Kristen A. Herbst, DO Orthopaedic Surgeon Sports Medicine Specialist PCL RECONSTRUCTION

Transcription

1 Kristen A. Herbst, DO Orthpaedic Surgen Sprts Medicine Specialist PCL RECONSTRUCTION Mst PCL injuries are treated nn-peratively. Hwever, if they are part f a multi-ligament knee injury r a patient has persistent instability after cnservative management a recnstructin can be perfrmed using either an autgraft r an allgraft. 1 Brace Rad, Suite B Cherry Hill, NJ P: F: Cper Rad, Suite 2 Vrhees, NJ P: F: Rehabilitatin Principles Be aware f cmprmised and/r repaired tissue Understand graft strain cncepts in rder t prtect the graft. In the first 6-12 weeks f rehab the fixatin f the graft itself rather than the graft is the limiting factr At 6 weeks revascularizatin begins t ccur and the graft itself is in its weakest state Revascularizatin is cmplete at 12 weeks Prtect the healing tissue by preventing any psterir translatin f the tibia and avidance f early hamstring activity. Understand that rehabilitatin after recnstructin f the PCL is significantly mre cnservative than after the anterir cruciate recnstructin. Resistance fr hip PRE s is placed abve the knee fr hip abductin and adductin; resistance may be distal fr hip flexin. Healing tissue shuld never be verstressed but apprpriate levels f stress are beneficial Inflammatry phase days 1-3 Tissue repair with prliferatin phase days 3-20 Scar tissue mst respnsive t remdeling days but ccurs frm 1 t 8 weeks Final maturatin taking as lng as 360 days Graft integratin Revascularizatin begins at 6 weeks Tissue reactivity f the knee and tissue healing will dictate the rehabilitatin prcess. Reactivity is determined by the clinical exam Level I Reactivity Resting pain, pain befre end range Aggressive stretching is cntraindicated Grade I-II mbilizatin fr neurphysilgic effect Level II Reactivity Pain nset ccurs with end range resistance Grade III and IV mbilizatin apprpriate per patient tlerance Level III Reactivity Engagement f capsular end feel with little r n pain. Pain ccurs after resistance Grade III and IV mbilizatin and sustained stretching is apprpriate Eliminate inflammatin as the cause f pain and neurmuscular inhibitin Initially nnweightbearing with crutches unless indicated therwise by physician (culd be partial weight bearing) Brace shuld be lcked in full extensin Psitin pillw under prximal psterir tibia at rest t prevent psterir tibial sag Utilize NMS fr reactivatin f quadriceps musculature, especially the VMO Ensure return f apprpriate jint arthrkinematics Apply techniques in lse packed unidirectinal and prgress t clse packed and multidirectinal based n tissue healing and patient respnse Identify mtin cmplicatins early and begin lw-lad, lng duratin stretching activity Range f mtin may ften be n the stiff side due t prtective phase PROM befre week 4 nly if directed by MD Week 4 6: 0 60 degrees

2 Week 7 8: degrees Week 9 16: full ROM Facilitate perfrmance f cmplex skills with prpriceptive and kinesthetic techniques: Lw t high, sagittal t frntal, bilateral t unilateral, stable t unstable, slw t fast, fixed t unfixed surface Initiate early prpriceptive activity and prgress by means f prpriceptin techniques Incrprate cmprehensive lwer extremity (hip and calf) muscle stabilizatin and strengthening activities as well as cre strengthening activities Address limb cnfidence issues with prgressin f unilateral activity Address limb velcity issues during gait with verbal and tactile cueing Encurage life-lng activity mdificatin. Educate n PPP, lw impact aerbic exercises, etc Encurage integratin f cre strengthening with therapeutic exercises Factrs that affect the rehab prcess Surgical apprach Tissue quality Presence f cncmitant pathlgy Age f patient C-mrbidities Pre and intra-perative range f mtin Pain and sensitivity levels Cgnitive abilities Pst p functinal guidelines Dependent n functinal range and strength, and neurmuscular cntrl Drive N research t supprt recmmendatins fr return t driving Refer patient t drug precautins Refer patient t aut insurance cverage Dependent n left r right invlvement Wrk Sedentary up t 1-2 weeks Medium t high physical demand level weeks, which will be cmmunicated with the physician Sprt Jgging n the treadmill N sner than 4 mnths Observe and minimize limb velcity asymmetry Encurage lwer impact activity Return t sprt team 9 mnths Dependent upn gd quad cntrl, full range f mtin, 80% scre n hp test, nrmal KT test (when rdered r recmmended by the PT) and 80% iskinetic scre (when rdered r recmmended by the PT) Pst p equipment guidelines Plar care as needed fr pain and inflammatin Brace Lcked at 0 degrees fr 4 weeks Unlck brace 0-60 degrees frm 4 6 weeks Unlck brace degrees frm 6-8 weeks Unlck brace at week 8 D/C lng leg brace at week 10/switch t custm PCL brace D/C custm PCL brace except fr sprts activities at week 16 Must wear custm PCL brace fr 12 mnths after return t sprt Assistive device (crutch, cane, walker) 2 crutches (nnweightbearing) fr 0 3 weeks 2 crutches (Nn t te-tuch weightbearing) fr 3 6 weeks At week 6, weightbearing as tlerated with ne r tw crutches Full weightbearing at week 8 Functinal Brace Fit at week 10

3 Rehabilitatin Week 1-3: Prtective ROM Phase Precautins/Limits: Swelling and effusin Inhibit pst-p muscle shut dwn Avid psterir tibial translatin N active knee flexin Clinical Expectatins by the end f week 3 Wrking tward visible, balanced quad cntractin Independent straight leg raise withut extensr lag (in brace) n sagging Minimizatin f swelling Gentle scar and patellar mbilizatin E-Stim, bifeedback, verbal, and/r tactile cuing fr quad re-educatin (dispense hme unit if indicated) Straight Leg Raises may d all directins except n prne extensin leg raises (may d in standing weeks 3-4) Hamstring and calf stretching Calf press with exercise bands Week 4-6: Prtective ROM Phase and Early Weight Bearing Precautins/Limits Swelling and effusin ROM Muscular inhibitin Avid psterir tibial translatin N active knee flexin Clinical Expectatins by the end f week 6 ROM: 0 degrees t 60 degrees Balanced, slid quadriceps cntractin Independent straight leg raise withut extensr lag 4/5 abductin strength Ambulatin with 2 axillary crutches nn r te tuch weightbearing PROM fr the knee therapist applies psterir t anterir pressure n the tibia t prtect PCL Scar and patellar mbilizatin E-Stim, bifeedback, verbal, and/r tactile cuing fr quad re-educatin Light knee extensin frm flexin limits t 40 degrees Straight Leg Raises Calf and hamstring stretching Calf press with exercise bands Abductin n multi-angle hip machine resistance abve the knee Weeks 6-8 Weightbearing/Strengthening Phase Precautins/Limits Swelling and effusin ROM precautins Muscular inhibitin Quad cntrl Gait and prpriceptive deficits still n active flexin avid psterir tibial translatin Clinical Expectatins by the end f week 8 ROM: 0 degrees t 100 degrees Nrmalized straight leg raise and 4+/5 abductin strength Ambulatin with single crutch with minimal deviatin Cntinue PROM, scar and patellar mbilizatin as needed

4 Cntinue stretching all previus muscle grups, adding gentle, prne quadriceps stretching Cntinue with e-stim, bifeedback, verbal, and/r tactile cueing fr quad facilitatin Gait training with ne crutch using cues fr asymmetries Begin bilateral standing exercises such as standing calf raises and light weight shifting Carefully begin sme unilateral standing exercises als if patient is judged t be f safe strength and perfrmance Gently prgress knee extensin exercises Prgress knee extensin 90º-40º t 2# Begin leg press and fur way multi-angle hip machine Light multi-angle ismetrics n knee extensin machine Begin light active knee flexin Weeks 8-10: Strengthening Phase Precautins/Limits Swelling and effusin ROM Prgressin dependent n quad cntrl and limb cnfidence 4. Avid psterir tibial translatin Clinical Expectatins by the end f week 10 Wrk gently tward full PROM Ambulatin withut crutch r deviatin Cntinue AROM, PROM, scar and patellar mbilizatin as needed Cntinue cmprehensive lwer extremity stretching prgram Gait training as needed, cueing fr prper frm withut assistive device r deviatin Prgress bilateral and unilateral clsed chain activies t increase limb cnfidence as well as prpriceptin, and RNT Initiate unilateral flexin activity under weight bearing Prgress knee extensin exercises Prgress lwer extremity and cre strengthening exercises Weeks 10-6 mnths: Functinal Strengthening Phase Limits/Precautins Swelling and effusin Full ROM Prgressin dependent n quad cntrl and limb cnfidence Graft is at its weakest during revascularizatin Clinical Expectatin by the end f week 12 Full, pain-free ROM (nte: it is nt unusual fr flexin t be lacking degrees fr up t 5 mnths after surgery) Gd, symmetrical quad cntractin Ambulatin withut crutch r deviatin with symmetrical limb velcities Increased pen and clsed chain hamstring strength (withut undue psterir knee irritatin) Wrk tward full ROM Cntinue cmprehensive lwer extremity stretching prgram Cue fr prper gait withut assistive device and address any limb velcities Prgress bilateral and unilateral clsed chain activities t imprve limb cnfidence, prpriceptin, and RNT Prgress unilateral flexin activity under weight bearing Prgress knee extensin strength, as well as pen chain hamstring strength Prgress lwer extremity and cre strengthening prgram Treadmill walking 12 weeks Swimming (n frg kick) 12 weeks Jgging in pl with vest r belt 12 weeks Initiate and prgress basic, single plane, bilateral hpping activities that require leaving the grund with emphasis n quality and shrt distances Base height and distance n lwer limb cntrl and frm 6 mnths 9 mnths: Initiate Return t Sprt Training

5 Limits/Precautins Swelling and effusin Address any limb velcity asymmetries Prgressin dependent n quad cntrl and limb cnfidence Clinical Expectatins by the end f 9 mnths Symmetrical quad cntractin Able t demnstrate gd landing with plymetric activity t include the fllwing: Gd athletic psture (spine erect and shulders back) N valgus psitin at the knees with landing Sft landing Stabilize the landing Able t land with symmetrical landing pattern with basic unilateral hpping activities Demnstrate 80% scre n the single let hp test (if returning t cmpetitive sprts) Prper crdinatin with higher level, single plane, dynamic activities Cntinue cmprehensive lwer extremity stretching prgram Cue fr prper gait and address any limb velcity asymmetries Prgress bilateral and unilateral clsed chain activities t imprve limb cnfidence, prpriceptin, and RNT Prgress unilateral flexin activity under weight bearing Prgress knee extensin strength Prgress lwer extremity and cre strengthening prgram Prgress basic bilateral hpping drills t unilateral activities that require leaving the grund with emphasis n quality and shrt distances Prgress basic bilateral plymetric activities including jump training frm different heights and increased distances Initiate higher-level, sprts-specific, single place, agility activities (frward, retr and lateral nly n cutting activities) 8-9 mnths: Return t Sprt Clinical Cnsideratins CMP Patellar Tednitis/Bursitis Quad Cntrl Patient Gals Level f Sprt r Activity Iskinetic testing

6 REFERENCES Brigham and Wmen s Hspital: Department f Rehabilitatin Services (Cpyright 2007). PCL Recnstructin Prtcl. Brtzman and Wilk (D Amat and Bach). Clinical Orthpaedic Rehabilitatin. 2 nd Editin. Msby Bullis DW, Pauls LE. Recnstructin f the Psterir Cruciate Ligament With Allgraft. Clinical Sprts Medicine 1994;13: Harner CD. Bimechanical Analysis f a Duble-Bundle Psterir Cruciate Ligament Recnstructin. American Jurnal f Sprts Medicine 2000;29: Makin, A. Anatmic Duble-Bundle Psterir Cruciate Ligament Recnstructin Using Duble-Duble Tunnel With Tibial Anterir and Psterir Fresh-Frzen Allgraft. Arthrscpy: The Jurnal f Arthrscpic and Related Surgery. 2006:22:684e1-684e5. M.J. Matava. Surgical f Psterir Cruciate Ligament Tears: An Evlving Technique. Jurnal f American Academy f Orthpaedic Surgens. 2009;17: R.F. Laprade, S. Jhansen J. Outcmes f an Anatmic Psterlateral Knee Recnstructin. Jurnal f Bne and Jint Surgery. 2010;92: Shields CL. Rehabilitatin f the Knee in Athletes. The Lwer Extremity and Spine in Sprts Medicine, Vlume 1. St. Luis, CV Msby, 1986.