Rehabilitation Guidelines for Knee Multi-ligament … Guidelines for Knee Multi-ligament...
Transcript of Rehabilitation Guidelines for Knee Multi-ligament … Guidelines for Knee Multi-ligament...
Dr. Laith M. Jazrawi Chief, Division of Sports Medicine
Associate Professor Department of Orthopaedic Surgery
Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
Back View Supraspinatus
Infraspinatus
MinorTeres
Front View
Subscapularis
MM
A B
AB
MedialCollateralLigament(MCL)
LateralCollateralLigament(LCL)
ACL
Menisci
ACL
PCLLCL
TibiaMCL
MM LM
Femur
Figure2aFigure2b
Figure1aFigure1b
Figure1a:Medialorinnerviewofthekneeshowingthemedialcollateralligament,b:Lateralorouterviewofthekneeshowingthelateralcollateralligament.Figure2a:Anteriororfrontviewofthekneeshowingtheanteriorcruciateligament(ACL),b:Posteriororbackviewofthekneeshowingtheposteriorcruciate(PCL)
ThekneejointiscomprisedofanarCculaConofthreebones:thefemur(thighbone),Cbia(shinbone),andpatella(kneecap).Thefemurhasamedial(inside)andalateral(outside)condylethatformsaradialorroundedboEomthatcomestogether,formingatrochleargrooveforthepatellatomove.ThemedialandlateralcondylesitontopoftheCbia,whichhasaflatsurfacecalledtheCbialplateau.Thekneealsoiscomprisedoftwomenisci,whicharefibro-carClaginousstructuresandeachmeniscusisthinnertowardsthecenterofthekneeandthickertowardtheperipheryoftheknee,givingitawedgeshapedappearance.Themedialmeniscusformsa“c”shapeandislocatedbetweenthemedialfemoralcondyleandthemedialaspectoftheCbia.ThelateralmeniscusformsanovalshapeandislocatedbetweenthelateralfemoralcondyleandthelateralaspectoftheCbia.ThemenisciacttoimprovestabilitybetweentheCbiaandthefemursecondarytoitswedgeshapethatactstolimittranslaCon.Thekneealsohasfourmajorligaments,whichconnectbonetoboneandprovidestabilitytothejoint.Theseligamentsaretermedthemedialcollateralligament(MCL)(Figure1a),lateralcollateralligament(LCL)(Figure1b),anteriorcruciateligament(ACL)(Figure2a),andposteriorcruciateligament(PCL)(Figure2b).TheMCLconnectsthefemurandCbiamedially(ontheinside)andresistsvalgus(kneebucklingin)kneemoCon.AcommonmechanismofinjurytotheMCLoccurswhenaforceisappliedtotheouterkneewhilethefootisplanted,causingthekneetomoveinward.TheLCLconnectsthefemurandthefibulalaterally(ontheoutside)andresistsvarus(kneebucklingout)kneemoCon.
Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
AcommonmechanismofinjurytotheLCLoccurswhenaforceisappliedtotheinnerkneewhilethefootisplanted,causingthekneetomoveoutward.TheACLandPCLaEachtheCbiaandfemurdeepinsidethekneejointandcrossoneanotherlikeguidewires.TheACLrestrainstheCbiafrommovingforwardandrotaCngexcessivelyonthefemur.MostACLinjuriesoccurwithoutcontact,mostcommonlywhenanindividualplantstheirfootandchangesdirecConwhileparCcipaCnginsports.ThePCLresiststheCbiafrommovingbackexcessivelyonthefemur.PCLinjuriesmostcommonlyoccurwhenananteriorforceisappliedontheCbiasuchaswhenthelowerleghitsthedashboardofacarduringacaraccidentorlandingonthekneewiththekneeflexedapproximately90degrees.Ligamentousinjuriesaretermedsprainsandaregradedbasedontheseverityoftheinjury.Agrade1ligamentsprainisaminimalinjurywithliEletonoincreaseinlaxitytotheligamentwhereasagrade3sprainisacompleterupturetotheligament.Kneeinjuriesthatinvolveoneofthefourligamentsaresomewhatcommon.Injuringtwoormoreofthefourmajorkneeligamentsisuncommonandusuallyoccursasaresultofahighenergytraumasuchasanautomobileaccident,fallorasignificantsportsinjury.1WhentwoormoreoftheligamentsarerupturedtheCbiaand
Figure3–a:RadiographshowinganexampleofanteriorkneedislocaCon,b:RadiographshowinganexampleofposteriorkneedislocaCon
A B
thefemurmaylosecontactfromoneanotherandspontaneouslycomeapartordislocate.AkneedislocaConbetweenthefemurandtheCbiaisnamedbythedirecContheCbiaisorientatedfromthefemurinadislocatedposiCon.SecondaryinjuriessuchasnervedamageandorvascularinjuryarecommonfollowingakneedislocaCon.(1)OYenthevascularornerveinjuriesrequireemergencyaEenContosavethelimborpossiblytheindividual’slife.Oncethekneeisevaluatedandsecondaryinjuries,ifany,arerepaired,theiniCaltreatmentofthemulC-ligamentinjuriesincludesimmobilizaCon,whichisfollowedbyconCnuedevaluaConanddiagnosCctesCngtodeterminetheextentoftheligamentdamage.TreatmentopConsincludesurgicalandnon-surgicalapproachestocare.TreatmentdecisionsoYenaremadebased-oneachindividual’spre-injuryfuncConandtheextentoftheligamentdamage.RecentstudieshavesuggestedpaCentsreceivingoperaCvetreatmenthaveimprovedfuncConaloutcomeswhencomparedwithnon-operaCvetreatment.(2)TheCmingofsurgeryiscriCcalwithevidencethatshowsifsurgeryisdoneimmediatelyfollowingtheinjury.
followingtheinjury,anindividualmayexperienceincreasedpost-operaCvesCffnessandscarring.(3)ResearchhasshownthatoutcomesofmulC-ligamentreconstrucConarebestwhenthesurgeryisdonewithin3weeksfrominjuryaYerthepaCentcanreducetheswellingfromtheiniCalinjury.Surgerywillvarydependingontheextentoftheligamentdamageandthespecificligament(s)involved.Iftheligamentisavulsedfromthebone(pulledoffthebone)thenthesurgeonmaybeabletoperformaprimaryrepairofaEachingtheligamentbacktothebone.WhenaligamentisruptureditoYenhastobereconstructed,whichmeansreplacingtheligamentwithotherCssue.ThiscanbedonebyusinganautograY(donorCssuefromaninjuredperson)oranallograY(donorCssuefromacadaver).RehabilitaConfollowingmulC-ligamentreconstrucConisvitaltoregainingmoCon,strengthandfuncCon.IniCallyaYersurgerythekneeisbracedandindividualsusecrutcheswithminimaltonoweightbearingforthefirst6weeks.GraduallymoreweightbearingandmobilityisallowedtopreventsCffnesspost-operaCvely.TherehabilitaConwillslowlyprogressintostrengthening,gaitandbalancingacCviCes.TheUWHealthsportsrehabilitaConguidelinesarepresentedinacriterionbasedprogression.GeneralCmeframesrefertotheusualpaceofrehabilitaCon.However,individualpaCentswillprogressatdifferentratesdependingontheirage,associatedinjuries,pre-injuryhealthstatus,rehabcompliance,Cssuequalityandinjuryseverity.SpecificCmeframes,restricConsandprecauConsmayalsobegiventoenhancewoundhealingandtoprotectthesurgicalrepair/reconstrucCon.
Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
Precautions Brace ROM: locked in full extension Weight bearing/ROM: touch down, weight bearing
Range of Motion Exercises
Weight bearing/ROM: Touch down, weight bearing then proceed to as tolerated by patient
Therapeutic Exercises
Quad Sets Ankle pumps Cryotherapy device Elevation Heel slides Seated flexion Prone flexion Wear knee brace for at least six weeks after post op
Phase I (Post-op Day 1 to 1 week after surgery)
Phase II (2 week to 5 week after surgery) Precautions Brace ROM: locked in full extension
Weight bearing/ROM: touch down, weight bearing
Range of Motion Exercises
Weight bearing/ROM: Touch down, weight bearing then proceed to as tolerated by patient
Therapeutic Exercises
Week 2-3 : straight leg raises with no weight Week 4-5: straight leg raises with 1 lbs. of weight Should have 90 degrees of flexion
Phase III (6 week to 12 week after surgery) Precautions Brace ROM: discontinue brace when quadriceps strengthening allows, neoprene sleeve with alteral
buttress optional
Range of Motion Exercises
Weight bearing/ROM: full:; should have normal ROM
Therapeutic Exercises
Week 6-7: start stationary bike Weeks 8-12: continue stationary bike Start shuttle jumps at week 12 Treadmill Isotonic leg press Toe press Leg curl Stool scooter
Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction
Phase IV ( 3 moths to 6 months following surgery)
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
Range of Motion Exercises
Brace ROM: Full; no brace Weight bearing: full
Therapeutic Exercises
Initiate progressive jogging program Advance to cutting and sport-specific drills Return to regular sports if cleared by MD
References 1. Rihn,Groff,Harner,Cha.Theacutelydislocatedknee:EvaluaConandManagement.JAmAcadOrthopSurg2004;334-346.2.Levyet.Al.DecisionMakingintheMulCligament-InjuredKnee:Evidence-basedSystemaCcReviewJourofArthroscopicandRelatedSurgeryApril2009430-38.3.Jari,shelbourne.NonoperaCveordelayedsurgicaltreatmentofcombinedcruciateligamentsandmedialsidekneeinjuriesSportsMedArthroscRev2001:185-192.