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Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction 333 38 th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com Back View Supraspinatus Infraspinatus Minor Teres Front View Subscapularis MM A B A B Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL) ACL Menisci ACL PCL LCL Tibia MCL MM LM Femur Figure 2 a Figure 2 b Figure 1 a Figure 1 b Figure 1 a: Medial or inner view of the knee showing the medial collateral ligament, b: Lateral or outer view of the knee showing the lateral collateral ligament. Figure 2 a: Anterior or front view of the knee showing the anterior cruciate ligament (ACL), b: Posterior or back view of the knee showing the posterior cruciate (PCL) The knee joint is comprised of an arCculaCon of three bones: the femur (thigh bone), Cbia (shin bone), and patella (knee cap). The femur has a medial (inside) and a lateral (outside) condyle that forms a radial or rounded boEom that comes together, forming a trochlear groove for the patella to move. The medial and lateral condyle sit on top of the Cbia, which has a flat surface called the Cbial plateau. The knee also is comprised of two menisci, which are fibro-carClaginous structures and each meniscus is thinner towards the center of the knee and thicker toward the periphery of the knee, giving it a wedge shaped appearance. The medial meniscus forms a “c” shape and is located between the medial femoral condyle and the medial aspect of the Cbia. The lateral meniscus forms an oval shape and is located between the lateral femoral condyle and the lateral aspect of the Cbia. The menisci act to improve stability between the Cbia and the femur secondary to its wedge shape that acts to limit translaCon. The knee also has four major ligaments, which connect bone to bone and provide stability to the joint. These ligaments are termed the medial collateral ligament (MCL) (Figure 1a), lateral collateral ligament (LCL) (Figure 1b), anterior cruciate ligament (ACL) (Figure 2a), and posterior cruciate ligament (PCL) (Figure 2b). The MCL connects the femur and Cbia medially (on the inside) and resists valgus (knee buckling in) knee moCon. A common mechanism of injury to the MCL occurs when a force is applied to the outer knee while the foot is planted, causing the knee to move inward. The LCL connects the femur and the fibula laterally (on the outside) and resists varus (knee buckling out) knee moCon.

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Page 1: 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.

Page 2: 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

Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction

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

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.

Page 3: 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

Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction

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

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

Range of Motion Exercises

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

Therapeutic Exercises

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

Range of Motion Exercises

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

Therapeutic Exercises

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

Page 4: 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

Rehabilitation Guidelines for Knee Multi-ligament Repair/Reconstruction

Phase IV ( 3 moths to 6 months following surgery)

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

Range of Motion Exercises

Brace ROM: Full; no brace Weight bearing: full

Therapeutic Exercises

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.


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