Rehabilitation principles
-No open chain N cord muscle training
-Usual healing time of the graft and bone is 12 weeks
-Be careful not to allow the tibia to flatten backwards (gravitational, muscular action)
-CPM is usually not performed
-PCL combined with posterior lateral horn repair or LCL repair follows different postoperative care
-Resistance exercises for the hip should be applied above the knee for hip abduction and adduction; when the hip is flexed resistance can be applied distally.
-Supervised physical therapy is generally required for 3-5 months postoperatively.
Phase I: 0-4 weeks postoperatively
Objectives.
-Protect healing of bone and soft tissue structures
-Protect the graft
-To reduce the effects of braking.
Bracing.
- 0-1 week: always locked in full extension knee position postoperatively
-One week after surgery, unlock the brace with the help of the therapist for passive mobility training
Weight bearing.
-Crutches for tolerable weight bearing with brace locked in extended knee position
Rehabilitation.
-Patella mobility in all directions
-Straight leg raising (SLR) in all directions
-Ankle pump
-N-string and calf retraction
-Hip extension in neutral standing position
-Functional electrical stimulation (based on weak quadriceps contraction)
Phase 2: 4-12 weeks postoperative
Criteria for entry into phase II.
-Good quadriceps control
-Approximately 60 degrees of knee flexion
-Full extension of the knee
-No signs of any active inflammation
Goals.
-Increased ROM (especially in flexion)
-Normal gait
-Continued improvement of quadriceps strength and N-cord muscle flexibility
Bracing.
- 4-6w: walking with locked brace in a controlled environment (i.e., patient can walk with PT or at home with locked brace)
- 6-8w: Brace locked during all activities
- 8w: discard brace and follow surgeon
Weight bearing.
- 4-8w: Crutches tolerable weight bearing
- 8w: Discard crutches if patient meets the following criteria.
No quadriceps lag at SLR
Full extension of the knee
Knee flexion of 90-100 degrees
Normal gait (may use a single crutch/crutches until gait is normalized)
-Continue crutches until 12 weeks if PLC or LCL repaired
Therapeutic exercise.
- 4-8w.
Squatting/micro-squatting against the wall ( 0-45 degrees)
Leg stretches ( 0-60 degrees)
Four ways of contacting the hip in the standing position, flexion, posterior extension, abduction, adduction (from neutral position with full knee extension)
Walking in the pool (resume normal toe gait in chest-deep water)
- 8-12w.
Power bike (feet in front of pedals, do not pedal with toes to minimize N-cord activity; seat set slightly above normal)
Closed chain resistance exercises at the end of the extended knee with straps and weight-reducing muscles. Note: Pay attention to the position of the resistance point to minimize tibial displacement
stairmaster
oElliptical trainer
Balance and proprioceptive training
Heel lifts in seated position
Stirrups (0-90 degrees)
Phase 3: 3 to 9 months after surgery
Criteria for entering Phase III.
-Full, pain-free ROM (Note: 5 months post-op, lack of 10-15 degrees of knee flexion is most common)
-normal gait
-Good normal quadriceps control
-No patellofemoral joint pain
-Clear initiation of more centripetal closed chain training by the surgeon
Objectives.
-Restoration of residual motion deficits that may impede functional progression
-Functional progression to prevent patellofemoral joint irritation
-Improve functional strength and train proprioception with closed chain exercises
-Continue to maintain quadriceps strength and N-cord muscle flexibility
Therapeutic Exercises.
-Continued closed chain exercises
-Running and walking
-Jogging in the pool with an undershirt or band
-Swimming (without breaststroke or “frog kick”)
Phase 4: 10th post-operative month until full return to activity
Criteria for entering Phase IV.
-Resumption of full or progressive/partial activities (i.e., return to work, recreation or athletic activities) as determined by the surgeon
-No significant patellofemoral or soft tissue inflammation
-Presence of the necessary joint mobility, muscle strength and endurance, and proprioception to safely return to competitive participation
Complete pain-free mobility
Satisfactory clinical examination
The quadriceps had 85% of the strength of the healthy leg
Functional tests had 85% of the healthy leg
No change in relaxation test
Objectives.
-Safe and progressive return to work or participation in sports
May involve sport specific training, work intensity, or work needs
Patients have a good understanding of the limitations they may have
-Maintain strength, endurance, and function
Therapeutic exercise.
-Continue closed chain exercises
-Sports specific functional progressions, which may include but are not limited to
Skateboarding
Jogging/running
Figure 8 running , backwards running, and braking in a hurry
Jumping ( super isometric exercise )