King Khalid University Hospital

Transcription

1 King Khalid University Hospital Rehabilitation Department Ortho Group Rehabilitation Protocol: PCL RECONSTRUCTION +/- ACL / MCL / LCL / POSTEROLATERAL CORNER 1. General Guidelines: Time lines in this rehabilitation protocol are approximate. If the physiotherapist feels the patient is not ready for progression (due to pain, swelling, inadequate ROM or strength), the time line should be extended to suit the patient. Assume 8-12 weeks for adequate incorporation of PCL graft and/or Posterolateral corner repair. Supervised physiotherapy takes place for 6 9 months as needed depending on patient s progress, activity level, and goals. Patients are to be discharged after completion of all appropriate functional progressions and adequate performance on strength and functional tests. Patients should be encouraged to exercise independently 3-5 times / week in addition to formal physiotherapy during phase II, III, and IV. Functional Milestones: Common functional activities the patient is expected to perform during each rehabilitation phase. Advancement Criteria: Objective criteria used to judge whether or not a patient is ready for progression to the next phase of rehabilitation (see Rehabilitation Progression below). 2. General Precautions: PCL reconstructions are very delicate and difficult please be careful. Isolated PCL: Avoid placing excessive strain on PCL reconstruction by avoiding open chain knee flexion exercises and kneeling on knee. It is important to prevent posterior tibial sagging at all times. Hinged brace for minimum 6 weeks is required. Multiple ligaments: It is important to prevent posterior tibial sagging at all times. PCL + LCL / Posterolateral Corner avoid varus stress and external rotation, hinged knee brace for 8 weeks. PCL + MCL avoid valgus stress and external rotation, hinged knee brace for 8 weeks. PCL + ACL hinged knee brace for 8 weeks. Meniscal repairs: Knee flexion 90 o on all weight bearing exercises (squats) x 4 weeks. Avoid weight bearing + twisting exercises (i.e. BAPS board) for a minimum of 6-8 weeks post op. Medial Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 4 weeks post op. Full weight bearing at 4 weeks as directed by surgeon. Lateral Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% Body weight) up to 6 weeks post op. Full weight bearing at 4-6 weeks as directed by surgeon. 3. Rehabilitation Progression: The following is a guideline for progression through the rehabilitation process. Progression is based on achieving advancement criteria for the next phase of rehabilitation and should take into account the patient s status and the surgeon s advisement If the patient does NOT meet the advancement criteria, extend the time in the current phase of rehabilitation. If the patient achieves the advancement criteria early, the physiotherapist may choose to advance the patient only AFTER 12 weeks post-op. If there is ANY uncertainty concerning the patient, please contact the surgeon. 4. Surgeon Advisement:

2 PHASE I Immediate Post-Op - 3 Weeks Post-Op Protect the PCL graft fixation (brace worn at all times). Decrease post-op pain and inflammation (can utilize Cryo-cuff for 8-12 hours/day x 2 weeks). Achieve full knee extension (MUST emphasize achieving full knee extension). Minimize the effects of immobilization (protect against posterior tibial sagging; NO C.P.M.). Educate patient on rehabilitation progression. 2. Brace / Crutches / Weight Bearing: Brace: Brace locked at 0 o. Brace worn at all times, except when under the supervision of the physiotherapist (remove only for ROM exercises) and when bathing. Elastic dressing worn at all times to keep compression on the knee. Crutches / Weight Bearing: Isolated PCL: crutches for 4 weeks, protected (with crutches and brace) partial ( 50% WB) weight bearing x 4 weeks. PCL + ACL/MCL/LCL/Posterolateral Corner: crutches for 8 weeks, Non-weight bearing x 4-6 weeks. Meniscal repair: crutches 4 to 6 weeks, Non-weight bearing x 2 weeks, then begin protected partial weight bearing ( 50% WB) x 4-6 weeks (medial 4 weeks / lateral 4-6 weeks as directed by surgeon). Ice after exercise program x 15 min. Brace unlocked for ROM exercises Pillow under tibia/calf to protect against posterior tibial sagging. Week 0 2: PROM exercise as tolerated in brace (protect against posterior tibial sagging by doing all ROM in prone position) (NO knee flexion >60 o ). Ankle pumps Quad sets (may consider muscle stimulation if poor quads). NO hamstring sets. Straight leg raise (with brace) in all planes. Hamstring / Gastroc & Soleus stretches. Patellar mobilization as required. Week 2 3: Continue above exercises (NO knee flexion >60 o ) (Multi-Ligament Repairs: Non-Wt Bearing with for all exercises). Isometric quad exercises, NO isometric hamstring exercises. Begin Active Assisted Extension ROM exercises. PROM Flexion exercises. Comfortable ambulation in brace non/partial weight bearing with crutches for protection. 5. Advancement Criteria for Phase II: Full extension Approximately 60 o of flexion No signs of active inflammation Good Quad Set and Straight leg raise without quad lag. PCL Rehab Protocol 1/16/2014 2

3 PHASE II 3 Weeks Post-Op - 6 Weeks Post-Op Protect PCL graft fixation. Control swelling. Maintain full extension ROM. Progress with flexion ROM. Restore normal gait. Return to work: light duties (desk work only). 2. Brace / Crutches: Brace: Brace unlocked at 0-90 o for controlled gait training only (patient may ambulate with unlocked brace while attending PT or when at home). Brace worn at all times, except when under the supervision of the physiotherapist (remove only for ROM exercises) and when bathing. Crutches: Isolated PCL: crutches for 4-6 weeks; may discontinue crutches when patient has full extension and no quad lag. PCL + ACL/MCL/LCL/Posterolateral Corner: crutches for 8 weeks, begin protected (with crutches and brace) partial (<50% BW) weight bearing at 4-6 weeks post-op. Meniscal repair: Continue partial weight bearing ( 50% BW) x 4-6 weeks (medial 4 weeks / lateral 4-6 weeks as directed by surgeon), then progressive protected weight bearing as tolerated. Discontinue crutches at 4-6 weeks when full weight bearing, as directed by surgeon. Ice after exercise program x 15 min Week 3 4: Week 4 6: Increase PROM exercise to o Flexion (Multi-Ligament Repair: NO knee flexion > 90 o and Non-Wt Bearing for all exercises). Begin hip Theraband exercises. NO hamstring strength exercises. Step-Ups (start with 4 block) (Isolated PCL only). Heel raises on surgical leg (Isolated PCL only) and gastroc / soleus stretches. Proprioceptive exercises: Protected single leg stand on surgical leg (Isolated PCL only). Double leg squat or leg press in brace (do not bend knee past 45 o ). (protect against posterior tibial sagging). Begin low resistance stationary cycling (begin with high seat and progressively lower to promote ROM). Double leg squat or leg press (do not bend knee past 45 o ) (Multi-Ligament Repair: 50% WB with for all exercises). NO hamstring strength exercises. Step-Ups (progress to 6-8 block). Step-downs (start with 4 block). Proprioceptive exercises: Double leg wobble board Begin Aquatic Exercises: water walking, hip exercises, swim with upper body (incisions must be fully healed) Full weight bearing in ROM brace +/- crutches. Progressive increase in ROM and quad strength. Light occupational duties (i.e.: desk work). 5. Advancement Criteria for Phase III: Increased active ROM: Full Extension to o Flexion. Strength: Grade 4 / 5 isometric extension (no extensor quad lag). Normal gait on level surfaces with brace. PCL Rehab Protocol 1/16/2014 3

4 PHASE III 6 Weeks Post-Op - 12 Weeks Post-Op Full ROM. Increase leg strength, endurance and proprioception. Avoid overstressing graft during remodeling period (may lead to graft laxity). Increase functional activities. Begin cross-training to maintain general fitness. Return to work: Light duties (avoid prolonged standing, squatting and kneeling). 2. Brace / Crutches: Brace: Isolated PCL week 6 8, Multi-Ligament week 8-12: Brace unlocked for all activities Brace off at night. Discontinue brace as directed by surgeon Patients may choose to wear custom PCL Knee Brace during rehabilitation. Crutches: Discontinue for Multi-Ligament Repair at week 8 if No quads lag Full knee extension Knee flexion up to o Normal gait pattern Week 6 9: Continue Passive / Active Assisted / Active ROM exercises as needed to achieve full ROM. (Multi-Ligament Repair: NO knee flexion > 100 o and 50% BW for all exercises up to 8 weeks). Continue double leg squat or leg press May progress to single leg squats. Begin Hamstring Theraband strength exercises Begin Wall Squats at 45 o (x 2 minutes). Proprioceptive exercises: Single leg wobble board Aquatic Exercises: may begin flutter kicks at side of pool (no whip kick). Theraband / Sportcord resisted quadriceps and hamstring home exercise program. Week 9-12: Continue Wall Squats progress to 60 o - 90 o (x 2 minutes). Begin Stairmaster. Begin closed chain strengthening exercises (do not bend knee past 90 o ) Proprioceptive exercises: slide board / fitter board. Aquatic Exercises: progress to water running and flutter board (no whip kick). Begin power walking at 9 weeks. Begin outdoor cycling at 12 weeks (level terrain, low gear, no toe clips). Driving automatic or standard vehicle with involved leg at 6 weeks (when brace unlocked). StairMaster at 8-10 weeks. Power walking at 9 weeks. Outdoor road cycling at 12 weeks (No toe clips). Light or modified occupational duties to accommodate functional limitations. 5. Advancement Criteria for Phase IV: Full pain free ROM. Strength: Grade 4-5 / 5 (50-75% of normal on leg press and hamstring curl). Normal gait on stairs. No evidence of patellofemoral joint irritation. PCL Rehab Protocol 1/16/2014 4

5 PHASE IV 3 Months Post-Op - 9 Months Post-Op Increase and maintain strength, endurance, and proprioception. Sport specific functional exercises at 6 months. Progressive return to sport after adequate performance on strength and functional tests at 9 months. Return to work: modified duties (avoid heavy lifting, squatting and kneeling). Patient education regarding possible restrictions / limitations. 2. Brace: Patients may choose to wear PCL Knee Brace during early return to sport, up to 12 months post-op. Months 3 4: Begin Lunges to 90 o : surgical leg in front at 12 weeks; behind at 14 weeks (20 reps.). Begin straight line running (12-16 weeks) (begin walk / run intervals and progress to running at therapist discretion no evidence of patellofemoral irritation). Advance closed chain strengthening exercises. Aquatic Exercises: progress swimming (no whip kick). Months 4-6: Begin isokinetic hamstring and quadriceps strengthening (anti-shear device for hamstring). Begin weight training / Nautilus equipment strengthening exercises program. Begin sport specific strengthening exercises. Begin plyometric program as appropriate for patient functional goals. Begin agility training. Begin functional progressions: Directional running: forward, backward, and sideways. ½ to ¾ to full speed running. Running up and down stairs. Cutting, cross-over, carioca and agility drills. Swimming whip kick. Months 6 9: Maintenance program for strength and endurance. Begin sport specific drills as appropriate. Gradual return to Light Sport Activity (ie: golf, skating, cross-country skiing) if: No inflammation or effusion. Full ROM. >75% quadriceps and hamstring strength. single leg hop test for distance >75% of normal side. Months >9: Progress to Pivoting and Contact Sports (ie: racket sports, court sports, and field sports, hockey, downhill skiing) if: No inflammation or effusion Full ROM single leg hop test for distance >90% of normal side >90% quadriceps and hamstring strength on instrumented strength testing (i.e. Lido, Biodex, Cybex) Return to Light Sports Activity at 6 9 months % leg strength with operative to non-operative side comparison. Return to Pivoting and Contact Sports at >9 months. Return to work: full duties. PCL Rehab Protocol 1/16/2014 5