Download - Rehabilitation Guidelines for Knee Multi-ligament … Guidelines for Knee Multi-ligament Repair/Reconstruction 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! the

Dr. Laith M. Jazrawi Chief, Division of Sports Medicine

Associate Professor Department of Orthopaedic Surgery

Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Back View Supraspinatus

Infraspinatus

MinorTeres

Front View

Subscapularis

MM

A B

AB

MedialCollateralLigament(MCL)

LateralCollateralLigament(LCL)

ACL

Menisci

ACL

PCLLCL

TibiaMCL

MM LM

Femur

Figure2aFigure2b

Figure1aFigure1b

Figure1a:Medialorinnerviewofthekneeshowingthemedialcollateralligament,b:Lateralorouterviewofthekneeshowingthelateralcollateralligament.Figure2a:Anteriororfrontviewofthekneeshowingtheanteriorcruciateligament(ACL),b:Posteriororbackviewofthekneeshowingtheposteriorcruciate(PCL)

ThekneejointiscomprisedofanarCculaConofthreebones:thefemur(thighbone),Cbia(shinbone),andpatella(kneecap).Thefemurhasamedial(inside)andalateral(outside)condylethatformsaradialorroundedboEomthatcomestogether,formingatrochleargrooveforthepatellatomove.ThemedialandlateralcondylesitontopoftheCbia,whichhasaflatsurfacecalledtheCbialplateau.Thekneealsoiscomprisedoftwomenisci,whicharefibro-carClaginousstructuresandeachmeniscusisthinnertowardsthecenterofthekneeandthickertowardtheperipheryoftheknee,givingitawedgeshapedappearance.Themedialmeniscusformsa“c”shapeandislocatedbetweenthemedialfemoralcondyleandthemedialaspectoftheCbia.ThelateralmeniscusformsanovalshapeandislocatedbetweenthelateralfemoralcondyleandthelateralaspectoftheCbia.ThemenisciacttoimprovestabilitybetweentheCbiaandthefemursecondarytoitswedgeshapethatactstolimittranslaCon.Thekneealsohasfourmajorligaments,whichconnectbonetoboneandprovidestabilitytothejoint.Theseligamentsaretermedthemedialcollateralligament(MCL)(Figure1a),lateralcollateralligament(LCL)(Figure1b),anteriorcruciateligament(ACL)(Figure2a),andposteriorcruciateligament(PCL)(Figure2b).TheMCLconnectsthefemurandCbiamedially(ontheinside)andresistsvalgus(kneebucklingin)kneemoCon.AcommonmechanismofinjurytotheMCLoccurswhenaforceisappliedtotheouterkneewhilethefootisplanted,causingthekneetomoveinward.TheLCLconnectsthefemurandthefibulalaterally(ontheoutside)andresistsvarus(kneebucklingout)kneemoCon.



AcommonmechanismofinjurytotheLCLoccurswhenaforceisappliedtotheinnerkneewhilethefootisplanted,causingthekneetomoveoutward.TheACLandPCLaEachtheCbiaandfemurdeepinsidethekneejointandcrossoneanotherlikeguidewires.TheACLrestrainstheCbiafrommovingforwardandrotaCngexcessivelyonthefemur.MostACLinjuriesoccurwithoutcontact,mostcommonlywhenanindividualplantstheirfootandchangesdirecConwhileparCcipaCnginsports.ThePCLresiststheCbiafrommovingbackexcessivelyonthefemur.PCLinjuriesmostcommonlyoccurwhenananteriorforceisappliedontheCbiasuchaswhenthelowerleghitsthedashboardofacarduringacaraccidentorlandingonthekneewiththekneeflexedapproximately90degrees.Ligamentousinjuriesaretermedsprainsandaregradedbasedontheseverityoftheinjury.Agrade1ligamentsprainisaminimalinjurywithliEletonoincreaseinlaxitytotheligamentwhereasagrade3sprainisacompleterupturetotheligament.Kneeinjuriesthatinvolveoneofthefourligamentsaresomewhatcommon.Injuringtwoormoreofthefourmajorkneeligamentsisuncommonandusuallyoccursasaresultofahighenergytraumasuchasanautomobileaccident,fallorasignificantsportsinjury.1WhentwoormoreoftheligamentsarerupturedtheCbiaand

Figure3–a:RadiographshowinganexampleofanteriorkneedislocaCon,b:RadiographshowinganexampleofposteriorkneedislocaCon

A B

thefemurmaylosecontactfromoneanotherandspontaneouslycomeapartordislocate.AkneedislocaConbetweenthefemurandtheCbiaisnamedbythedirecContheCbiaisorientatedfromthefemurinadislocatedposiCon.SecondaryinjuriessuchasnervedamageandorvascularinjuryarecommonfollowingakneedislocaCon.(1)OYenthevascularornerveinjuriesrequireemergencyaEenContosavethelimborpossiblytheindividual’slife.Oncethekneeisevaluatedandsecondaryinjuries,ifany,arerepaired,theiniCaltreatmentofthemulC-ligamentinjuriesincludesimmobilizaCon,whichisfollowedbyconCnuedevaluaConanddiagnosCctesCngtodeterminetheextentoftheligamentdamage.TreatmentopConsincludesurgicalandnon-surgicalapproachestocare.TreatmentdecisionsoYenaremadebased-oneachindividual’spre-injuryfuncConandtheextentoftheligamentdamage.RecentstudieshavesuggestedpaCentsreceivingoperaCvetreatmenthaveimprovedfuncConaloutcomeswhencomparedwithnon-operaCvetreatment.(2)TheCmingofsurgeryiscriCcalwithevidencethatshowsifsurgeryisdoneimmediatelyfollowingtheinjury.

followingtheinjury,anindividualmayexperienceincreasedpost-operaCvesCffnessandscarring.(3)ResearchhasshownthatoutcomesofmulC-ligamentreconstrucConarebestwhenthesurgeryisdonewithin3weeksfrominjuryaYerthepaCentcanreducetheswellingfromtheiniCalinjury.Surgerywillvarydependingontheextentoftheligamentdamageandthespecificligament(s)involved.Iftheligamentisavulsedfromthebone(pulledoffthebone)thenthesurgeonmaybeabletoperformaprimaryrepairofaEachingtheligamentbacktothebone.WhenaligamentisruptureditoYenhastobereconstructed,whichmeansreplacingtheligamentwithotherCssue.ThiscanbedonebyusinganautograY(donorCssuefromaninjuredperson)oranallograY(donorCssuefromacadaver).RehabilitaConfollowingmulC-ligamentreconstrucConisvitaltoregainingmoCon,strengthandfuncCon.IniCallyaYersurgerythekneeisbracedandindividualsusecrutcheswithminimaltonoweightbearingforthefirst6weeks.GraduallymoreweightbearingandmobilityisallowedtopreventsCffnesspost-operaCvely.TherehabilitaConwillslowlyprogressintostrengthening,gaitandbalancingacCviCes.TheUWHealthsportsrehabilitaConguidelinesarepresentedinacriterionbasedprogression.GeneralCmeframesrefertotheusualpaceofrehabilitaCon.However,individualpaCentswillprogressatdifferentratesdependingontheirage,associatedinjuries,pre-injuryhealthstatus,rehabcompliance,Cssuequalityandinjuryseverity.SpecificCmeframes,restricConsandprecauConsmayalsobegiventoenhancewoundhealingandtoprotectthesurgicalrepair/reconstrucCon.



Precautions Brace ROM: locked in full extension Weight bearing/ROM: touch down, weight bearing

Range of Motion Exercises

Weight bearing/ROM: Touch down, weight bearing then proceed to as tolerated by patient

Therapeutic Exercises

Quad Sets Ankle pumps Cryotherapy device Elevation Heel slides Seated flexion Prone flexion Wear knee brace for at least six weeks after post op

Phase I (Post-op Day 1 to 1 week after surgery)

Phase II (2 week to 5 week after surgery) Precautions Brace ROM: locked in full extension

Weight bearing/ROM: touch down, weight bearing


Weight bearing/ROM: Touch down, weight bearing then proceed to as tolerated by patient


Week 2-3 : straight leg raises with no weight Week 4-5: straight leg raises with 1 lbs. of weight Should have 90 degrees of flexion

Phase III (6 week to 12 week after surgery) Precautions Brace ROM: discontinue brace when quadriceps strengthening allows, neoprene sleeve with alteral

buttress optional


Weight bearing/ROM: full:; should have normal ROM


Week 6-7: start stationary bike Weeks 8-12: continue stationary bike Start shuttle jumps at week 12 Treadmill Isotonic leg press Toe press Leg curl Stool scooter


Phase IV ( 3 moths to 6 months following surgery)



Brace ROM: Full; no brace Weight bearing: full


Initiate progressive jogging program Advance to cutting and sport-specific drills Return to regular sports if cleared by MD

References 1.  Rihn,Groff,Harner,Cha.Theacutelydislocatedknee:EvaluaConandManagement.JAmAcadOrthopSurg2004;334-346.2.Levyet.Al.DecisionMakingintheMulCligament-InjuredKnee:Evidence-basedSystemaCcReviewJourofArthroscopicandRelatedSurgeryApril2009430-38.3.Jari,shelbourne.NonoperaCveordelayedsurgicaltreatmentofcombinedcruciateligamentsandmedialsidekneeinjuriesSportsMedArthroscRev2001:185-192.

Download - Rehabilitation Guidelines for Knee Multi-ligament … Guidelines for Knee Multi-ligament Repair/Reconstruction 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! the

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