Objectives. Multi-Ligament Knee Injury. Knee Anatomy. Knee Dislocation classification 3/6/2017

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1 Objectives The Complex Cases-Rehabilitation of Multi-Ligament Knee Reconstruction & Meniscus Pathology Tyler Opitz, DPT, SCS March 3 rd, 2017 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 Knee Anatomy 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 1

2 Knee Anatomy MOI 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 Regional Interdependence DVT Compartment syndrome 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 fromvarious body regions and systems regardless of proximity to the primary symptom(s). (Sueki et al., 2013) 2

3 Full and adjacent body segment assessment Rehabilitation Considerations 1. Diagnosis/pathology/surgical procedure 2. Severity of tissue damage/invasiveness 1. 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 NOT mean 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 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? Car Analogy 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 SHEARforces on knee joint Increased knee extension in closed chain increases COMPRESSIVEloads 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. 3

4 Reinold, 2009 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): ) 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 Static Resistance Dynamic Plisky, 2013 Double leg No resistance In BOS Lower level Single leg Resistance Out of BOS Higher level Don t Be Intimidated by This! Post Op/Acute Goals Minimize pain Decrease swelling Protect surgically repaired tissue Achieve isometric muscle activation Initiate PROM 4

5 Phase I- Acute phase Articular Joints 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 Waste Phase I- Acute phase 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 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 sequencesin 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 5

6 Phase II-Protective Phase Continue to progress basic strengthening (Romeyn et al., 2008) Mini squats/hip hinge LAQ 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) 6

7 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 7

8 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 Goals Phase IV: Dynamic Stability/Proprioception Progress limb strength, stability, and control working towards limb symmetry Progress deceleration and eccentric control Achieve stability through resisted range Rehab guidelines 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 8

9 Goals of Aquatic Therapy Aquatic Therapy Advanced Advance and Integrate: Running Deceleration work Change of direction Power, force development, explosiveness Criteria to progress to Phase V Phase V- Controlled Activity Phase Involved leg strength >75% of uninvolved limb Tolerated plyometrics without pain or instability Sufficient core strength-plank seconds no deviations (Nessler, 2013) Appropriate pre-requisite movement patterns and strength to advance functional activities 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 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 9

10 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 NOTgrounds 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 10

11 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 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 2 nd 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 2 nd ACL injury within 3 years (Webster et al., 2014) 87% female (Paterno et al., 2014) 75% sustained 2 nd on contralateral knee. Young athletes that RTS are 15xmore likely to have 2 nd 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!!!! 11

12 THANK YOU & GO DAWGS!!! 12