The Sideline Utility of Advanced Manual Therapy

Playing 8s football on an 11s field creates a fast-paced, hard-hitting, high scoring game. As might be expected, at schools small enough to play 8 sided football games, rosters can sometimes stretch quite thin. As of Friday, September 21st we have 13 on our roster. For last nights game we were missing one and had one sidelined, the count was 11 on our side at the start of the game. As one might imagine this makes my job interesting.

Mid way through the 3rd quarter of a 52-12 loss, our 5'7'' 145lb grade 9 starting tailback came off the field with a pronounced limp and 5/10 pain over his right lateral knee. He reported taking a helmet to the outside of his knee on the previous run down the far sideline. He denied feeling his knee give out or feeling weak and did not recall hearing or feeling any popping sounds. He had mild visible swelling and discoloration over and above the right fibular head near the lateral joint line consistent with a contact injury. This area was also tender to palpation elevating his pain to a 6/10. There was no crepitus or abnormal laxity with articulation of the proximal fibula, valgus stress test results negative, varus stress test results negative, Lachman's results negative, anterior and posterior drawer results negative, and McMurray's test results negative. Passive terminal knee flexion also elevated his pain to a 6/10 and he was unwilling to actively flex his knee through full AROM due to similarly elevated pain. With no reason to suspect any structural damage to his knee, the patient stood up off the treatment table and was able to walk without issue. However, his attempt to lift his right knee to his chest actively was unsuccessful. When I asked him to squat, he stopped roughly 1/4 of the way through the movement complaining of 5/10 pain. Given the direction of contact during the initial injury I took a guess at Mulligan in an attempt to restore loaded AROM in a squat pattern. 2 sets of 5 squat MWMs with external rotation of the tib/fib at the knee reduced the patient's pain to a 2/10 with full AROM in a squat pattern. He was then able to sprint full speed and returned to the field without issue for the remainder of the game. The patient did not report any further issues after the game in the Athletic Training facility.

Patient interactions like this have become commonplace over the last year and a half. I imagine this is the entire point of my education. In total I have to imagine this evaluation and treatment was likely faster and with a much better outcome than if I had not been exposed to the clinical reasoning and treatment techniques that I have throughout my education. However, it is not hard to imagine holding out a grade 9 football player who starts on his varsity team during a route of a loss such as this yet I felt completely comfortable returning him to the field. Had I not been trained in Mulligan Concept it is likely that I either would have held him out, or would have taken much more time to return him to participation. In situations like this, is it possible that we are preventing further injury by restoring function and reducing pain prior to putting someone back on the field/court/ice who would likely have returned to play in any case?