Physiotherapy rehabilitation exercises following superior tibiofibular joint sprain with possible partial ligament tear

[Narcissus]

Summary – requesting a short program or list of exercises I can do to rehabilitate superior tibiofibular sprain with possible ligament tear.

Injury Description and History: So 5 weeks ago my knee took significant lateral/twisting force and I heard a loud pop. There was pain when it happened but I managed to walk around fine afterwards, but by the next day I couldn’t walk easily. Hit it with rest, ice and compression and elevation for 48 hours. There wasn’t a lot of swelling, and in 3 days time I was walking fine. I was able to do most activities (I do a lot of sport) pain and discomfort free, including lifting weights (squats, deadlifts), running, boxing, etc. In fact the only thing that caused me discomfort was Brazilian Ju Jitsu (BJJ), when lateral or twisting force was forced on my knee by sparring partners (which happens a lot in BJJ) or when stretching. Any full flexion of the knee joint caused a tiny amount of pain, but more pain was felt during stretches that applied some kind of lateral or torsional force on the knee joint, see photos of Ardha Baddha Padma, Ardha Baddha Padmottanasana Variation and Floor piriformis stretch. There was (and continues to be) pain at the head of the fibula on the outside of the knee, which hurts when touched with pressure or pushed.

Diagnosis: Since I am in a non-English speaking country it was difficult to get in to see a sports surgeon, but I did see one 2 weeks ago, 3 weeks after the injury. He diagnosed a sprain of the superior tibiofibular joint and ligament with likely ligament partial tear secondary to acute subluxation period. Based on what I have read online and the symptoms, especially the pain on the head of the fibula, I cannot see what else this could be, so I will proceed with my post assuming this is a correct diagnosis. The surgeon recommended complete rest for 6-12 weeks and no surgery at this point, and also did not recommend any physiotherapy exercises.

Current situation: Sport makes up a huge part of my life, so given that there was absolutely no pain doing most exercises, after getting the diagnosis, I stopped anything that caused pain (BJJ and stretches that hurt the knee), but continued stretching, lifting weights and boxing all without pain. Things don’t seem to have changed in the 2-3 weeks after seeing the surgeon. I have done no sport for 1 week now (due to other commitments) and if anything, the knee seems more sore to touch and when the Ardha Baddha Padmottanasana Variation rotation/lateral force is applied to it than while I was doing sport.

Request: I have seen online that most of the time the recommended treatment for this injury is physiotherapy to rehabilitate the joint and capsule ligaments. Since I am not in an English speaking country, nor in a city I can easily access an English speaking Physiotherapist, I was hoping someone could recommend a list of exercises that I could do to hopefully speed up recovery and strengthen the joint? If the exercises have well known names, I can simply Google them, so just the name of the exercise is fine, but for anything more exotic, I’d really appreciate a video link if you have one? Also, how will I know when it is ok to go back to full activity, including Brazilian Ju Jitsu, where the opponent is actually using 100% of his strength to actively twist this joint?

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[physiobob]

HI Narcissus and thanks for your informative post. You did not actually say what you were doing when the injury happened. Sometimes that information is useful so we can understand the direction of forces applied to the area at the time.

Your doctor is pretty correct in 6-12 weeks (and more like 12 weeks) being standard for this type of injury. The issues of the ligaments are poorly supplied with blood and so healing is slower than other areas. Additionally if you want to keep a tight ligament structure you don't want to be stretching it too much to soon in that process. This is why commonly a knee brace is prescribed following collateral ligament injury combined with complete rest. Exercises as such are not going to help although if it is pain free stationary cycling should be OK, as would freestyle swimming (avoid breaststroke). I have found it useful, both personally and with clients, to take some glucosamine sulphate supplements which seems to assist the rate of healing (could be direct or indirect effect on the bodies healing functions). In some cases it was only after 7-10 days of taking the additional 'food' that my pain resolved completely. Another option would be to do some work on the footbar of a pilates reformer (see if there is a local pilates studio with equipment).

So the take home message here is to back off, do activities that do not cause rotational or lateral stress on the structures, and perhaps take some additional supplement to assist the healing. If the pain does persist you can get someone to do deep cross-frictional massage to the injured structures, as well as some deep tissue massage to the hamstrings, as that can also be of help if there is some persistent pain.

Let us know how you get on and we can give some more input.

regards

PhysioBob

[Narcissus]

Thank you for the very prompt and detailed response PhysioBob.

You did not actually say what you were doing when the injury happened.

Apologies for that, I was wrestling and the knee took lateral force from another person with continued pushing in that lateral direction. There was a pop that was most likely the subluxation of the tibiofibular joint (I assume).

Just to be clear, the pain itself doesn't bother me, it is minimal and only occurs when the knee is pushed in a lateral direction, like the stretches I showed or certain BJJ positions. It's more about the knee not feeling 'right', and worrying about doing it future, permanent damage. Could I just ask for a couple of quick clarifications, as I want to make sure I understand correctly.

1. Recovery - With this 6-12 weeks of rest, this gives the ligament time to heal in a 'tight' structure to avoid future issues with the knee. In 6-12 weeks, if things go as expected, then all pain and discomfort from those positions should disappear and this will be my sign it is ok to go back to full training?

2. Risks of continued exercise - if I continue to exercise before the ligament has completely healed my risks include:
a. Short Term - With a partially torn ligament and continuing to train, joint is more likely to subluxate again or even dislocate while engaged in activity.
b. Long Term - Even if there is no catastrophic sublaxation or dislocation while exercising before the ligament is fully healed, the activity itself (before ligament has healed) could lead to a permanently looser ligament structure which increases the probability of problems (subluxation, dislocation) in the future while training.

Have I understood correctly? I'd very much appreciate if you could confirm if my understanding is correct, or I am misunderstanding?

Thanks again.

[physiobob]

Hi again Narcissus,

Thanks for the further information and questions. The issue is that you heard a 'pop' that to me would indicate a complete tear of the ligament either within it's structure or at the boney attachment. These typically do not show on an x-ray as that only shows bone damage. An MRI or Ultrasound scan would give more information but then given your current recovery status the treatment approach would not really change. Of course the pop might have been a subluxation of bone too but typically you need to go through the ligament to set to the bone. Bone healing takes a good 12 months to really be stable although in 12 weeks if should be quite stable. Discomfort can however last a good while longer. Everyone is different and every injury is slightly different so we can't really be more specific. As a general rule you should be back to things at 3 months albeit with some discomfort. You'll be able to work out what things aggravate it and can reduce those as required. And have specific treatment to the ligament structure with friction massage and even acupuncture if the pain is persistent.

Continued exercise in the event or a rupture or good strain will indeed lead to a less stable ligament structure and therefore more bone movement and risk of secondary injury down the line. However normal joint movements as I suggested in the earlier email should be OK. Again monitor any discomfort. I would NOT however recommend doing any of the stretches you mentioned in your post as they truly challenge the joint whilst unstable and could lead to some meniscal (knee cartilage) irritation.

And yes normally a ligament that has been over strained does remain lengthened than pre-injury. So unfortunately the joint will be slightly less stable as a result. That said this is all part of life and we cope and continue to perform sport without much of an issue. So personally I would not worry to much about the long term. It will just be one of those little issues to manage as part of your daily life and should not cause you any day to day problems.

[Narcissus]

Thank you for the follow up answers, much appreciated.

I will stop stretching totally until 12 weeks from the date of the injury, and avoid any exercise that causes pain or discomfort to the knee. After 12 weeks from the date of the initial injury, I will resume Brazilian Jiu Jitsu sparring with the knowledge that it might be a year until the discomfort stops. At the 12 week date I'll start stretching again, but continue to avoid those stretches (like the photos I sent) that put the most lateral pressure on the knee until a later date. I'll revert back with feedback.

Thanks for the advice.

[Edgarquin]

Hi Narcissus,

I am curious how did the training go. I have the same thing as you do and after 3 months, I want to play soccer again but I'm afraid of hurting again.