MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION CLINICAL PRACTICE GUIDELINE

Transcription

1 MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION CLINICAL PRACTICE GUIDELINE Prgressin is time and criterin-based, dependent n sft tissue healing, patient demgraphics and clinician evaluatin. Cntact Ohi State Sprts Medicine at if questins arise. Backgrund The medial patellfemral ligament (MPFL) is a ligament n the medial apsect f the knee which helps stabilize the patella against lateral mvement. This ligament may be injured in a patella dislcatin. A MPFL recnstructin surgery uses a ligament frm smewhere else in the bdy t recnstruct this ligament stabilizing the patella. Summary f Recmmendatins Risk Factrs Patellar instability Altered mechanics with functinal mvement Bny mrphlgy Quadriceps strength deficits Crrective Interventins Manual fr patellar mbility and knee ROM Neurmuscular re-traning t imprve LE strength and nrmalize mechancis NMES fr quadriceps activatin Sprt-specific activity training Vaspneumatic device fr edema cntrl Precautins WBAT with crutches (until n extensr lag with SLR) Prtected electrical stimulatin prgram if warranted Patellar Glides/Mbilizatin: passive superir and medial glide nly until 6 weeks NO LATERAL PATELLA GLIDES Avid islated hamstring strengthening if autgraft used until 8 weeks Outcme Testing Ismetric testing at 10 weeks Iskinetic Testing at 12 weeks Functinal Test: Hp testing Manual therapy Patellar Mbilizatin: Passive superir glide and medial glide nly until 6 weeks Knee extensin/flexin PROM Scar massage Sft tissue mbilizatin as apprpriate Criteria fr Functinal Test discharge Single leg and triple crss-ver hp test fr distance (within 15% f uninvlved limb) Iskinetic Testing 10% difference in iskinetic peak trque with knee extensin and knee flexin (60º/sec, and 300º/sec) between invlved and uninvlved limbs Quadriceps t hamstring iskinetic strength rati = 60% N signs f patellar instability with clinical testing. Cmplete sprt-specific drills withut cmpensatry mvements, exacerbatin f symptms r reactive effusin Fr OSUWMC USE ONLY. T license, please cntact the OSU Technlgy Cmmercializatin Office at

2 Phase I Weeks 0-2: Prtectin (Pst-Operative 2 weeks) Gait WBAT with crutches Cnfirm with surgen if WB status is nt dcumented in the chart Gait training: fcus n equal weight distributin bilaterally and nrmalizatin f gait mechanics Begin ambulatin with 2 crutches, then 1 crutch then n supprt nce gait mechanics are nrmalized Evaluate fr symmetrical jint lading during stance phase, heel strike with full knee extensin at initial cntact, apprpriate push-ff at te ff ROM Begin passive, active-assisted, and active ROM as tlerated Biking: bike with ½ revlutins and full revlutins per precautins N frced flexin beynd 90º with meniscal repairs Patellar mbilizatin Emphasis n superir and inferir mbility NO lateral mbilizatin Heel slides IT Band stretch and sft tissue mbilizatin Gastrc/Sleus Stretching in seated psitin Strengthening Quad sets Glute sets SLR in flexin, abductin Avid extensr lag Neurmuscular Electrical Stimulatin t quadriceps at Multi-angle knee extensr ismetrics frm 60º-90º are als apprpriate fr thse patients wh cannt tlerate high-intensity neurmuscular electrical stimulatin Pain and Effusin Ice/crytherapy, cmpressin, elevatin t reduce pst-perative effusin 1. Full active quadriceps cntractin with superir patellar glide 2. Full passive knee extensin 3. Effusin: 2+ (effusin can at least be swept ut f medial sulcus) 4. SLR x 10 secnds withut extensr lag 5. Patient is able t tlerate full WB withut increased pain r 3+ effusin 6. Patient able t walk with assistive device, withut bvius deviatins n bservatin

3 Phase I Weeks 2-4: Prtectin (Days 14-28) Gait WBAT Gait training emphasizing avidance f flexed r stiff-knee gait and nrmal push-ff with gastrcnemius/sleus cmplex t restre nrmal gait speed and cadence ROM Cntinue passive, active-assisted, and active ROM as tlerated Meniscal repairs: n frced flexin beynd 90º Twel stretching, prne hangs, bag hangs t achieve and maintain knee extensin symmetrical t the cntralateral limb Bike with NO resistance Patellar mbilizatin with emphasis n superir/inferir glides Begin light Quad and HAMSTRING stretching Strengthening Cntinue weeks 0-2 Quad set prgressin (i.e. prne QS, supine, TKE) SLR in flexin, abductin, adductin, extensin NMES at 60º knee flexin Initiate HAMSTRING activatin exercises (heel slide, hamstring sets, bridges) Step-ups (2 starting height) prgressed withut increased pain and gd technique Begin trunk and lumbpelvic strengthening Bridging, planks, pelvic tilts, teach abdminal bracing Shuttle/Leg Press (90º 0º) bilateral t single-leg presses per patient tlerance and gd mechanics/cntrl increase resistance per patient tlerance Single leg stance Eyes pen t eyes clsed Prgress t dynamic mvements and/r unstable surface Heel/te raises Squat crrect in mdified range 1. Effusin: Patient is able t tlerate full WB withut increased pain r effusin 3. Patient able t walk n level surfaces withut assistive device and nrmal mechanics 4. Patient able t stand n single-leg at least 30 secnds withut lss f balance

4 Phase II Weeks 4-6 ROM Cntinue passive, active-assisted, and active ROM as tlerated ***Cncerns with limited ROM shuld be cmmunicated directly with surgen*** Cntinue patellar mbilizatin as needed Bike-light resistance Cntinue with quadriceps and hamstring flexibility Strengthening Cntinue NMES Weighted multi-angle SLRs Resistance exercises fr gluteal strengthening Resisted side stepping, and backward walking, clamshells, reverse clamshells Prgressive resistance quadriceps and hamstring exercises per patient tlerance Partial ROM lunges Prgress WB/CKC (shuttle, aquatics, Ttal Gym, etc.) strengthening Squat prgressins n stable and unstable surface with gd mechanics NO JOGGING OR SINGLE-LEG PLYOMETRICS 1. Patient is able t tlerate therapeutic exercise prgram withut increased pain r effusin grade ( 1+) 2. Full, pain-free AROM is equal t cntralateral limb (***CONTACT MD IF ABNORMAL***) 3. Nrmal patellfemral mbility withut apprehensin 4. Patient demnstrates nrmal mechanics withut pain during reciprcal stair ascent and descent Phase II Weeks 6-10 Strengthening/ Dynamic Cntrl Prgress WB strengthening exercises fr quadriceps and hamstring Lunges, shuttle, steambats, sidestepping, leg press, squats, single leg Rmanian dead lifts (RDLs), etc. Step up and step dwns (heel tuch) Prgress step height as tlerated by patient Begin sub-maximal leg extensins, 90º - 45º nly Begin bilateral shuttle jumping = 50% bdy weight (shuttle, Ttal Gym, etc.) emphasizing symmetry in landing and take-ff phases Wrk n endurance with lw impact activities - Treadmill walking, stepper, elliptical Prgress single leg balance activities Begin full weight landing mechanics if gd mechanics n shuttle with visual cueing Duble t single leg lading respnse Duble leg jumping in place Week 8: Initiate islated hamstrings strengthening per tlerance. 1. Effusin 1+ (can be swept ut f medial sulcus and returns nly with lateral sweep) 2. Patient is able t tlerate therapeutic exercise prgram withut increased pain r effusin grade 3. Maintain Full, pain-free AROM is equal t cntralateral 4. Nrmal patellfemral mbility 5. Patient demnstrates nrmal mechanics with CKC exercise and early jumping activities

5 Phase III Weeks ROM Cntinue with stretching and Bike Strengthening/ Dynamic Cntrl/ Functinal Activities Full weight bearing (FWB) strengthening exercises Strength prgressin frm stable t unstable surface Prgress full range pen-chain knee extensin exercises as tlerated withut pain Prgress hamstrings strengthening as tlerated (i.e. Duble leg hamstrings curls with physiball, resisted leg curls, etc.) Plymetric prgressin Squat jumps/ brad jumps initially at 50% effrt fr height/distance then prgress when crrect technique is demnstrated Intrduce single leg jumping and rtatinal activities and jgging with increasing resistance Initiate walk-jg prgressin Criteria t initiate jgging Full active knee extensin Nrmal landing mechanics and single leg squat pattern Strength f invlved limb is at least 80% f uninvlved limb Audible rhythmic strike patterns and n grss visual antalgic pattern 1. Effusin 1+ (can be swept ut f medial sulcus and returns nly with lateral sweep) 2. Patient is able t tlerate therapeutic exercise prgram withut increased pain r effusin grade 3. Maintain Full, pain-free AROM is equal t cntralateral 4. Nrmal patellfemral mbility 5. Patient demnstrates nrmal mechanics with all CKC exercise and early jumping activities

6 Phase IV: Return t Sprt/Activity Weeks ROM Maintain ROM equal t uninvlved limb Strengthening Emphasize perfrmance f the quadriceps, hamstrings and trunk dynamic stability Emphasize muscle pwer generatin and absrptin Fcus n activities that challenge muscle demand in intensity, frequency, and duratin f activity Emphasize sprt- and psitin-specific activities Return t Sprt Activities Cnsider Duble leg and single leg activities and transitins Vary planes f mvement and change f directin Perturbatins and alter supprt surface (indr and utdr) Challenge multiple muscle grups (lwer extremity and cre) simultaneusly Examples Weight lifting: squats, leg extensin, leg curl, leg press, deadlifts Lunges-frward, backward, rtatinal, side Rtatinal trunk exercises n static and dynamic surfaces Unilateral shuttle jumping with increasing resistance and mid-air rtatins Emphasize apprpriate symmetry in weight-bearing, jint lading and technique during perfrmance f all therapeutic activities and plymetrics Emphasize sprt- and psitin-specific activities Add ball, racquet, stick Independent Prgram Cnsider: Impact lading and apprpriate attenuatin strategy, cue regarding hard landings Duble leg and single leg activities and transitins Vary planes f mvement and change f directin Examples: Single-leg hp dwns frm increasing height (up t 12 bx) Single-leg hp-hlds (stable surface..airex pad) Duble and single-leg hpping nt unstable surface (i.e. Airex pad) Tuck jumps (fcus n increasing multijint flexin during landing and hlding stable psitin) 90º t 180º jumps Begin agility exercises between 50-75% (utilize visual feedback t imprve mechanics) Side shuffling Hpping Carica Figure 8 Zig-zags Back pedaling Resisted jgging (Sprts Crd) in straight planes, etc Functinal Test Single leg and triple crss-ver hp test fr distance (within 15% f uninvlved limb) Iskinetic Testing 10% deficit in iskinetic peak trque with knee extensin and knee flexin (60º/sec, and 300º/sec) cmpared t uninvlved limb Quadriceps t hamstring iskinetic strength rati = 60% Cmplete sprt-specific drills withut cmpensatry mvements, exacerbatin f symptms r reactive effusin Authrs: Adam Ingle PT, DPT, Chelseana Davis, PT, DPT Reviewers: Jhn DeWitt, PT, DPT, SCS, ATC Cmpletin date: 4/8/15