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The Complex Cases- Rehabilitation

of Multi-Ligament Knee

Reconstruction

Tyler Opitz, DPT, SCS

March 4th, 2017

Objectives

• Understand basic healing times and to be able to prioritize pathology within rehabilitation continuum.

• Gain knowledge of precautions and biomechanics behind specific tissue restrictions and function with rehab tasks.

• Utilize rehabilitation principles incorporating criteria based rehabilitation competently and appropriately.

• Discuss patient outcomes, expectations, and determine return to play/sport criteria

Multi-Ligament Knee Injury

• Defined as injury to 2 or more of the 4 major ligaments in the knee (Dywer et al., 2012)

• Multi-ligament knee injuries are often associated with knee dislocations

– Knee dislocation 0.02% of all orthopaedic injuries (Skendzel et al., 2012)

– Invariably results in 3 of 4 knee ligament injury (Fanelliet al., 2005)

• 11% of all ligamentous injuries (Bispo et al., 2008)

• 98.2% males (Bispo et al., 2008)

Knee Dislocation classification

• Classification of knee dislocation is primarily based on the direction the tibia dislocates relative to the femur.9,10 This results in 5 different categories: anterior, posterior, lateral, medial, or rotatory. The anterior-medial and lateral, posterior-medial, and lateral dislocations are classified as “rotatory” dislocation. Other factors to be considered include whether (1) the injury is open or closed, (2) the injury was caused by “high-energy” or “low-energy” trauma, (3) the knee is completely dislocated or subluxated, and (4) there is neurovascular involvement. Furthermore, one should be acutely conscious of the fact that a complete dislocation may spontaneously reduce, and any tripleligament knee injury constitutes a frank dislocation.

• Fanelli et al., 2005

• KD-I- Single cruciate torn (ACL or PCL)

• KD-II- Bicruciate disruption, MCL/LCL intact

• KD-III- Bicruciate disruption, torn MCL or LCL/PLC

• KD-IV- ACL, PCL, MCL, LCL torn

• KD-V- All ligaments torn with fracture

Knee Anatomy

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Knee AnatomyMOI

MOI Complications

• Injuries to Popliteal

artery, common fibular

nerve. (Mills et al.,

2004)

– Popliteal injury 4.8%-

65% of time

• High energy injuries

increased incidence

– Fibular nerve injury 20%

of time (Robertson et al.,

2006)

Regional Interdependence

• Concept of Regional Interdependence is the relationship of adjacent and distant segments have on motion and stability of body parts of seemingly unrelated sections that can contribute to pathology or have an effect on one another. (Wannier et al., 2007)

• New definition:

• Does not limit to musculoskeletal system– “the concept that a

patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s).” (Sueki et al., 2013)

Full and adjacent body segment

assessment

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Rehabilitation Considerations

1. Diagnosis/pathology/surgical procedure

2. Severity of tissue damage/invasiveness1. Involved structures- nerve, vascular supply

2. Comorbidities with injury (compartment syndrome)

3. Pain level

4. Duration since injury

5. Tissue healing & quality

6. Patient stage of rehab

7. Current level of function and movement quality

8. Patient Goals

9. Outcomes expectations

10. Psychosocial factors

Criteria Based Rehab (CBR)

• Progression NOT based on time out from surgery but ability to perform progressive functional tasks

– Walking without crutches not based on being 4 weeks post op:

• Full quad and hip muscle activation

• Walk without deviations with 2 crutches -> 1 crutch with and without brace.

• Then can walk without brace and crutches

• No sense in allowing patient to develop bad movement patterns and habits because they are not ready

• Functional tasks are a byproduct of doing basic movement patterns properly, NOT a product of TIME!!!

C.B.R. Principles• *PRECAUTIONS GUIDE PROGRESSIONS*

• Once tissue is at appropriate healing level for activity…• Ability to perform PROGRESSIVE FUNCTIONAL rehab tasks in

sequence determines progression NOT given amount of weeks from surgery

• Example): Just because they are 12 weeks out DOES NOTmean they should advance to plyometrics if they can’t perform a basic squat– Walking without crutches not based on being 4 weeks post op:

• Full quad and hip muscle activation

• Walk without deviations with 2 crutches -> 1 crutch with and without brace.

• Then can walk without brace and crutches

• Functional tasks are a byproduct of doing basic movement patterns properly, NOT a product of TIME!!!

Grzybowski et al., 2015, Wahoff et al., 2014

Rehabilitation pyramid

Performance

Functional Movement &

Strength

Foundational Movement & Strength

ROM

• PROM

• AROM

Basic Strength

• Against gravity strength

• 5/5 MMT

Function

• Normal Reciprocal Gait

• Step pattern- lumbopelvic dissociation

• Positional activity Tolerance- Quadruped, SL stance, hip hinge

• Static Balance- kneeling, Standing

Dynamic

• Activities against external resistance

• Combined body movements

• Reactive demands- vary surfaces, vary resistance mid activity, change positions within positions

• Integration of prior activity demands- control environment (plyometrics)

Performance

• Return to sport activities- advanced plyometrics

• High threshold activities

• Full return to play- usually not performed in PT**

C.B.R.Rehabilitation Outline

• Phase I- Protective phase• Manage weight bearing

• Pain management

• Control swelling

• Basic ROM

• Phase II- Advanced protective phase• Basic strength

• Progress ROM

• Minimize atrophy

• Initiate WB and light proprioception

• Phase III- Intermediate phase/ Progressive strengthening phase• Dynamic flexibility

• Functional movement correction

• Combine functional strength/stability

• Phase IV- Advanced Intermediate phase• Dynamic strength/

proprioception

• Functional stability

• Phase V- Controlled Activity phase• Initiate plyometrics

• Initiate running if appropriate

• Initiate components of sport specific activities

• Phase VI- Return to activity phase play• Performance

• RTS

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Phase I- Protective phase• Muscular activation

– Quad sets

– Glut sets

– NMES

– PCL involved-avoid hamstring activation

• Establish independent performance of HEP– Pain management strategies

– Use of pain pump

– Use of home NMES

• Weight bearing– Surgical dependent

• Manage expectations– Rehab progression

– Outcomes

– Goals

– Sensations in knee

• Minimize pain– Patellar mobilizations

– Calf stretching/Hamstring stretching

• Minimize swelling– Modalities

– Compression

– elevation

• ROM– to protocol guidelines

– PCL- don’t force extension• posterior medial bundle is taught

and ALB is lax (reversed in 90 degrees knee flexion)

• ROM- 10-70 degrees initially

• Limit atrophy– SLR

– 4-way ankle

– Multi-angle isometrics

– Peanut bridges*

Maximal Protection Phase

• NWB x 5-6 weeks

• Knee extended locked at 0° x 3-5 weeks (Fanelli et al., 2005)

• 90 degree knee flexion desirable by week 6

• Minimize compressive, distraction, and shear loads on repaired tissue

• Surgery dependent* (Edson et al., 2013)

Criteria to progress to Phase II

• Perform active quad set with appropriate

VMO activation and SLR without lag

• ROM to appropriate protocol guidelines

• Pain decreased by 50% at rest from highest

rating in phase I

• Tissue healing appropriate for progression to

Phase II

• Independent with initial HEP

Phase II- Advanced Protective Phase

• Achieve full muscle activation at full knee extension– Quad activation at knee

extension with SLR

• Continue use of brace

• Achieve full PROM by end of phase II – or to protocol guidelines

• Initiate weight bearing in brace– Weight shifts

– TKE

• Restore normal gait kinematics with/without AD– Expect soreness to increase

with increased weight bearing and activities*****

• Initiate closed chain muscle activation– Mini squat/Hip hinge

– Mini band walks in/out of brace

– Shuttle/leg press- 0-(45-75)

• Muscle activation at multiple angles– Static loads

– SLR from elevated position

• Minimize pain, atrophy, and swelling

• Initiate Aquatic Therapy if available

• Continue to provide motivation and support to patient in rehab process

Criteria for Advancing to Phase III

• Ambulate without deviations and AD

• Against gravity strength in all directions

• Ability to perform SL stance on ground eyes

open for 10 seconds (in or out of brace)

• Swelling decreased

– brush test to 2/3 or less

– Dec by 1-2 cm in swelling at joint line

• PROM to within 90% of full (PCL the exception)

Phase III- Intermediate Phase

• Discontinue post surgical brace-– fit for functional brace

• MD discretion WITH rehab suggestions!!

• Achieve full A/PROM

• Progress functional strengthening activities– Open/closed chain

– Concentric vs eccentric

– Double leg before single

– Body weight versus loaded

• Advance depth of knee flexion exercises– EMPHASIZE ECCENTRICS**

• Advance aquatic therapy

• Reinforce form over function, control over speed– Ex.) Proper squat form before

doing cleans

• Progress unilateral balance activities– Gradually integrate UE

involvement

– Integrate unstable surfaces

• Initiate kneeling and quadruped activities– PCL exception

– May initiate earlier depending on surgery

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Criteria to progress to Phase IV

• Perform DL squat without deviations

• SL squat to 30 degrees no deviations

• Full functional AROM if PCL involved

• Pass step and hold

• Ability to perform controlled step down no

deviations

Phase IV- Advanced Intermediate

• Maintain full AROM

• Initiate Plyometrics– Rapid response -> jump rope

-> 2’’ runs

– Shuttle jumps

• Dynamic strengthening phase– Russian curls

– Sled push

– Sport cord

• Perform baseline functional testing

• Progress combined body movements– Chops/lifts

– TGU

– Plyo-ball program

• Advanced aquatic therapy– Aquatic running

– Advance plyometrics• Emphasize deceleration

• Initiate faster speed open chain/low joint force closed chain movements– Peanut kicks

– Rapid bridges

– Standing leg cycles

Criteria to progress to Phase V

• Involved leg strength >75% of uninvolved limb

• Tolerated plyometrics without pain or

instability

• Sufficient core strength- Plank 45 seconds no

deviations (Nessler, 2013)

Phase V- Controlled activity phase

• Initiate interval running

program

• Initiate advanced

plyometrics

– Speed ladder drills

– DL jump -> land elevated

– Drop jump catches

• Progress multiplane

deceleration tasks

Walk to Jog Progression Criteria to progress to Phase VI

• Near symmetrical limb girth

• No swelling or pain with advanced plyometrics

• Pass 2 of 3 Y-balance directions

• No 0/1 asymmetries on FMS

– “2/3 asymmetry is NOT grounds for limitation of activity progression”- Gray Cook, Founder of FMS

• SFMA- no dysfunctional or functional painful(s)

• Biodex within 20-25% side to side strength

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Phase VI- Return to

Activity/Performance

• Sport specific drills

• Power development

• Speed development

• Enhancing activity ability emphasis

• Rehab usually not significant part of this phase

Return to Play Criteria• Full ROM pain free

• Full pain free strength

• Passing subjective questionnaire on ability (KOS, IKDC, etc)

• Passing Functional testing measures– SFMA, Y-balance, FMS, Biodex, Hop testing

• Successful completion of functional sport movement assessment(s)– Drop jump catches, single leg lands, change of direction

assessment

• Completion of interval running program– Linear and multi-direction

– Agility drills- Shuttle, T-drill, 3 cone, etc.

• Pain free participation in interval practice and full practice programs

• Participate in simulated game without setbacks

Return to Play Criteria

• Criteria:

– Wait >9 Months

– Within 10% side to side of uninjured limb strength

and hop test scores

– Agility T-test in under 11 seconds

– Performing sports specific conditioning/training

• = significantly reduced risk of re-injury upon RTS

(Grindem et al., 2016, Krytsis et al., 2016)

Y-Balance

• Left to right: anterior Posteriormedial, posterior lateral

• Within 4 cm anteriorly, 6 cm posteriorly

• Composite >85-95% depending on sport

Selective Functional Movement

Assessment (SFMA)• Head-toe movement

assessment

• 4 Categories• FN- Functional Non-painful

• DN- Dysfunctional Non-painful

• FP-Functional Painful

• DP- Dysfunctional Painful

• Assess motor control vs

restriction limitation

Functional Movement Screen

• 7 movements

• Scored 0-3

• Return to Sport

• No 0’s or 1’s

• No dysfunctional

asymmetries

• 14< total score

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Hop Testing

• Single leg hip

• Triple hop

• Cross-over hop

• >95% side<->side distance (Reid

et al., 2007)

• Greater distance -> increased

risk for injury (Brumitt et al., 2013)

Rehab at Andrews Institute… With

Andrews

• ALL YOU NEED TO KNOW…

• ALL YOU NEED TO DO…

Dynamic Movement Assessment Dynamic Movement Assessment

Outcomes

• Not as consistent as single ligament injuries (aaos.org, 2016)

• Restoration of ligamentous stability in 44% of patients; 20% had 5-10 mm residual laxity

• 44% had degenerative changes a time of surgery (Wang et al., 2002).

• 100% negative Lachman test, 66% negative posterior drawer, 44% had grade I posterior drawer. (Ohkoshiet al., 2002)– Fanelli et al., 2005 found 94%

negative Lachman, 46% negative posterior drawer.

• 0-139° PROM 100% of knees with 2 stage reconstruction (3 months apart PCL then ACL) for PCL, ACL/MCL or PLC. (Ohkoshiet al., 2002)

Outcomes

• 23-25% of subjects (mean age 16) sustained 2nd ACL injury within 12 months upon RTS following ACLR. (Paterno et al., 2014– 29% of patients under age of

20 sustained 2nd ACL injury within 3 years (Webster et al., 2014)

– 87% female (paterno et al., 2014)

– 75% sustained 2nd on contralateral knee.

– Young athletes that RTS are 15x more likely to have 2nd ACL injury (Paterno et al., 2012)

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Outcomes

• 90% objective stability

success rate (Moulton

et al, 2016)

Rehab Principles

• Restore functional ROM, mobility, and strength

• Don’t forget the THORACIC SPINE

• Progressively overload tissues

• Static -> Dynamic

• Ensure dynamic movements are performed with

proper joint alignment prior to progressing exercise.

• TREAT IMPAIRMENTS (WHOLE BODY)!!!!

• We treat patients NOT protocols!!!!

THANK YOU & GO

DAWGS!!!