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The Complex Cases- Rehabilitation

of Multi-Ligament Knee

Reconstruction & Meniscus

Pathology

Tyler Opitz, DPT, SCS

March 3rd, 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 (Fanelli et al., 2005)

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

• 98.2% males (Bispo et al., 2008)

Knee Dislocation classification

Factors• 5 Categroies of dislocation- Direction

oriented:– Anterior

– Posterior

– Lateral

– Medial

– Rotatory- Anterior-medial & -Lateral, Posterior-medial & lateral

• Open vs closed

• High energy vs low energy

• Dislocated vs subluxed– Complete dislocation may spontaneously

reduce

– Any triligamentous injury constitutes dislocation

• Neurovascular involvement– Fanelli et al., 2005

Classifications

• 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)

Complications

• DVT

• Compartment syndrome

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)

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Full and adjacent body segment

assessmentRehabilitation Considerations

1. Diagnosis/pathology/surgical procedure

2. Severity of tissue damage/invasiveness1. Involved structures- Ligaments, Menisci, 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 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

Car Analogy

• If you have a flat tire, is

it because the tire is

bad or is it because the

alignment was off

and/or the shocks bad

causing the tired to

have abnormal wear.

• Does fixing the tire

solve the problem?

• Be sure to fix the

alignment and treat the

shocks.

Knee Symmetry Model

• Goal is to restore limb symmetry between limbs

• Utilizes subjective and objective measures to

determine when successful rehab has concluded. (Biggs et al., 2009, Kinzer et al., 2010)

– Measures Include:

• ROM

• Strength

• Stability

• Girth

• Subjective questionnaire scores

Rehab Concepts

• Increasing depth of squat increases SHEAR forces on knee joint

• Increased knee extension in closed chain increases COMPRESSIVE loads on knee joint.

• Protect lateral meniscus as has increased translation with knee motion than medial meniscus

• Bone tunneling has increased risk for stress fractures compared to healing of traditional fractures

• Avoid loading maturing reconstructed ligaments even though patient function is improving.

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Joint Reaction Forces

• Knee deviation increases joint reaction forces and shear on cartilage, meniscus and ligamentous lading

• Decreased knee flexion– Decreased

patellofemoral force

– Increased force to hips(J Biomech. 2007; 40(16): 3725-3721)

Reinold, 2009

Rehabilitation Outline• Phase I- Acute phase

• Manage weight bearing

• Pain management

• Control swelling

• Basic ROM

• Phase II- 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

Position Resistance

Supine/prone No Resistance- Pattern Assist

Quadruped No resistance

Kneeling Resistance- Pattern Assist

Standing Resistance

Static Dynamic

Double leg Single leg

No resistance Resistance

In BOS Out of BOS

Lower level Higher level

Plisky, 2013

Don’t Be Intimidated by This! Post Op/Acute

Goals

• Minimize pain

• Decrease swelling

• Protect surgically repaired

tissue

• Achieve isometric muscle

activation

• Initiate PROM

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Phase I- Acute phase

Therapy

• Minimize pain & swelling– Patellar mobilizations

– Calf & hamstring stretching

– Cryotherapy, Compression, Elevation

• Post op precautions– Dressing change

– Bathing/ADLs

– Brace locked in extension

• Initiate PROM– to protocol guidelines

• Limit atrophy– Quad sets, Multi-angle

isometrics

– 4-way ankle

Articular Joints

Waste

Phase I- Acute phase

Therapy

• Muscular activation– BFDB/NMES

– Glut sets

– PCL involved-avoid hamstring activation

• Patient Education– Pain management strategies

– Use of pain pump

– Use of home NMES

– Weight bearing• Surgical dependent

• Manage expectations– Rehab progression

– Outcomes/Goals

– Sensations in knee

Acute Phase

• NWB x 5-6 weeks

• 90 degree knee flexion desirable by week 6

• Minimize compressive and shear loads on repaired tissue

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

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

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- Basic Strength

Goals

• Full PROM (surgery dependent) by end of phase

• Improve soft tissue flexibility

• Achieve against gravity strength in all LE movements through full range• Ability to sustain contraction through

movement

• Ambulate without AD with symmetrical reciprocal gait by end of phase

• MINIMIZE FORCES TO RECONSTRUCTED TISSUES

Rehab Guidelines

• Correct faulty individual sequences in movement patterns

• TRAIN THE HIP HINGE

• Progress:• Static before dynamic

• Kneeling before standing

• Stable before unstable

• Unweighted before weighted

• Control before speed

• Eyes open before eyes closed

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Phase II- Protective Phase

• Continue to progress basic strengthening (Romeyn et al., 2008)

– Mini squats/hip hinge

– LAQ- 90-30

– Shuttle press/CKC 0-60 degrees

• Continue use of brace

• Progress PROM/AROM – to tissue healing guidelines

• Initiate weight bearing in brace– Weight shifts

– TKE

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

increased weight bearing*****

Phase II- Protective Phase

• Minimize loads to ligaments, menisci, and other static stabilizer healing structures– Avoid:

• CKC squatting past 45 degrees

• OKC Terminal knee extension

• Minimize pain, atrophy, & swelling

• Initiate Aquatic Therapy*

• Continue to provide motivation and support to patient

Aquatic Therapy- Phase I

Criteria for Advancing to Phase III

• Ambulate without deviations and no AD

• Against gravity strength in all directions

• Ability to perform SL stance on ground eyes open for 5-10 seconds (in or out of brace- surgery dependent)

• Swelling decreased

– brush test to 2/3 or less

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

• Full PROM (or within protocol guidelines)

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Phase III

• Goals:

– Correct functional movement dysfunction

– Strengthen weakened muscles

– Initiate multiplane and multi-joint exercises

• Integrate:

– Functional body movement training vs single

isolated muscle groups

Phase III- Intermediate Phase • Discontinue post surgical

brace-– fit for functional brace

• MD discretion

• Achieve full AROM

• 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

Phase III- Intermediate Phase

• Progress unilateral

balance activities

– Gradually integrate UE

involvement

– Integrate unstable

surfaces

• Initiate kneeling and

quadruped activities

– Surgery dependent

– Patient tolerance

dependent

Aquatic Therapy- Intermediate

• Activities:

– Step up holds, corrective squat, step down

– Lunges

– Med ball work, wall drills

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Aquatic Therapy- Intermediate Criteria to progress to Phase IV

• Perform DL squat without deviations

• SL squat to 30 degrees no deviations

• Full individual AROM equal to contralateral

limb

• Pass step and hold movement

Phase IV:

Dynamic Stability/Proprioception

Goals Rehab guidelines

• Progress limb strength,

stability, and control

working towards limb

symmetry

• Progress deceleration and

eccentric control

• Achieve stability through

resisted range

• Strength at end ranges of stability

• Outside BOS stability

• Multi-plane resistance movements/exercises

• Perturbations

• Light Plyometrics

• Loading/unloading mid movement

Phase IV- Advanced Intermediate• 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

– Kettle bell swings

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Goals of Aquatic Therapy

• Advance and Integrate:

– Running

– Deceleration work

– Change of direction

– Power, force development, explosiveness

Aquatic Therapy Advanced

Criteria to progress to Phase V

• Involved leg strength >75% of uninvolved limb

• Tolerated plyometrics without pain or

instability

• Sufficient core strength- Plank 30-45 seconds

no deviations (Nessler, 2013)

• Appropriate pre-requisite movement patterns

and strength to advance functional activities

Phase V- Controlled Activity Phase

Goals

• Advance plyometrics

• Eliminate deficits found on

functional testing

• Initiate components of

return to sport/activity

requirements

Rehab guidelines

• Initiate walk to jog program if appropriate

• Be very observant of patient activities and form*

• Don’t overwork tissues

– If lacking deceleration/eccentric strength = increased JRF to knee and subsequent pain and swelling

• Form over function

Phase V- Controlled Activity Phase

• Advance Plyometrics

– Rapid response, 2’’ runs, jump rope

– Speed ladder drills

– Drop jump catches

– Mini jump on/off stable/unstable surfaces

• Initiate interval running program

– Walk –> Skip -> High knees -> controlled fall -> run

– Initiate sport specific drills

Phase V- Controlled activity phase

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Running Progression 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

Phase VI- Return to

Activity/Performance

• Sport specific drills

• Power development

• Speed development

– Shuttle run, T-drill, 3-cone, bag drills, cone drills

• 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

Dynamic Movement Assessment

• Drop jump catches

• Deceleration from run

• Change of direction

running

• Tuck jumps

• SL jumps

• Can utilize:

– Slow motion video

analysis

• Iphone

• Hudl

• Myjump

– Force plate

– Agility test run times

• shuttle run times

• T-test time

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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)

Rehab at Andrews Institute… With

Andrews

• ALL YOU NEED TO KNOW…

• ALL YOU NEED TO DO…

Outcomes

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

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

• ACL and PCL reconstruction:

– 100% negative Lachman test, 66% negative posterior drawer, 44% had grade I posterior drawer. (Ohkoshi et 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. (Ohkoshi et al., 2002)

• Knee dislocation with lateral side injury: (Kinzer et al., 2010)– 91.3% IKDC score

– 16/17 achieved full knee ROM

– 15/17 achieved >90% knee strength with isokinetic testing

– 13/16 return to sport at same level after surgery

Outcomes

• 23-25% of subjects (mean age 16) sustained 2nd

ACL injury within 12 months upon RTS following ACLR. (Paterno et al., 2014, Grindem et al., 2016, Krytsis et al., 2016)– 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)

• 90% objective stability success rate with PLC surgery (Moulton et al, 2016)

Outcomes

• Return to outcomes vary, are surgery dependent, and are inconsistent due to case by case basis of injury

• ACL, PCL, PLC Outcomes: (Strobel et al., 2006)

– 29.4% “nearly normal stability”

– 58.8% “abnormal stability”

– 11.8% “grossly abnormal”

– Most patients able to recover a functionally stable knee and improved knee function compared to pre-operative measures

– Limitations: Unable to restore normal tibiofemoral kinematics

Rehab Principles

• Restore functional ROM, mobility, and strength

• Don’t forget the THORACIC SPINE

• Progressively overload tissues

• Static -> Dynamic

• Ensure movements are performed with proper joint

alignment, positioning, and timing prior to

progressing exercise.

• TREAT IMPAIRMENTS (WHOLE BODY)!!!!

• We treat patients NOT protocols!!!!

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THANK YOU & GO

DAWGS!!!