of which were associated to their injury. The physiotherapist then performed the with Rugby League football clubs. The majority of following tests in sequence. subjects were from the Canterbury Bulldogs National Rugby League Football Club. Ethical approval for this The palpation test involved systematic digital probing study was granted by the Human Ethics Committee of from the lateral border of the vastus lateralis to the The University of Sydney. All participants signed a medial side of the thigh with the patient in long statement of informed consent. sitting, after which the physiotherapist subjectively noted, then recorded, the muscles injured and the area of injury (distal third, middle third or proximal third Examiners To obtain maximum generalisability of of the thigh). the reliability measures to the population of judges (Shrout and Fleiss 1979) all nine physiotherapists working at the designated clinics participated as Muscle firmness testing was performed with fingertip examiners in this study. Their experience ranged from palpation, with the muscle firmness at the site of the one to 13 years, with an average of 5.3 years. injury compared with the firmness of the same site on 168 Australian Journal of Physiotherapy 2000 Vol. 46 Alonso et al: Predicting recovery time from the initial assessment of a quadriceps contusion injury the uninjured leg, and rated on an 11-point scale from These tests were performed during the patient’s first -5 (comparatively decreased muscle firmness) to +5 consultation, in conjunction with the routine physical (comparatively increased muscle firmness). A zero examination. When another physiotherapist was rating was applied if the muscle firmness of the injury available, re-assessment for test reliability site was similar to the muscle firmness of the non- determination was carried out immediately following injured thigh. the first assessment. The second physiotherapist performed the same tests and recorded their results on Circumference measures were taken at the a separate data sheet, without referring to the results suprapatellar border, and at 10 and 20 centimetres of the earlier examination. proximal to this site on both thighs, using a purpose- made device which was designed to ensure that the Treatment In order to establish the predictive validity distances above the suprapatellar border were of the tests, given a cryokinetics management constant for all subjects. The bottom of the Velcro® program, thereafter all the quadriceps contusion strap was positioned in line with the suprapatellar injuries were treated as similarly as possible. All the border and the tape measures applied such that they injuries were treated by cryokinetics in the manner were just in contact with the skin surface of the thigh. described by Knight (1995). Ice was applied to the Measurements were recorded to the nearest injured area until numbness was achieved. All millimetre. subjects then worked to regain full pain-free knee flexion range by pulling on a strap wrapped around their foot, passively flexing the knee to the point of Passive knee range of motion testing was performed momentary discomfort, then releasing. Once the with the subject in prone, with the hip in neutral, and pain-relieving effects of ice had minimised, ice was the foot and distal third of the shank over the edge of reapplied and passive stretching continued. The the plinth to enable positioning of the Baseline® treatment program also required that subjects digital inclinometer (Fabrication Enterprise, Inc., returned to modified training only, meaning