Tibial Tubercle Osteotomy ( Distal / Medial)

Transcription

1 Physical Therapy Post Operative Guidelines Tibial Tubercle Osteotomy ( Distal / Medial) Phase I: 0-3 Weeks Precautions: Flexion ROM limited to 90 x 2 weeks; No OKC quad strengthening (to avoid pull at osteotomy site through patellar tendon); Observe for wound healing PWB ( 50% BW) *May stand in tandem for brief periods On & locked at KF at all times except w/cpm or P/AAROM exercises; on & locked w/leg lifting Emphasize full Ext; progress Flex to 90 multiple times/day CPM Quad Sets *NMES as needed SLR x 3 in locked brace (Flex, Abd, Ext) Beginner mat exercises for core and proximal hip strength Goals: Control effusion and pain; ROM 0-90 ; Attain a strong quad set; SLR w/no lag; Able to perform 30 reps prior to fatigue w/leg lifting Phase II: 3-6 Weeks Precautions: No OKC quads through large arc of motion (mini-saq still permitted) PWB ( 50-75%) (In-home walking w/brace locked permitted per symptoms) On when up and with leg lifting exercises Brace gradually opened w/crutch walking Full Ext Progress to full Flexion as tolerated *May initiate stationary bike for ROM Initiate Basic Poses *Use exercise ball under legs for comfort w/positioning Increase reps w/proximal hip/abdom exercises Initiate basic 2 limb CKC strength drills *Early KF angles for PF loading Initiate 2 limb L/E proprio/balance Emphasize terminal knee extension control in CKC Goals: Effusion resolving; Preserve full extension; Flexion ROM 120 ; Multi-planar L/E strength = Grade 5/5 w/mmt NOTE: Distal transfer of tubercle osteotomy may need extended time to heal. Pain with weight-bearing at osteotomy site dictates slower progression. jmonson1@fairview.org Tibial Tubercle Transfer arend001@umn.edu (1)

2 Phase III: 6-10 Weeks Precautions: WBAT allowed in-home only & PWB for out-of-doors initially; Maintain effusion/pain control with WB and HEP progression; Avoid pivoting on a planted foot; Instruct proper knee/hip alignment with CKC drills; Observe for knee hyperextension thrust during stance phase w/gait Progress gradually PWB WBAT FWB Progression to FWB dictated by MD clearance/radiographic signs of healing *Normalize gait pattern, avoiding knee hyperextension in early stance Open per quad control Protective use when out of home: environmental hazards, crowds Full, symmetrical ROM Progress core poses Basic Intermediate Initiate basic cardio with bike, elliptical, walking (15-20 minutes, minimal intensity, steady pace) Progress CKC drills: -Deeper angles KF as tolerated -Early KF angles w/1 leg per control/tolerance Progress L/E proprio/balance drills: single limb per control/tolerance Phase III Goals: Effusion resolved; ROM WNL; Progressing toward normal gait pattern in FWB; Able to perform 30 reps prior to fatigue w/leg lifting; Normal LE kinematics w/2 leg CKC activities Phase IV: Weeks* Phase IV Precautions: Caution w/ extended periods of walking in FWB (per MD o.k. & symptoms); Observe/instruct proper L/E alignment w/ckc drills (avoid functional valgus); Avoid pivoting on planted foot Initiate basic cardio with bike, elliptical, walking (15-20 min. minimal intensity, steady pace) Progress drills: -Add Surface Challenge/Perturbation in bilateral support Single limb activities on level surface Intermediate Advanced Core poses per control Strength Progress CKC drills to 1 leg per control/symptoms Initiate basic large muscle group weight training: 2 leg support Phase IV Goals: Restore normal mechanics with single leg CKC activities, Gait speed & distance normalizing; Able to perform 2 leg squat 60 x 20 reps w/kinematic & symptom control; Able to maintain single leg balance 60 sec.; Restore normal stair climbing Conduct Level I (Return to Function) Lower Extremity Physical Performance Testing Goal = Achieve 85% LSI w/level I Test Activities *Time frames in later phases of rehab are estimates only. Patients may be progressed faster/slower based on their ability to attain goals for each phase. jmonson1@fairview.org Tibial Tubercle Transfer arend001@umn.edu (2)

3 Phase V: Weeks* Precautions: Observe for return of effusion and/or pain with increased activity levels; Observe kinematic control w/ckc activities Strength Progress cardio with bike, elliptical, walking (20-25 minutes, moderate intensity, steady pace) Initiate running program if scores 85% w/level II Testing Add Surface Challenge or Perturbation BOSU, Dynadisc, trunk and/or extremity movement, perturbation 2 1 limb support Intermediate Advanced Core poses per control Reps to fatigue w/ckc strength drills (squat, lunge) per symptoms for muscular endurance Progress CKC drills with directional challenge (lunging, resisted side stepping) Progress weight training to single leg (First eccentric phase only, then both eccen/conc) Phase V Goals: Quad girth returning; Normalized walking speed and distance; Restore normal stair climbing; Able to perform 2 leg squats to 60 KF x 20 reps w/proper alignment (per symptoms); Able to perform a single leg squat 45 knee flexion with normal mechanics; Improving low-impact cardio base Conduct Level II (Return to Fitness) Lower Extremity Physical Performance Testing Goal = Achieve 85% LSI w/level II Test Activities Note: Return to running should be based on the following criteria: 1) Chondral health at the Patellofemoral/Tibiofemoral joints 2) Previous history of regular running 3) Level II PPT scores 85% Attention: Progression to Phases VI and VII only pertinent to patients with an athletic history who desire to return to pounding/pivoting activities. Progression based on PF joint chondral health, symptom tolerance, and patient s return of strength, fitness and coordination. jmonson1@fairview.org Tibial Tubercle Transfer arend001@umn.edu (3)

4 Phase VI: weeks* Precautions: Closely observe/instruct alignment with plyometric, agility, cutting and sport drills; Modify intensity of exercises per symptoms and L/E alignment control; Advise return to running per criteria below* Strength/ Power minute workout (moderate intensity) w/3-5 brief near-maximal intensity bursts w/recovery periods Once able to run x 20 minutes symptom-free, initiate sprint drills -Linear -Focus on acceleration phase -Progress % intensity per fatigue, symptoms 1 leg stance w/surface challenge/perturbation 1 leg stance w/sport simulation activity Dynamic movement elements: -Dot drills -Reaching drills Add resistance band at U/E or L/E for challenge Advanced Core Stability Poses Add challenge w/exercise/bosu ball under legs/trunk Add dynamic mvmt, plyometric elements Initiate basic 2 leg plyometric drills (emphasize controlled landing into deep squat with good alignment) Initiate basic agility/footwork drills (initiate quick foot chopping, feet and hips move together, no pivoting on a planted foot) Goals: Normal quad girth; Able to perform 2 leg squat to 90 x 20 reps & 1 leg squat 60 KF x 20 reps w/kinematic & symptom control; Good self-awareness of proper kinematics w/ckc drills Phase VII: 24+ Weeks* Precautions: Observe for return of effusion and/or pain with increased activity level and modify HEP; Closely observe alignment with plyometric, agility, cutting and sport drills Continue regular cardio workouts 4-6x/wk Progress sprint drills: -Increase % intensity -Add direction change in acceleration Add deceleration drills -Add direction change in deceleration Blend strength elements (CKC L/E, OKC U/E) into balance drills per control Continue to progress dynamic challenge elements Blend upper body/lower body strengthening elements into core stability poses Strength/ Power Progress plyometrics: -Increase intensity -2 1 leg take-off/land -Traveling -Direction change -Surface challenge on landings (BOSU) Progress agility/footwork drills: -Increase % intensity/speed Goals: Patient to become independent with exercise program and demonstrate good self-awareness of proper L/E alignment with high level drills Conduct Level III (Return to Sport) Lower Extremity Physical Performance Testing Note: Return to sport based on the following criteria: 1) MD clearance, 2) Level III PPT scores 85% LSI, 3) Preserved symptom control w/sport jmonson1@fairview.org Tibial Tubercle Transfer arend001@umn.edu (4)

5 Physical Therapy Post Operative Guidelines Medial Patellofemoral Ligament Reconstruction Phase I: 0-3 Weeks Precautions: No OKC quads through large arc of motion (mini-saq 10-0 KF permitted) PWB WBAT May stand in tandem Advance off crutches indoors per quad control/rom/ swelling Locked at KF On when up, with leg lifting Optional for sleep Open for seated ROM Emphasize full Extension Progress Flex multiple x/day (NO forceful flexion) Gentle stationary bike for ROM Quad Sets/Mini-SAQ *NMES as needed SLR x 3 (Flex, Abd, Ext): Locked brace No brace per quad control Beginner mat exercises for core and proximal hip strength (Isometrics) Goals: Control effusion and pain; Attain full knee extension; Attain a volitional quad set; No lag w/slr; KF ROM 90 ; Able to perform 30 reps prior to fatigue w/leg lifting Phase II: 3-6 Weeks Precautions: Continued effusion/pain control w/wb and HEP progression; Avoid pivoting on a planted foot; Observe/correct for knee/hip alignment w/ckc drills; Observe for knee hyperextension with stance phase of gait FWB Per quad and pain control (Normalize gait pattern; Avoid hyperextension thrust in early stance) Gradually open brace per quad control with gait, CKC activities Full Ext Progress Flex toward full ROM Initiate Basic Poses Increase repetitions w/proximal hip strength/abdom exercises (up to 40 reps) Initiate basic CKC drills: 2 leg support Emphasize terminal knee extension control in CKC (espec. w/gait) Initiate basic L/E proprioception and balance drills: 2 leg support Goals: Effusion resolved; Preserve full extension; Flexion ROM 120 ; Normalizing gait pattern in FWB; Normal LE kinematics w/2 leg CKC activities; Multi-planar L/E strength = Grade 5/5 w/mmt jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (1)

6 Phase III: 6-10 Weeks* Precautions: Continue to observe/instruct for proper L/E alignment and mechanics with CKC drills (avoid functional valgus); Avoid pivoting on a planted foot FWB Protective use when out of home: environmental hazards, crowds Full ROM Progress core poses Basic Intermediate Initiate basic cardio with bike, elliptical, walking (15-20 minutes, minimal intensity, steady pace) Progress CKC drills to 1 leg per control/symptoms Progress L/E proprio/balance drills to single limb Goals: Able to perform 2 leg squat 60 x 20 reps w/kinematic & symptom control; Restore normal mechanics with single leg CKC L/E activities; Able to maintain single leg balance 60 sec.; Restore normal stair climbing Conduct Level I (Return to Function) Lower Extremity Physical Performance Testing Goal = Achieve 85% LSI w/level I Test Activities Phase IV: Weeks* Precautions: Observe for return of effusion and/or pain with increased activity levels Cardiovascular Fitness Strength Progress cardio w/ bike, elliptical, walking (20-25 minutes, moderate intensity, steady pace) 2 1 limb support w/challenge elements Surface Challenge/ Perturbation BOSU, Dynadisc, trunk and/or extremity mvmt, perturbation Intermediate Advanced Core poses per control Progress CKC drills with directional challenge (lunging, resisted side-stepping) -Progress reps to endurance level per symptoms/tolerance Initiate basic L/E large muscle group weight training: 2 1 leg support (First w/eccentric phase only, then both conc/eccen) Goals: Quad girth returning; Normalization of walking speed and distance; Able to perform 2 leg squat to 90 x 20 reps & 1 leg squat 45 KF x 20 reps with kinematic & symptom control jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (2)

7 Phase V: Weeks* Precautions: Observe for return of effusion/pain with increased activity levels; Avoid sporting activities involving significant pivoting at 6 mos. post-op; Advise return to running per criteria below* Strength/ Power Progress weight training to 1 leg minute workout (moderate intensity) w/3-5 brief near-maximal intensity bursts w/recovery periods Initiate running program if scores 85% w/level II Testing 1 leg stance w/sport simulation activity Add resistance band at U/E or L/E for challenge Advanced Core Stability Poses Add challenge w/exercise ball under legs/trunk Add trunk rotation, U/E movement patterns w/ckc strength drills (squatting, lunging) Initiate basic 2 leg plyometric drills (emphasize squat landing with good alignment) Initiate basic agility/footwork drills (initiate quick foot chopping, feet and hips move together, no pivoting on a planted foot) Goals: Normal quad girth; Demonstrates good self-awareness of proper L/E alignment with CKC drills; Able to perform 1 leg squat 60 x 20 reps w/kinematic & symptom control Conduct Level II (Return to Fitness) Lower Extremity Physical Performance Testing Goal = Achieve 85% LSI w/level II Test Activities Note: Return to running should be based on the following criteria: 1) Chondral health at the Patellofemoral/Tibiofemoral joints 2) Previous history of regular running 3) Level II PPT scores 85% jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (3)

8 Attention: Progression to Phase VI only pertinent to patients with an athletic history who desire to return to pounding/pivoting activities. Progression based on PF joint chondral health, symptom tolerance, and patient s return of strength, fitness and coordination. Phase VI: 18+ Weeks (Athletic Progression)* Precautions: Closely observe alignment with plyometric, agility, cutting and sport drills; Modify intensity of exercises per symptoms and control over L/E alignment Continue regular cardio workouts 4-6x/wk Once able to run x 20 minutes symptom-free, initiate sprint drills -Linear -Focus on acceleration -Progress % intensity per fatigue, symptoms Progress sprint drills: -Increase % intensity -Add direction change in acceleration -Add deceleration drills -Add direction change in deceleration Blend strength elements (CKC L/E, OKC U/E) into balance drills per control Continue to progress dynamic challenge elements Advanced poses w/movement and/or plyometric elements (w or w/o ball, BOSU) Blend upper body/lower body strengthening elements into core stability poses Strength/ Power Progress plyometrics: -Jump intensity -2 1 leg (take-off/land) -Traveling -Direction change -Surface challenge w/landing (BOSU) Progress agility/footwork drills -Increase intensity/speed Initiate sport specific drills Goals: Normal quad girth; Patient to become independent with exercise program and demonstrate good selfawareness of proper L/E alignment with high level drills good self-awareness of proper L/E alignment with high level drills Conduct Level III (Return to Sport) Lower Extremity Physical Performance Testing Goal = Achieve 85% LSI w/level III Test Activities Note: Return to sport based on the following criteria: 1) MD clearance 2) Level III PPT scores 85% LSI 3) Preserved symptom control with return to activities *Time frames in later phases of rehab are estimates only. Patients may be progressed faster/slower based on their ability to attain goals for each phase. jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (4)

9 Physical Therapy Post Operative Guidelines Microfracture: Trochlear Groove Defect Phase I: 0-4/6 Weeks (Time frame dictated by size, location of lesion) Precautions: Brace locked 0; No OKC quad through arc of motion WBAT w/brace locked at 0 Crutch use per comfort/symptoms Locked 0 KF On when up & with leg lifting Optional for sleep Open when seated for ROM Emphasize full Extension Progress Flex multiple x/day (NO forceful flexion) Goals: Full hyperextension; Good quad set/activation; Resolving effusion CPM x 8 hrs/day minimum Quad Sets in full knee extension *NMES as needed SLR x 3 (Flex, Abd, Ext): Locked brace No brace per quad control Beginner mat exercises for core and proximal hip strength (Isometrics) Phase II: 4/6-12 Weeks Precautions: Observe & correct for knee/hip alignment (functional valgus at knee and pelvic drop) w/squatting & single limb stance activities; Observe for return of effusion & regress activities accordingly FWB Per quad and pain control *Limit reciprocal stair activity Gradually open brace per quad control with gait, CKC activities Full Ext Progress Flex to full ROM Stationary bike for ROM Initiate Basic Poses Progress OKC mat exercises: reps, resistance Initiate basic CKC drills: 2 leg support (Manipulate squat depth per location of lesion) Initiate basic L/E proprioception/balance drills: 2 legs Flutter kick swimming o.k. (NO kick turns) Goals: Effusion resolved; Full ROM; Normalizing gait pattern in FWB; Multi-planar L/E strength = Grade 5/5 jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (1)

10 Phase III: 12+ Weeks* Precautions: Continue to observe/instruct proper L/E alignment w/ckc drills (avoid functional valgus); Avoid pivoting on a planted foot, excessive impact or resistance activities through arc of motion (until 4 mos. post-op) FWB Protective use when out of home: environmental hazards, crowds Full ROM Progress core poses Basic Intermediate Initiate basic cardio with bike, elliptical, walking (15-20 minutes, minimal intensity, steady pace) Progress CKC drills to 1 leg per control/symptoms Progress L/E proprio/balance drills to single limb Goals: Able to perform 2 leg squat 60 x 10 reps w/kinematic & symptom control; Restore normal mechanics with single leg CKC L/E activities; Able to maintain single leg balance 60 sec.; Restore normal stair climbing; Cuing for shock absorption with progression into higher level CKC activities and early impact activities *Progression with therapy and physical activities beyond this point should be dictated by patient strength, coordination, symptom control (pain & effusion), and prior level of function. jmonson1@fairview.org MPFL Reconstruction arend001@umn.edu (2)