The posterior cruciate ligament is the main structure that limits the posterior displacement of the tibia relative to the femur, and posterior cruciate ligament injuries are less common than anterior cruciate ligaments. Injury alone presents as a posterior sinking of the tibia, as in a motorcycle accident where the fender strikes the proximal front of the lower leg directly. The clinical symptoms are mild and easily missed.
It is currently believed that conservative treatment is recommended for simple posterior cruciate ligament II° injuries (posterior instability less than 10 mm), while III° injuries, where posterior instability exceeds 10 mm, should be treated with posterior cruciate ligament reconstruction. II° injuries can usually compensate for posterior cruciate ligament function if the quadriceps is well developed and strong, and the athlete can continue to play sports. After rehabilitation, patients who still have symptoms of posterior cruciate ligament injury instability will require reconstructive surgery. The surgery is more difficult than ACL reconstruction and the results are less predictable. Currently, the most commonly used grafts are autologous N-cord tendon and quadriceps tendon. Allograft tendons or Achilles tendons may also be chosen. Double-bundle reconstruction is more consistent with the anatomic features of the posterior cruciate ligament. Most posterior cruciate ligament reconstructions are followed by a slower rehabilitation process than anterior cruciate and less intense training; the rehabilitation protocol depends on the graft material, patient tolerance, and surgical size.
Therefore, individualized training and rehabilitation programs should be implemented according to the patient’s actual condition. For example, our orthopedic department at Changhai Hospital used autologous N cord muscle, allograft Achilles tendon, and LARS artificial ligament for reconstruction of posterior cruciate ligament injury respectively. Among the three, we are the most conservative in patients who use autologous N cord tendon for reconstruction, and the speed of rehabilitation is slightly slower than the conventional rehabilitation program, especially in the early stage, we emphasize the protection of 0° position of the brace, and for those who use allograft Achilles tendon, because the tibial end graft has a bone block and is firmly fixed, and the femoral end is mostly fixed by double bundle, the following rehabilitation program is basically followed; LARS artificial ligament, because of double bundle fixation, the toughness of artificial ligament fixation and the maximum failure The LARS artificial ligament is stronger than the first two, and most of the patients who underwent artificial ligament surgery were near the tibial side of the posterior cruciate injury, and the ligament stump was preserved intraoperatively, with LARS as a reinforcement, and the preserved PCL itself has a tendency to heal, so the rehabilitation can be more positive.
Rehabilitation program phase training I (0-6 weeks postoperatively)
The goal of this phase of rehabilitation is to improve patellar mobility and prevent quadriceps atrophy; it is often difficult to completely straighten the knee joint after posterior cruciate ligament reconstruction, and early exercise can reduce the occurrence of this complication, with particular attention to early postoperative calf padding, knee suspension, and relying on gravity to press the leg straight; knee mobility should reach 0-90° at 6 weeks.
1.Postoperative elevation of the affected limb and continuous cold compresses
2.Ankle pump exercise
Encourage patients to do plantar flexion and dorsiflexion of the foot, one flexion and one extension for one time, 20-30 strokes each time, 3-4 times a day, active stretching and passive pulling of the flexor muscles of the lower leg to promote blood circulation in the lower limb and prevent the formation of deep vein thrombosis in the lower limb.
3, gentle patellar release, sliding left and right mainly, sliding up and down carefully
4.Quadriceps isometric contraction, this exercise is performed gradually under the conditions that the patient can tolerate
Instruct the patient to do quadriceps (front thigh muscle group) tensing action, the muscle must be maximum active contraction maintained for 6 seconds, and pay attention to check whether the quadriceps internal testing head is contracted strongly, which is a key point. 30-50 times/hour, exercise 2-3 times a day.
5, brace locked at 0°, practice straight leg raise, if recovery can, without brace for straight leg raise exercise straight leg raise to 30° and stay for more than 6 seconds, some patients may not lift at once, can first active assist practice
6.In the 3rd week after surgery, start passive knee mobility exercises
A. Passive knee extension exercises: supine position, calf pillow, passive knee extension completely by gravity
B. Bedside knee flexion exercises: patient sits on the edge of the bed and the affected limb is passively flexed under gravity, aiming to flex the knee to 70° at 4 weeks after surgery.
7.In the 5th postoperative week, active assisted knee flexion exercises
A. Active knee flexion exercises in sitting position: the patient sits at the bedside and actively flexes the knee, with the aid of the gravity of the healthy limb after the pulling sensation, aiming to flex the knee to 90° after 6 weeks
B. Heel sliding exercise: sliding the heel in supine position, active assisted knee flexion exercise, such as strain can be placed in front of the affected ankle cross, assisted by the affected knee flexion.
Phase 2 (7-12 weeks after surgery) The goal of this phase of rehabilitation is to gradually increase knee mobility, start weight bearing, and gradually normalize gait
1. Knee brace locked in the fully extended position, crutches can be used, 50%-70% weight bearing on the affected limb; or no crutches, walking with weight as tolerated by the patient, when walking without pain, the crutches can be removed
2, gait exercises, walking exercises facing the mirror, correct poor walking posture; if conditions can be, walking with weight or increase the walking distance
3.Continue knee flexion exercises, and strive to achieve 120° of knee flexion angle at 3 months after surgery
A, supine end flexion exercises: supine position, active knee flexion, in the end of the knee flexion range of strain, can use elastic band to assist the knee flexion or use the hands to flex the hip and hold the knee
B, prone terminal knee flexion exercises: prone, active knee flexion, heel try to close to the hip, in the end of the knee flexion range of strain, the use of elastic bands to assist in flexing the knee
4, resistance straight leg raise (need to support fixed in 0 ° knee extension position, tolerance is appropriate)
A.Straight leg elevation in supine position
B.Straight leg lateral elevation
C.Straight leg elevation in prone position
5.After reaching 4, active knee extension: 60°～0° open chain progressive resistance exercises. (Avoid active open chain resistance knee flexion exercises)
6, single-leg stance exercises single-leg stance, raised leg exercises 90 ° backward knee flexion and maintain balance, alternating legs, each lasting more than 6 seconds, 8-10 times each day
7.Start to practice on the step, step height from 10cm gradually transition to 20cm
8.If appropriate, try to step down training at this stage, step height from 10cm to 20cm gradually
Phase 3 (13-18 weeks after surgery) The goal of this phase of rehabilitation is to restore knee mobility and enhance muscle strength, flexibility and stability of the lower limbs
1.Continue knee mobility exercises
2.Static squatting exercises against the wall, legs apart, standing with the back to the wall, slowly squatting down to reach the maximum tolerated position. After reaching 80 ° began to gradually transition to a free squat without the wall, whether against the wall or not to test the wall should not bend the knee more than 80 °
3, began to step down exercises, step height from 10cm gradually transition to 20cm
4, pain-free up and down the steps, start up and down the stairs training, morning, midday and evening training for half an hour each
5.Elastic band terminal knee extension exercise
6.Elastic band terminal knee flexion exercises
7.Standing position resistance exercises in all directions
The ends of the elastic band were fixed at the level of the calf, standing inside the elastic band circle, resistance exercises in all directions
Phase 4 (19-22 weeks postoperative) This phase continues the lower extremity muscle strength, flexibility and stability exercises to prepare for the return to sports
1.After going up and down the steps without pain, start the stair training, half an hour each in the morning, midday and evening
2.Jogging exercises at a uniform speed.
The ground should be smooth, preferably in the park and playground runway, the distance of running is not limited, the beginning of the first control within 50-100 meters, generally to the body slightly sweating and warm, avoid painful conditions practice.
3, double-legged reciprocal jumping step exercise, step height from 10cm gradually transition to 20cm
Place a solid box on the ground, jump on both legs at the same time, landing gently on the affected limb, and then jump down again, also pay attention to the protection of the affected limb. Exercise for half an hour in the morning and half an hour in the afternoon, and rest for 2 minutes in the middle of the exercise; if there is no box, place a jump rope horizontally, adjust the appropriate height and then jump with both legs, jumping around continuously.
4.Jumping and shooting exercises, in order to further practice the sense of balance, you can practice the action on a loose bed
5.Simulated shear gait exercises elastic band flush waist level fixed ends, people standing in the elastic band circle inside, in a shear gait resistance static squat
6, 6 months after surgery in the doctor’s consent can be appropriate for low-intensity sports, such as swimming, cycling or badminton
Note: The above training program can meet the basic needs of ordinary people and low-intensity activities, for athletes and sports enthusiasts who need to return to high-intensity sports and participate in competitions, after 22 weeks need to carry out special exercises under the guidance of professional rehabilitators.