Postsurgical Sports Rehab: Knee & Shoulder

101 Pages·2013·1.95 MB·English

by  Darrell Smth

Postsurgical Sports Rehab: Knee & Shoulder-
Module 2: Knee Ligament Injuries-ACL

Course Description:
This course is derived from the textbook by Robert Manske, PT, DPT, MEd, SCS, ATC, LATC,
CSCS, “Postsurgical Orthopedic Sports Rehabilitation Knee & Shoulder” ©2006. The text
focuses specifically on post-surgical guidelines for successful rehabilitation of the knee and
shoulder for sports patients. Content covers basic concepts related to soft tissue healing, as
well as core concepts in sports medicine rehabilitation, all of which lay the groundwork for
discussions of specific protocols. Detailed descriptions of the latest post-surgical procedures
for various knee and shoulder pathologies equip professionals with essential knowledge
needed to recommend the most effective treatment plans.

Module 2: Knee Ligament Injuries-ACL covers chapters 8 through 12 and 17.

Chapter 8: Reconstruction Using Ipsilateral Patellar Tendon Autograft
Chapter 9: Rehabilitation after Anterior Cruciate Ligament Reconstruction with a
Contralateral Patellar Tendon Graft: Philosophy, Protocol, and Addressing
Problems
Chapter 10: Anterior Cruciate Ligament Reconstruction Using the Hamstring-Gracilis Tendon
Autograft
Chapter 11: Anterior Cruciate Ligament Reconstruction with Allograft
Chapter 12: Complications in Anterior Cruciate Ligament Reconstruction
Chapter 17: Preventing Injury to the Anterior Cruciate Ligament

Methods of Instruction:
Online course available via internet

Target Audience:
Physical Therapists, Physical Therapy Assistants, Occupational Therapists, Occupational
Therapy Assistants, Athletic Trainers, and Certified Strength and Conditioning Specialists

Educational Level:
Intermediate

Prerequisites:
None

Course Goals and Objectives:
At the completion of this course, participants should be able to:
1. Identify the key events in the historical evolution of postsurgical rehabilitation
2. Understand why patient profiling is important in rehabilitation
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3. List ways to reestablish normal range of motion postsurgically
4. Recognize the clinical pathways for ACL reconstruction and identify their phases
5. Identify pathways to assist in muscle reeducation
6. Identify phase I, II, III and IV rehabilitation protocols following a contralateral patellar
tendon graft
7. List rehabilitation phases and subsequent goals
8. Identify potential problems/complications
9. Identify a program to alleviate anterior knee pain postsurgically
10. Recognize the most commonly used autografts
11. List advantages and disadvantages of a hamstring-gracilis tendon autograft
12. Understand the preferred method of hamstring anterior cruciate ligament
reconstruction
13. Identify the phases in postoperative rehabilitation of the hamstring-gracilis tendon
autograft
14. Define allograft
15. Identify the advantages and disadvantages of an allograft
16. List preoperative ACL management considerations
17. List modalities and explain their effectiveness postsurgically
18. Identify considerations with preoperative graft selection
19. Give an overview of the graft procedure
20. List terms to describe loss of motion
21. List the signs and symptoms of DVT
22. Identify anatomical structures of the ACL and PCL
23. Identify and differentiate between extrinsic and intrinsic risks for ligament injury
24. Recognize the Dynamic Neuromuscular Analysis Training Protocol

Criteria for Obtaining Continuing Education Credits:
A score of 70% or greater on the written post-test

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DIRECTIONS FOR COMPLETING
THE COURSE:

1. This course is offered in conjunction with and with written permission
of Elsevier Science Publishing.
2. Review the goals and objectives for the module.
3. Review the course material.
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answers as you go along and then transfer them to the actual test. A
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“My Account”.
5. After reading the course material, when you are ready to take the
test, go back to your “My Account” and click on “View/Take Test”.
6. A grade of 70% or higher on the test is considered passing. If you
have not scored 70% or higher, this indicates that the material was
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After the survey, your certificate of completion will immediately
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[email protected] and we will forward it on to the author.
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405-974-0164.

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SEC TION II
Knee Ligament Injuries
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CHAPTER 8
Reconstruction Using Ipsilateral Patellar
Tendon Autograft
Robert E. Mangine, MEd, PT, ATC
Stephen J. Minning, MPT
Marsha Eifert-Mangine, EdD(c), PT, ATC
W. Bays Gibson, MPT
Angelo J. Colosimo, MD
CHAPTER OUTLINE
Historical Evolution of Postsurgical
Rehabilitation
Patient Profiling
Program Objectives
Reestablishing Range of Motion
Weight Bearing
Muscle Reeducation
Muscle Function Phase II
Return to Activity
Summary
159
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160 SECTION II: KNEE LIGAMENT INJURIES
NO STRUCTURE IN SPORTS MEDICINE strated that intraarticular graft models did not follow
literature has received as much attention as the anterior cruci- traditional healing models, but required a prolonged period
ate ligament (ACL). From the first attempt to surgically for full maturation; this development became known as the
correct the anatomic integrity of the ligament in 1898 by ligamentization process.7,10 Rehabilitation in this era was based
Mayo Robards to today, the fascination with its function is on the slow response of the graft to revascularize and form
precedent setting.1 Rehabilitation protocols for the ACL mature collagen. The result of these studies translated into
patient have evolved in the literature, encompassing prolonged periods of casting, beginning initially for 12 weeks
programs from both a conservative nature as well as more and then dwindling to 6 weeks. Weight bearing also required
accelerated pathways.2,3 As Frank4 states, “It is generally an extended period of restriction for upward of 14 weeks. The
acknowledged that rehabilitation is critical to the success of long-term sequelae of this process resulted in significant
the treatment of the anterior cruciate ligament.”The current complications and led to new models of research to improve
trend in rehabilitation is to establish pathways according to rehabilitation outcomes and decrease morbidity to the joint.
evidence-based principles; these attempt to provide us with In the 1980s the trend changed yet again, this time doing
a defined pathway. However, patient variability leads to away with casting entirely, while incorporating early continu-
failure because outlying patient models go unrecognized; this ous passive motion. In the 1970s and 1980s a great deal of
increases our failure rate secondary to arthrofibrosis versus work was performed that analyzed the effect of motion on
redevelopment of joint laxity. the traumatized joint without deleterious side effects.8,11-15
The evolution of the ACL in terms of the existing methods The intent of this chapter is to describe a protocol designed
for surgical intervention has taken many twistsand turns in to account for the wide variance of ACL graft selection
the last quarter century. Although the initial trial of surgical because there is no conventional standard procedure. Attempts
intervention is over 100 years old, anatomic and mechanical to define the ideal graft over the last 20 years have evolved
studies since the 1970s have refined the procedure to to the current trend, which supplies the surgeon with several
significantly improve the outcome.5-7 Simultaneous with the options. The three most popular methods involve the patellar
advancement of surgical technique was the scientific rationale tendon, the hamstring, or a variety of allograft tissues16-18
of the rehabilitation pathway. Because of the wide variance (Figure 8-1). When working with past patients, the senior
in surgical procedures, the rehabilitation specialist is required author has had the opportunity to rehabilitate patients with
to manipulate protocols to match the given surgery. These the aforementioned grafts, as well as using Gore-Tex, carbon-
concepts fueled the development of a model for protocol fi ber, and ligament augmentation devices. In most cases,
design based on evaluation methods; this has produced reha- long-term outcome did not demonstrate an improved joint
bilitation techniques resulting in suffi cient latitude to adjust stability or changes in functional outcomes, which has led to
for patient variance. the current graft choices.19-21
In 1990 the senior author of this chapter undertook a Several recent studies comparing patellar tendon and
process to identify key elements of postsurgical ACL reha- hamstring grafts show no significant difference in long-term
bilitation and to strengthen the techniquesused by providing functional outcome and minimal biologic differences.18,19
a scientific foundation.2,8,9 The development of a consensus However, it is again important to note that the key variable
panel composed of rehabilitation specialists explored the
various facets of the rehabilitationprocess and provided evi-
dence. The effort culminated in the published works identi-
fied as evaluation-based rehabilitation. This chapter both
explores and outlines a postsurgical management algorithm
based on this format, which heightens the reader’s success in
this patient population. The therapist must evaluate the fol-
lowing areas: joint mechanics, surgical techniques, soft tissue
response, muscle function, articular cartilage function, joint
neurology, and psychologic factors.
HISTORICAL EVOLUTION OF
POSTSURGICAL REHABILITATION
Just as surgicalintervention has evolved, so too has the reha-
bilitation process. In the 1960s most postsurgical programs
were designed with the foundation based on classic healing
models, identifying initial healing in a 3- to 4-week period.
ACL patients were placed in a cast for a short-term period,
after which the patients were pushed to resume normal activ-
ity in an 8-to 10-week period. Studies in the 1970s demon- Figure 8-1: ACL graft placement.
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Chapter 8: ReconstructionUsing Ipsilateral Patellar Tendon Autograft 161
is the patient, which requires the clinician to profile the • Reestablish joint range of motion (ROM) to avoid dele-
patient’s rehabilitative capability, and that time frame–based terious motion loss (primary objective)
protocols may enhance the risk of biologic failure while still • Regulate postsurgical pain to avoid influence on ROM
permitting functional activities.
and muscle contraction
• Reduce postsurgical hemarthrosis to avoid muscle shut-
PATIENT PROFILING down and arthrofibrosis
Outcome success is dependent on the understanding that • Advance weight bearing and development of normal gait
patients have intrinsic and extrinsic variable factors that mechanics without affecting the biologic graft
influence the level of activity to which they return. Intrinsic • Establish early exercise sequences to recondition the
factors include but are not limited to tissue type, muscle type, muscular system while minimizing risk to the biologic
potential for excessive scar formation, general medical well- graft
being, osseous alignment, lower extremity mechanics, and • Retrain the mechanoreceptor system through proprio-
compliance with the program. Extrinsic variables include but
ception program
are not limited to social habits, use of nicotine products,
• Establish subjective and objective data to identify devia-
environmental situations, and economic factors. Rehabilita-
tions from norm to minimize influence on outcome
tion requires the therapist to address many of these issues,
but patient morphologic type is critical.2,8 • Establish a functional algorithm to verify functional
A select group of patients demonstrate hyperelasticity of progression
joint motion, which results in the clinician having to factor • Maintain progressive functional return to activity and
in an altered collagen tissue variable in the rehabilitation sport
pathway (Figure 8-2). Postsurgically these patients have the
This chapter discusses each of these areas of the rehabili-
potential to lay down poor collagen tissue that may compro-
tation process and integrates acceptable exercises or proce-
mise the biologic graft. Hypoelastic patients demonstrate
dures that minimize the risk of biologic failure of the graft.
tight joint arthrokinematics, and postsurgically may have a
tendency to develop arthrofibrosis, which must be recognized
early on to avoid motion complications. Normal elasticity, REESTABLISHING RANGE OF MOTION
as demonstrated in the majority of patients, best fits the
The use of continuous passive motion (CPM) after surgical
traditional postsurgical time frame–based rehabilitation
procedures arose from a combination of animal and human
pathways.
studies in the late 1970s and early 1980s.11-14 The primary
focus of these studies was to assess forces applied by early
PROGRAM OBJECTIVES motion on the biologic graft and surrounding tissues. This
was a 180-degree shift in postsurgical management. The
The key is to identify the rehabilitation components that
rationale for the changing philosophy was the negative mor-
the therapist must address in order to restore the ability to
bidity of the joint associated with prolonged immobilization.
perform activities of daily living, and then titrate the exercise
Early studies were undertaken to determine if early use of
program to higher levels of activity until the patient achieves
CPM would provide a positive influence on graft revascu-
an optimal level of function. The therapist considers a staged
larization and collagen regeneration, but findings demon-
approach and must assess the interaction of how one compo-
strated no cause-and-effect relationship. The positive findings
nent is infl uenced by another. The program includes the fol-
identifi ed with these studies included the following:
lowing components:
• Earlier redevelopment of ROM
• Decreased postsurgical pain
• Decreased joint hemarthrosis
• Decreased scar tissue
• Maintaining viability of the articular cartilage in the
joint
Currently, we continue to recommend the use of a CPM
machine (Figure 8-3) immediately after surgery for 10 to 12
hours per day until the unit is at maximum range. Most
patients are able to tolerate gradual increase in motion with
discontinuing the unit by 7 to 10 days. On average, the
patients adjust their motion 10 to 15 degrees per day. If CPM
Figure 8-2: Patient demonstrating hyperelasticity with is not desired, self-ranging exercise can be performed using
hyperextension at the elbow and wrist. the contralateral extremity on an hourly basis. Clinically, the
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162 SECTION II: KNEE LIGAMENT INJURIES
Force with leg extension
250
200
150
s.
b
L
100
50
0
0˚ 10˚ 20˚ 30˚ 40˚ 50˚ 60˚ 70˚ 80˚ 90˚
Knee flexion angle
ACL force ACL force
Quadriceps force
5 lbs. on foot No weight on foot
Figure 8-3: Continuous passive motion machine. Figure 8-4: Forces applied onACL during open kinetic chain
extension.
use of a Biodex extremity system (Biodex Medical Systems
Inc., Shirley, NY) either as a warm-up before the exercise
sessions or in the cool-down phase is benefi cial.
Active-assistive ROM and active ROM are also permitted
by the patient in the early phase to stimulate extensor mecha-
nism training. Although some data suggest that open chain
exercise movement may stress the healing tendon, no direct
study has identified this as problematic22,23 (Figure 8-4).
Two key side effects after surgery that delay the redevelop-
ment of motion in the immediate phase are pain and joint
hemarthrosis. To maximize pain relief in the initial 24 hours,
the patient is provided not only narcotics but also a femoral
nerve block for a longer period of pain suppression. The use
of a nonsteroidal antiinflammatory drug (NSAID) may be
recommended to control the postsurgical hemarthrosis. This
intervention may also have a secondary effect on the joint
Figure 8-5: Game Ready (CoolSystemsInc., Berkeley, CA)
hemarthrosis. With the trend in endoscopic procedure for
system of vasopneumatic cryotherapy.
ACL surgery, there is generally a lesser amount of hemar-
throsis. Minimizing joint hemarthrosis has led to the discon-
tinued use of a joint hemovac, which can cause further
inhibition to the extensor mechanism.
The second influence on ROM is joint pressure, which is
cold device. This is applied for the traditional 20 to 30
created by the hemarthrosis. This pressure within the joint
minutes because it simultaneously generates pressure, allow-
is applied to the capsular mechanoreceptors, resulting in a
ing a deeper penetration.
heightened pain level, exhibiting a limiting influence.24-26
Protocols that have evolved in the last 15 years have placed
Although CPM may aid in the joint effusion reabsorption,
a reduced emphasis on regaining ROM, instead concentrat-
as well as NSAIDs, standard cryotherapy is a must. Aggres-
ing on accelerating weight bearing and return to function. In
sive use of ice, elevation, and compression is essential in
these protocols the patients are placed in a long leg immobi-
controlling joint swelling.27,28 Several modalities have been
lizer and permitted full weight bearing. Little mention is
developed that, when applied postsurgically, appear to be
made of the need to regain ROM. Although it is eventually
benefi cial in controlling the swelling. Immediately after
regained, two questions arise:
surgery we have recommended that the patient use a Game
• How long does it take to regain ROM?
Ready system (CoolSystems Inc., Berkeley, CA) (Figure 8-5)
on a continuous basis. The patient can wear some of these • Is the potential for an arthrofi brotic complication
devices even while in the CPM machine. Clinically, the increased?
utilization of the Game Ready system (see Figure 8-5) has Multiple studies have described motion complication rates
proven to be an added benefit by way of applying a pneumatic ranging from 9% to 74%.13,28-35 The implementation of an
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Chapter 8: ReconstructionUsing Ipsilateral Patellar Tendon Autograft 163
immediate motion program minimizes the risk for compensation beginning on day 1. Concurrently, the patient
this unwarranted side effect. If the patient has not regained is placed in a gait-training program to emphasize the proper
full ROM by 3 weeks, the need to initiatea more aggressive positions and strength.
program is essential. The senior author has developed an To progress the weight-bearing program, it is key for the
algorithm that was published in 1992 dealing with this clinician to assess the factors that influence the gait pattern
patient population.32Changes can occur in the periarticular and the biologic graft:
tissues, decreasing ROM. The structures most involved com- • Motion must progress as weight bearing advances but is
monly include the infrapatellar fat pad, which can result in not to be compromised at the expense of ROM.
a patella infra; the posterior capsule; and the medial and
lateral retinaculum of the patellar capsule.29-32 • Extensor strength is able to control 0-degree ROM
The use of manual mobilization techniques may be mini- without extensor lag.
mized if an expedited motion program is implemented. • Joint effusion is resolving as demonstrated by objective
Because the primary intervention is motion in this phase, the measures.
constant cycling of the joint capsule provides self-stress • Joint arthrometer evaluation is not significantly changed
forces, maintaining capsular elasticityand self-mobilization. on a test-retest basis.
In this initial phase the primary concern centers on the • Pain control has been achieved to avoid sympathetically
patella and its normal superior mechanics. In the 1980s it
maintained pain patterns.
was not uncommon to have a patient develop a patella infra
position with an incident rate of 11% to 15%. A patella infra Joint laxity evaluation has now become established as a
is a distally translated patella, which leads to an extensor lag. standard measure to objectively assess the biologic graft. The
Tambrello and colleagues33 described abnormal inferior dis- use of joint arthrometry as part of the comprehensive evalu-
placement of the patella in a population of patellar tendon– ation process provides information that aids and integrates
reconstructed patients, resulting in a mechanical block.The the findings to the rehabilitation pathway.36 The KT-1000
conclusion was that early patellar glides and extensor mecha- arthrometry system (MEDmetric Corporation, San Diego,
nism reeducation were needed. Wojtys and colleagues34 CA) (Figure 8-6) is designed to measure joint translation, in
described altered collagen alignment in patients who devel- one degree of freedom. This evaluation defines the ligament’s
oped a patella infra, which was not reversible. The patients ability to restrain forces by an objective analysis. For
in each of these studies also had a high percentage of patel- maximum reliability several factors must be taken into con-
lofemoral complaints. Therefore our program emphasizes a sideration. The patient must be relaxed, without muscle
clinical and self-directed program of patellar glides for a guarding of either the quadriceps or hamstrings. Accurate
minimum of six cycles per day. Table 8-1 summarizes the placement of the arthrometer is critical, as wellas maintain-
first weeks of the postsurgical phases and flows through the ing neutral positioning of the tibia. Consistent force must be
ROM procedures. applied and the test performed for three trials to avoid patient
accommodations.
Force application by the clinician is 20 to 30 pounds, and
WEIGHT BEARING the total anteroposterior translation should be compared
The second goal in the early rehabilitation period is the titra-
tion of the weight-bearing process. Again, there is a range of
weight-bearing progression in current protocols, some of
which advocate immediate full weight bearing in a locked
extension brace, whereas others advocate the use of crutches
for up to 4 to 5 weeks. The concept of immediate full weight
bearing has prevailed with the thought that it facilitates faster
extensor mechanism return. There appear to be no data sup-
porting this claim, and in our experience the patient accom-
modates for a poor extensor mechanism by ambulating in a
leg vault gait pattern.3,32 Allowing an asymmetric gait pattern
secondary to extensor mechanism weakness leads to the
potential development of a recurvatum midstance position.
This may result in an unwarranted side effect of a prolonged
altered gait pattern at midstance caused by poor extensor
eccentric control as the knee attempts to go into fl exion of
15 to 20 degrees, which is unable to be achieved. Our
approach has evolved to allow immediate partial weight
bearing in either a protective ROM device or no brace at all. Figure 8-6: KT-1000 arthrometry system (MEDmetric
From the initial phase, gait mechanics are retrained without Corporation, San Diego, CA) for testing ligamentous laxity.
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1
6
TABLE 8-1 4
S
Clinical Pathway for Postoperative Management of ACL Reconstruction EC
T
I
O
WHEN PHASE 1 PHASE 2 PHASE 3 PHASE 4 N

MAXIMAL MODERATE MINIMAL RETURN TO ACTIVITY II
:
PROTECTION PROTECTION PROTECTION 6 MONTHS AND LATER K
N
DAY 1 TO WEEK 4 WEEKS 5 TO 10 WEEKS 11 TO 24 E
E

L
Patient presentation • Postoperative day 1–3 • Pain controlled • No instability • No instability I
G
• Postoperative • Joint swelling • No swelling • Muscle function 70% A
M
hemarthrosis controlled • No pain of noninvolved
E
• Postoperative pain • No increased joint • Good to normal • No symptoms of N
T
• Decreased ROM instability strength (MMT) instability, pain, or I
N
• Decreased voluntary • Full or near-full ROM • Unrestricted ADL swelling in the previous J
U
quadriceps contraction • Fair-plus to good function phase R
• Dependent ambulation muscle strength (MMT) IE
S
• Postoperative brace • Muscular control of
(may or may not have) joint
• Independent
ambulation
Key evaluation • Pain scale • Pain scale • Ligament stability— • Full clinical
procedures • Hemarthrosis—girth • Effusion—girth joint arthrometer examination
• Ligament stability— • Ligament stability— • Muscle strength • Ligament stability
joint arthrometer (day 7- joint arthrometer • Functional status • Muscle strength
14) • ROM • Functional status
• ROM • Patellar mobility
• Patellar mobility • Muscle strength
• Muscle control • Functional status
• Functional status
Treatment intervention Early: Days 1-14 Early: Weeks 5-6 • Continue LE flexibility • Continue as Phase 3,
• Protective bracing, ice, • Continue isometric • Advance PRE advance as appropriate
compression, elevation exercise, multiple angles strengthening • Advance agility drills
(PRICE) • Advance PRE • Advance closed chain • Advance running drills
• Ambulation training: program: quadriceps, exercise • Implement drills
crutches—WB 25%- hamstrings, • Advance specific to sport or
50% gastrocnemius, hips proprioceptive training occupation
• PROM/AAROM • Advance closed chain • Agility drills specific • Determine the need for
(range-limiting braces strengthening to skill protective bracing before
may or may not be used • LE flexibility program • Advance endurance return to sport or work
during this phase) • Advance trunk stability training
• Patellar mobilization, • Endurance training: • Isokinetic training (if
grades I and II bike, pool, ski machine, desired)
etc.
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