Knee Ligaments Injuries PDF

Knee Ligaments Injury Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology  ACL Injuries: Mechanisms Non-contact: 80% – Foot planted, valgus/rotational load (cutting, pivoting) – Hyperextension load (step in pot hole) Contact: – Posteriorly directed...

Knee Ligaments Injury Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology  ACL Injuries: Mechanisms Non-contact: 80% – Foot planted, valgus/rotational load (cutting, pivoting) – Hyperextension load (step in pot hole) Contact: – Posteriorly directed blow to anterior femur (hyperextension)  ACL Injury: Signs and Symptoms Severe pain with joint effusion “Popping”, “Giving way”, “Buckling” Continued effusion, recurrent “giving way” with ADLs Quad inhibition Limited motion in flexion and extension + Lachman/Anterior Drawer, pivot-shift Flexed Knee Gait  Differential Diagnoses Meniscal involvement Multiple ligament involvement “Unhappy Triad of O’Donoghue  Important Issues In Post-operative Ligament Rehabilitation Pre-op Considerations Post-op Considerations for Graft Healing Joint Mobility Muscle Function Neuromuscular Control Criterion Based Progression of Function Modifications Related to Graft Type Modifications with Meniscal Repair Modifications for Combined Ligament Procedures  Pre-operative Considerations Pain Effusion Range of motion Muscle function  Pre-operative Considerations Modalities to decrease pain and swelling Resolve the presence of a knee extensor lag prior to surgery Establish 0-120 degrees of ROM  ACL Reconstruction Graft is passed through tunnels drilled in the tibia and femur  Post-operative Considerations Initial graft strength Fixation Healing and maturation of the graft  Initial Graft Strength Central third of patellar 186% of native ACL tendon Semitendinosis 70% of native ACL Gracilis 49% of native ACL Noyes, JBJS. 1984  Histological Considerations of the Graft Initially: the graft is avascular 6 weeks: the graft shows signs of avascular necrosis 8-10 weeks: revascularization begins; mesenchymal cells invade the graft 16 weeks: vascularization is complete; mesenchymal cells proliferate and form collagen What are the implications for return to full activity before 16 weeks post-op?  Histological Considerations of the Graft 1 year post-op: – graft takes on the appearance of a ligament, with dense, oriented collagen bundles – Strength and stiffness of the graft is 30-50% of the native ACL Shino et al., 1991 Histological Considerations of the Graft Graft strength decreases during the period of necrosis and then it increases as it remodels and matures, but it does not reach the original strength of the native ACL  Autograft vs. Allograft 6 months post-op allografts demonstrate: – Greater decrease in their structural properties from the time of implantation – A slower rate of biological incorporation – A prolonged presence of an inflammatory response as compared with autografts Jackson,et al. Am J Sports Med 1991  Implications for Rehab Rehab following allograft reconstruction may need to be less aggressive compared to rehab of an autograft. Little is known about the graft’s ability to withstand loads and strain during healing and maturation.  Joint Mobility: Post-op Full passive extension within 1-2 weeks post- op Full active extension within 3-4 weeks post- op 90 to 100 degrees of flexion within 2-3 weeks post-op Full flexion by 4-6 weeks post-op Joint Motion Techniques Problems with Restoration of Joint Motion Restricted Mobility of Incision/Portal Scars Patellofemoral Entrapment “Cyclops” Lesion Poor Graft Placement Surgeon should be notified if full extension is not achieved by 4 weeks post-op  Restoring Quadriceps Function Quadriceps activation failure a problem with PTB autograft Reduced quad function can lead to patellofemoral arthrofibrosis Restoration of quad function correlates with ADL function in early stages of recovery  Restoring Quadriceps Function Quad Sets Straight Leg Raises With and without Biofeedback Active Knee Extension Against Gravity: No Added Resistance  Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following ACL reconstruction. Journal of Orthopaedic and Sports Physical Therapy. September 2003. 2500hz, 75 burst/sec 10 contractions 10 on/ 50 off Stimulus produces full, sustained quad contraction with evidence of superior patellar glide Special Concerns for Quad Strengthening after Patellar Tendon Autograft Reconstruction Patellar fracture – No aggressive strengthening for 6-8 weeks – Avoid high eccentric loading for 12 to 16 weeks Patellar Tendon Rupture – Persistent extensor lag with SLR at 4 weeks post-op – Inability to perform a SLR 1-2 weeks post-operatively – Surgeon should be notified  Lower Extremity Strengthening Use a combination of open and closed chain exercises Open chain leg extension limited to 90-60 arc of motion to minimize strain on ACL graft. Open chain leg curls limited to 0-90 to avoid active insufficiency and hamstring cramping Use cuff weights initially until patient can tolerate 3 sets of 12 to 15 reps with 10 pounds (4.5 kg). Then progress to leg extension and leg curl machines  Lower Extremity Strengthening Begin leg extension and curl machines about 6 weeks post-op. 1 plate X 3 sets of 10 Progress to: – 1 plate-10 reps – 2 plates – 6-8 reps – 3 plates – 3-5 reps Add 1 plate to each set when tolerates 2 consecutive sessions at above intensity. Arc of Motion = 90 to 60 Leg curl machine progressed in similar fashion  Lower Extremity Strengthening Initiate closed chain exercise with body weight when patient can fully weight bear without crutches. – Double and single leg squats (0-45) – Lateral and forward step ups – Calf raises (up on toes) Progress to leg press when tolerating 3 sets of 15 reps for two consecutive sessions without pain, swelling, instability  Lower Extremity Strengthening Begin leg press with double leg and eventually progress to single leg Begin with 50 to 75% of body weight Use similar progression of plates as described for leg Arc of Motion = 0 to 45 extension  Neuromuscular Control Altered proprioception and lower extremity muscular control has been associated with ACL Injury Unclear if these deficits fully resolve after ACL reconstruction Functional retraining programs for post-op ACL rehab may need to emphasize enhancement of lower extremity neuromuscular control strategies  Progression of Weight Bearing Post-op Brace locked in extension for PWB ambulation with cruthces for 1st week. Unlock brace during ambulation after 1 week. Emphasize heel-toe gait pattern, discourage flexed knee gait pattern Progress to Full weight bearing without crutches when: – No extensor lag during straight leg raise – 90 to 100 degrees of knee flexion – No pain during ambulation  Progress to Straight Running Begin with treadmill running. Must meet following criteria: – All criteria for full weight bearing ambulation – Quad strength = 70% of uninvolved limb Progress to track and road running when tolerating 1 to 2 miles of treadmill running without pain, swelling, instability Criteria for Advancing to Agility Training Track or Road Running for 1 to 2 miles without pain, swelling, instability Quad Strength = 80% of uninvolved limb Begin agility activities with 50% effort, progress to 75% then 100% effort provided no pain, swelling, instability Criteria for Lower Level Sport Specific Skill Training Tolerating all agility training at 100% effort without pain, swellling, or instability Quad function = 85% of uninvolved limb  Progress to Sprinting Tolerating all agility and low level sport specific training. Quad strength 85 to 90% of uninvolved limb Begin with running at 50 and 75% effort, progress to 100% when tolerating these without pain, swelling, instability  Return to Sports Tolerating 100% Sprinting. Begin with opposed practice of sport specific skills (training partner). Return to practice with team when tolerating opposed practice of skills. Return to sport when no difficulty with all practice activities.  Modifications Based On Graft Type Patellar Tendon Autograft – Higher incidence of patellofemoral pain, persistent quad weakness, injury to extensor mechanism – Avoid early heavy eccentric loading of extensor mechanism – Use modifications in quad strengthening to reduce patellofemoral joint stress  Modifications Based On Graft Type Semitendinosis Autograft – Fixation not as strong as bone-tendon-bone procedure. – Disruption of hamstring – Weight-bearing restrictions may be prolonged (4 weeks) – Avoid resisted knee flexion ex for 4-6 weeks – May need to emphasize hamstring stretching to reduce spasm and pain  Modifications Based On Graft Type Allograft (Patellar or Achilles tendon) – Slower rate of biological incorporation, greater decrease in structural properties of graft compared to autograft from time of implantation. – Weight-bearing restrictions may be prolonged – Return to activity will need to be more gradual than autograft procedures Modifications For Concomitant Meniscal Repair Procedure Must protect mensical repair site Weight bearing as tolerated with knee brace locked in extension for first 4 weeks Avoid closed chain ex for first 4 weeks, then limited arc closed chain ex (0-45) Resisted hamstring ex and forceful stretching into flexion should be avoided for first 6 weeks. Modifications for Combined ACL/MCL procedure Must control valgus forces Rehab brace 4-6 weeks Avoid adduction SLR Some patients produce excessive valgus thrust on climbing machines Greater risk of losing motion. Early motion in rehab is critical.  PCL Injury: Mechanisms Hyperflexion Fall on flexed knee with foot PF Hyperextension Mechanisms – Blow to anterior tibia (dashboard) – Step in pot hole  PCL injury: Signs and Symptoms Posterior knee pain Not as much effusion as ACL Flexion beyond 90 may increase pain (non-wt. bearing) 10-20 limitation in knee flexion Difficulty descending stairs, squatting, running Not as much problem with quad inhibition + sag sign, post drawer with reduced palpation of step off  PCL Tests Sag Sign or Chair Test Posterior Drawer with Step-Off Palpation  Differential Diagnosis Patellofemoral Pain: Patients with chronic PCL insufficiency can develop PF pain. Why? Need to rule out posterior-lateral complex involvement  PCL Injury: Non-operative Treatment Early mobility, quad strengthening No flexion beyond 60 with quad strengthening Full wt. bearing at 3 weeks Begin hamstring strengthening at 5 weeks post- injury Agility and Sport Specific Activity at 6-8 weeks Return to full activity at 10-12 weeks Quadriceps Neutral Angle Knee flexion range at which tension in the quadriceps does not create anterior or posterior shear force. Less than 60 produces anterior shear. Greater than 75 produces posterior shear. PCL Reconstruction  PCL Reconstruction: Post-op Rehab Early mobility (0-90), posterior proximal tib should be supported by therapist P-F mobility Quad isometrics and strengthening (0-60) No hamstring contractions 6-8 weeks, Initiate hamstring contractions with wt. bearing activities at 6-8 weeks  PCL Reconstruction: Post-op Rehab Gradual increase in wt. bearing from 2-6 wks (brace locked in ext 4-6 weeks) Initiate full flexion ROM at 6-8 weeks Return to running at 5-6 months, light athletics at 6-7 months, full activity at 9 months.  Combined ACL/PCL Procedure First 8 weeks is similar to PCL post-op rehab guidelines Need to protect PCL graft, limit posterior tibial translation forces Primary complication is loss of knee flexion  Combined ACL/PCL Procedure Full passive extension achieved in 1 week Passive flexion performed with therapist supporting posterior proximal tibia, 0-90 for first 6 weeks Initiate full flexion beginning at 6 weeks, should be achieved by 8-10 weeks  Combined ACL/PCL Procedure WBAT with brace locked in extension for 4-6 weeks. Full weight bearing from 6-8 weeks Quad isometrics and limited arc leg extensions (60-45) Closed chain ex for quads and hamstrings delayed until 6 weeks Avoid open chain resisted hamstring ex  Combined ACL/PCL Procedure Low impact aerobics (walking, cycling, swimming) at 8 weeks Initiate running at 6 months Initiate agility and sport specific skill training at 6-8 months Return to full activity at 8-9 months