TREATMENT GUIDELINES FOR GRADE 3 PCL TEAR

Transcription

1 GENERAL CONSIDERATIONS Posterior cruciate ligament (PCL) injuries occur less frequently than anterior cruciate ligament (ACL) injuries, but are much more common than previously thought. The PCL is usually injured in combination with other structures, but if the injury is isolated, most experts recommend a conservative treatment approach. The goal of rehabilitation is to minimize the harmful stress on the supporting posterior knee structures initially, then gradually increase stresses to the knee in a criterion based symptom limited manner. The rehabilitation of the PCL whether reconstructive or non-operative, is greatly dependent on dynamic quadriceps stability. Current rehabilitation methods address dynamic quadriceps strengthening and should not be approached in the same manner as rehabilitation of the ACL. The quadriceps act as the agonists for the PCL and actively work to prevent posterior shear forces. The anatomy, biomechanics, and natural history of the PCL-deficient knee differ dramatically from the injured ACL knee, and the treatment approach should reflect these considerations. Although closed kinetic chain (CKC) exercises are often prescribed after ACL injury, this approach is not taken in a PCL treatment guideline. The stress applied to the posterior structures of the knee by the hamstrings in CKC is detrimental to healing in the early stages. Research has shown that open kinetic chain (OKC) knee extension from the neutral range of 60 degrees can be safe, but as the knee flexion angle increases the strain on the posterior structures of the knee also increases. OKC knee flexion exercise should be avoided during early rehabilitation of the PCL deficient knee because isolated hamstring activity creates large posterior shear loads. OKC knee flexion exercises should be the last form of strengthening exercise used to selectively strengthen the hamstrings. Depending of the severity of injury and the stage of healing, the clinician must add variables to the training regimen to progressively increase the stresses placed on the healing ligament. 8/23/07, Page 1 of 6

2 A post injury protocol for physical therapy should begin 2 to 5 days post injury. PHASE I - PROTECTIVE (0-3 WEEKS POST-OP) 1. General Care Issues/Precautions 2. Range of Motion (ROM) 1. General Care Issues/Precautions Brace should be worn at all times (Exceptions: Physical Therapy, Showering, Home Exercises) Brace locked from 0 to 30 degrees. Pillow should be placed under the proximal tibia at rest to prevent sagging. Avoid pivoting, twisting, active knee flexion Ace wrap from proximal calf to proximal thigh for edema. Ice and elevate leg with for 15 minutes, 3-5 times per day. 2. Range of Motion 0 to 30 degrees s Quad Sets Elevated Ankle Pumps Straight Leg Raise Side Lying Hip Abduction/Adduction Hamstring and Calf Stretches **NO TIBIAL SAGGING* Ice compression for 20 minutes 3 to 5 times per day. HVGS Biofeedback Criteria for Progression to Phase II: No lag with SLR Knee extension to 0 degrees 8/23/07, Page 2 of 6

3 PHASE 2 - EARLY MOBILITY (WEEKS 3-6) 1. Range of Motion (ROM) 1. Range of Motion PROM to 90 degrees by week 6 Perform all PROM with anterior drawer applied to tibia WBAT Early gait training with brace in 0 to 30 degrees of flexion. Bracing parameters to be determined by MD and PT. Discharge brace when patient demonstrates: o Proper heel strike with full knee extension o Proper knee stabilization at midstance o Adequate knee flexion for swing phase 3 way hip exercises in standing with resistance proximal to the knee (no hip extension) TKE LAQ to 60 degrees Single leg balance Total Gym to 60 degrees of knee flexion Mini Squat to 45 degrees Anterior Step Up Ice compression for 20 minutes 3 to 5 times per day. HVGS Gait Analysis Criteria for progression to phase III PROM knee flexion to 90 degrees Normal Gait pattern Able to perform 10 6 inch anterior step ups with good concentric quadriceps control 8/23/07, Page 3 of 6

4 Phase 3 - Gradual Motion and Strength Progression (WEEKS 6-10) 1. Range of Motion (ROM) 1. Range of Motion (ROM) Begin gradual active knee flexion and progress to full ROM by 10 weeks Maintain tibia in anterior drawer position with early knee flexion No brace for gait training activities Begin multi-directional gait activities Squat to 90 degrees Total Gym/Leg Press to 90 degrees Prone knee flexion to 60 degrees Anterior Step Downs Lunges (Anterior, Lateral) Bike at 8 weeks with low resistance and high seat. Keep foot forward on pedal to decrease posterior stresses. Single leg balance activities Ice compression for 20 minutes 3 to 5 times per day if still needed for edema. Biodex at week 8 Criteria for progression to phase IV: Full ROM < 30% Quad Deficit < 30% Hamstring Deficit Able to perform 10 six inch anterior step downs with good eccentric quadriceps control. 8/23/07, Page 4 of 6

5 Phase 4 - Functional Progressive Strengthening (WEEKS 10-24) 2. Test Assessment MD will provide short hinged brace for activities at week 10 Brace for out of house activities Light resistance to hamstrings is progressed. Exercise (Higher Intensity lower repetitions) Increased balance and proprioceptive exercises (Plyo toss, Airex) Treadmill walking until week 12. Progress to jogging at week 14. Jump rope at week 16. Quad Stretch Begin lateral movements Sport cord Single Leg Squat Cycle at 80 RPM 2. Test Assessment Biodex at week 12 Criteria for progression to phase V: <10 % quadriceps deficit < 10 % hamstring deficit 8/23/07, Page 5 of 6

6 Phase 5 - Return to Sport/Activity (WEEK 16 to 28) 2. Tests Assessment No brace Increase endurance Sport specific conditioning 1. Running progression i. Sprinting vertical ii. Figure 8 iii. Circles iv. 45 degree turns v. 90 degree cuts vi. Carioca vii. Sport Specific sprinting Plyometric Program 2. Tests Assessment Biodex testing Single Leg Hop Test Motion Monitor Drop Land Test Criteria for discharging the athlete: 8/23/07, Page 6 of 6