Non-operative Treatment for Type 1 Tibial Plateau

Fracture By: Britt Dickman

Rehabilitation of Athletic Injuries

Dr. Valerie Moody

Spring 2014

1

Introduction:

The knee has a medial and lateral tibial plateau, on which the menisci sit and articulate

with the femoral condyles. These types of fractures only account for one percent of all fractures

and up to 70% of isolated tibial plateau fractures occur to the lateral plateau, whereas 25% are

isolated medial tibial plateau fractures.1, 2 The mechanism of injury to cause a tibial plateau

fracture is produced by an axial load with either a valgus or varus force.1, 2 According to the

Brigham and Women’s Hospital, motor vehicle accidents account for the majority of tibial

plateau fractures due to impact on collision, followed by falls and sport injuries. A fracture to the

proximal tibia results from low-energy trauma or high-energy trauma.3 With both types of

trauma, soft tissue injury also needs to be assessed.

When a fracture to the proximal tibia occurs, the articulating anatomical structures to the

area are at risk for being damaged. The medial and lateral condyles are separated by the

intercondylar eminence, which is the attachment site for the cruciate ligaments. The lateral and

medial collateral ligaments are taken into account as well because they surround the knee joint.

The attachment of the muscles in the area are evaluated for damage due to the attachment sites

above and below the tibial plateau. Each of these structures are inspected to help determine the

severity of the injury.

The Schatzker system is used to classify the severity of tibial plateau fractures. The

system has six groups: a type I fracture is a split of the lateral plateau; a type II involves a split

and depression of the lateral plateau; type III is a pure depression of the lateral plateau; type IV

fractures involve only the medial plateau; type V are bicondylar fractures; and type VI are

bicondylar with separation of the metaphysis and diaphysis of the tibia.1 Management of tibial

plateau fractures vary from conservative non-operative to operative. If the soft tissue in the knee

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is damaged or the fracture is displaced and not stable, operative treatment is required. A non-

displaced to partially displaced, stable fractures are treated with a brace and non-weight bearing.3

A published article on outcomes of patients 20-years after non-operative treatment revealed the

majority of the patients had excellent outcomes.4 A similar study followed patients for 10 years

that had displaced fractures and were treated non-operatively. The majority of the patients had

moderate to severe arthritic changes. Decoster et al. recommends surgical forms of treatment

when the tibial plateau fracture is displaced.5

The purpose of surgery in tibial plateau fractures is to repair the ligamentous structures,

realign the bones, and stabilize the knee. Fracture fixation includes plates, screws, or external

fixations. In some severe cases, bone grafts are used. The degree and severity of the injury

indicates what type of surgery is performed.2 The longevity of knee joints are analyzed after

suffering a high-energy tibial plateau fracture and repaired with external fixation.1 All reports

were good to excellent outcomes. The technique of external fixation helps minimize disruption to

the soft tissues, while allowing for realignment and proper healing to be restored in the joint.4

What was common among all of these surgical techniques was that all patients were required to

wear hinge brace and were non-weight bearing for 12 weeks.1

Applying the knowledge of the knee’s anatomy and peer-reviewed studies on clinical

findings for tibial plateau fracture rehabilitation, this plan of care focuses on rehabilitating the

knee back to pre-injury function and strength. This is accomplished with a method that is slow

enough to prevent stiffness and malunion.1 To avoid these issues from happening,

communication between the patient and clinician is necessary. Most importantly, patient

compliance is stressed throughout the rehabilitation process, as it is very beneficial for a positive

rehabilitation outcome.

3

Clinical Findings:

The patient, a 17-year-old male pole-vaulter, missed the landing on his jump and landed

on the track. The team physician evaluated the athlete and determined from the way he landed on

the track caused a type I tibial plateau fracture. After the evaluation, the team physician

established there was minimal displacement but the knee was stable. The athlete has been put

into a hinge brace for the next 12 weeks and to be non-weight bearing for 6 weeks.

Rehabilitation has been instructed to start immediately.

The physician’s examination showed the athlete is lacking 25 degrees of extension and he

only has 55 degrees of flexion due to pain. Normal range of motion (ROM) for flexion of the

knee is 0-145 degrees and normal extension is 0-10 degrees, though slight hyperextension is

common at the knee.6 Knee flexion and extension is essential for activities of daily living (ADL)

and for sport specific activities. Loss of ROM affects the function of the entire lower extremity.

If knee flexion is not regain to normal ranges, alterations to gait occur, and a person has

difficulty going up stairs and sitting.7 Limited knee extension also affects gait patterns along with

running and jumping because of the failure to attain the proper closed-packed position of the

knee.7 In order to pole-vault, an athlete needs to sprint down the track, which requires them to

have full ROM of the knee. Sprinting requires at least 125 degrees of flexion and full extension.6

If these ROM problems are not resolved, it is impossible for the athlete to perform at the

previous level of competition, not to mention perform activities of daily living such as walking

and sitting properly. To complete ADL’s, a flexion of 70 degrees and extension of 30 degrees is

required at the knee.6

4

In addition to ROM, patellar mobility was assessed to be about 50% of normal. As the

knee goes from flexion to extension, the patella should track medially within the 45-18 degree

range and then track laterally in the last 18 degrees of extension.6 Tracking of the patella depends

on the relationship between the femur and tibia, the Q-angle, the integrity of the patella’s soft

tissue restraints, foot mechanics, and the flexibility of the muscles surrounding the knee joint.6, 7

If the patella is not moving properly, the function of the lower extremity is altered. Alterations to

the lower extremity affect activities of daily living and inhibit athletic performance.7 Referring

back to having adequate range of motion at the knee, the knee needs to move within the full

ROM in order for the athlete to pole-vault. When the patella has only half of its mobility, the

knee does not have the proper biomechanics to have normal function. Little evidence is found to

support or refute patellar mobility prediction of how the lower extremity functions.6

The team physician’s examination of the patient notes a large effusion around the knee.

Effusion is fluid accumulating around the joint, also known as swelling. Many signs and

symptoms of swelling include pain, stiffness, and bruising.6 Joint effusion induces quadriceps

joint inhibition and knee joint mechanics.7 Each of these signs all need to be addressed early in

rehabilitation to help regain ROM and mobility.

The information from the physician’s exam highlights the importance of applying

exercise to regain ROM early in the rehabilitation program. The athlete first needs to get to the

point where he performs activities of daily living. Once he accomplishes this, regaining full

ROM needs to occur in order for the athlete to have a chance to return to his sport. Assisting the

athlete to return to the ROM and mobility that he had pre-injury helps stabilize the knee and

helps the athlete return to play without fear of re-injury.

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Long Term Goals:

The primary goal of the rehabilitation program is to control the effusion of the affected

knee and regain full ROM. While increasing the ROM of the knee through exercise, the next

goal of the rehabilitation plan is to improve patellar mobility. Most importantly, the long term

goal of the rehabilitation plan is to return the athlete to play with full range of motion and proper

strength and endurance of the muscles of the affected knee needed to compete and train in his

sport. After 18 weeks the affected knee should be strong enough to practice pole-vaulting

without the brace. The athlete only progresses towards the long-term goal only if he completes

the short-term goals as outlined in this plan of care.

Phase I (0-6 weeks post-injury):8

The main focus in the first phase of this plan of care is to control to reduce pain and to

inflammation and to increase range of motion on the affected knee. Treating inflammation early

is important to prevent secondary metabolic injury.9 Increasing range of motion early with

exercises is to prevent the formation of joint stiffness and deep vein thrombosis, which can result

secondary to prolonged immobilization.10 Both effect the athlete’s ability to perform at the

previous level of competition. All ROM exercises are done actively in this phase. Modalities are

used accordingly to help treat pain.

To assess the goal of decreasing edema in the joint, the circumference of the affected

knee and unaffected knee is measured daily, prior to each session. Three measurements are

recorded on each knee, one at midpatella, one 7 cm above the superior border of the patella, and

one 15 cm above the superior border of the patella.11 The goal is to have the measurements of the

affected knee equal the measurements of the unaffected knee by week 4. To obtain these results

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modalities are used in conjunction with a compression wrap on the affected knee. Most

importantly, the athlete compliance determines if the goal is met or not, because utilizing the

RICE (rest, ice, compression and elevation) method is required at home.

The second goal of this phase, increase ROM, is observed using goniometric

measurements. The affected knee’s ROM is measured at the beginning of each session just like

the circumference measurement. The axis of the goniometer is placed on the lateral epicondyle,

the stationary arm lines up with the greater trochanter, and the movement arm lines up with the

lateral malleolus.6 By week 6, the knee is able to flex to 90 degrees. This goal is achieved by

active ROM exercises and joint mobilization techniques for the knee.

Along with increasing ROM and decreasing edema, rebuilding the strength of the hip

flexors and extensors, hip internal and external rotators, knee flexors and extensors, knee internal

and external rotators, ankle dorsiflexors and plantarflexors is important. All strengthening is

done isometrically moving to isotonic exercises towards the end of the phase. The upper and

lower leg are strengthened with quadricep sets and hamstring sets.12 Core strength is essential for

pole-vaulters to compete at all levels. Throughout this phase, core strengthening is incorporated

with addition to exercises to help maintain the athlete’s cardiovascular endurance.

Cardiovascular endurance is maintained with an upper extremity bicycle. Pool exercises are used

towards the end of this phase.

Core strengthening and stabilization is important in helping with dynamic functional

strength and neuromuscular efficiency through the whole kinetic chain.12 The first part of core

strength teaches the athlete to actively contract the transversus abdominis (TA) and its force

couple, the multifidus. Verbal cues help the athlete visualize how to contract their TA and

multifidus. The athlete utilizes the prone and supine position to activate the TA due to the

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inability to weight bear and lack of ROM.12 In order to move onto the second phase of

rehabilitation, these exercises are important.

Exercise Sets and Repetitions

Knee ROM Wall Slides to 90 Degrees 2 sets, 10 reps

Hamstrings Hold-Relax Technique for 1 minute (within pain free

ROM)Piriformis Stretch Static Assisted for 1 minute

Sidelying IT Band Stretch Hold-Relax Techniques- hold for 1 minute

Quadriceps Hold for 1 minute (within pain free ROM)

Patella Mobility 3-5 minutes

Gastroc/Soleus Stretching Hold for 30 seconds repeat 3 times

Strength Exercises

(Week 1-2)

Quadricep Sets 2 sets, 10 reps

Hamstring Sets 2 sets, 10 reps

Straight Leg Raise (Multi-Plane)

3 sets, 10 reps

Strength Exercises

(Week 2-4)

4 Way Hip(Prone and Side lying with resistance inferior to knee)

3 sets, 8 reps

4 Way Ankle(With Resistance Band)

3 sets, 8 reps

PNF Knee Pattern (through pain free ROM)

2 sets, 10 reps

Star Toe Touches (Standing on unaffected, affected leg

doesn’t touch ground)

5 reps

Strength Exercises

(Week 4-6)

Hip Adduction with Cuff Weight

3 sets, 10 reps

Hip Abduction with Cuff Weight

3 sets, 10 reps

Clam Shells 2 sets, 10 reps

Core Exercises TA Isometrics 2 set, 10 reps, hold for 10 sec

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(Week 1-3) Multifidus Isometrics 2 set, 10 reps, hold for 10 sec

Press Ups 2 set, 15 reps, hold for 5 sec

Abdominal Rolls 2 set, 10 rolls on each side

Prone Cobra 2 set, 15 reps

Core Exercises

(Week 4-6)

Superman’s 2 set, 20 reps, hold for 3 sec

Toe Taps 3 sets, 10 reps

Heel Slides 3 sets, 10 reps

Abdominal Crunches 3 sets, 20 reps

Russian Twists 3 sets, 25 reps

Cardiovascular Exercises(Week 1-4)

Upper Extremity Bicycle Interval Workout

10 seconds of high intensity and 20 seconds of low intensity (25 minutes)

Cardiovascular Exercise(Week 4-6)

Upper Extremity Bicycle Interval Workout

15 seconds of high intensity and 20 seconds of low intensity (25 minutes)

Pool Workout Walking Forward and Backward (20 minutes)

Stationary Bike 20 minutes at a moderate intensity as tolerated

Rationale:

Through phase I, all ROM exercises are done actively. Using active motions helps

prevent the joint from moving in the painful arc of motion, which passive stretching of the

musculature around the knee is used in the beginning weeks.12 The damaged structures are given

time to heal when ROM is kept in the pain free arc, which helps prevent instability around the

knee.8,12 Patellar glides are utilized during this phase to help increase knee extension and flexion

and to help stretch the lateral retinaculum and tight medial structure.12 By the end of this phase,

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patellar mobility is back within normal limits. The gastrocnemius and soleus stretch help with

knee extension.12

As ROM in functional patterns is important, it is also important to strengthen the muscle

of the affect knee. This includes muscles of the hip, knee, and ankle. Initially, the muscles that

act upon the knee are trained isometrically.12 The isometric exercises include the quadriceps sets

and hamstring sets. Additionally, all exercises that strengthen the hip, ankle, and lower leg are

completed while the athlete is out of the hinge brace.8 The athlete is in a controlled environment

and monitored for safety and stability of the knee while out of the brace.

As ROM is increasing, proprioceptive neuromuscular facilitation (PNF) patterns are

utilized to help increase ROM, strength, and neuromuscular control. PNF exercises utilize

sensory, motor and psychological feedback.12 The patterns of PNF are through functional patterns

and assist muscles on re-education of individual motor elements through neuromuscular control,

joint stability, and coordination.12 During phase I, the athlete only moves through the ranges that

are pain free. PNF exercises are performed without the brace to increase the cutaneous feedback

to the athlete.

Using resistance bands for the ankle helps build initial strength in these muscles without

stressing the knee. The four way knee is performed prone and side lying with the resistance band

inferior to the knee to help prevent torque of the knee. During these exercises, the clinician

instructs the athlete on proper form and pace of the exercises. The straight leg raise through the

multi-plane patterns initiate functional movements the lower extremity works in and also starts

preparing the muscle to start strengthening.8 The athlete has a light cuff weight around the

inferior portion of the knee decreasing the stresses on the knee. These exercises help regain

muscular control and minimize atrophy.12

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Cardiovascular fitness need to be maintained to prevent deconditioning of the athlete

while they are out of practice.12 Since the athlete is non-weight bearing and restricted to 90

degrees during the first six weeks, the upper extremity arm bicycle is utilized. It allows the

athlete to keep up his cardiovascular fitness and work his upper extremity. Towards the last three

weeks of the phase, the athlete starts walking in the pool with assistance. The pool eliminates

gravitational stresses on the knee. This is a gait way into partial weight-bearing exercises during

phase II.12 The stationary bike is during the last week of phase I. The seat is lowered to the angle

of knee flexion the patient has. The stationary bike is used to facilitate cardiovascular training,

and it is used to help regain active range of motion in the knee. The athlete goes at an intensity

that causes no pain.

In order for the athlete to progress to phase II of the plan of care, he must exhibit active

knee extension to 90 degrees and full knee extension. All ranges are pain free. Also, the athlete is

able to complete sets and repetitions for each strengthening exercise. Making sure the athlete is

able to do the strengthening exercises in this phase is important because phase II strengthening

exercise become more rigorous. Progressing the athlete without an adequate foundation of

strength has a negative effect on the stability of the knee. Imbalances in strength between the

affected leg and the non-affected leg result in an increase of re-injury and favoring of the non-

affected leg.13

Phase II (7-12 weeks):8

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The second phase of this plan of care focuses on regaining full ROM of the knee joint. By

week 12, the athlete has knee flexion equal to the unaffected knee.3 This phase focuses on

progressing the athlete from non-weight bearing to partial weight bearing to full-weight bearing.

Closed-kinetic-chain exercises are added to the strengthening exercises. These exercises help re-

establish neuromuscular control around the knee, which facilitate dynamic stability of the knee.12

By week 12, the athlete will no longer needs the hinge brace to help stabilize the knee.

At the beginning of this phase, bone healing is in the remodeling process. Wolff’s law is

utilized to ensure bone tissue is being laid in the direction in which forces are placed on the

bone.9 The forces that are placed along the bone causes the bone to realign along the lines of

tensile force. It is important for forces to gradually increase throughout the rehabilitation process

in order for bone to heal properly.9

Exercise Sets and Repetitions

Knee ROM(Week 7-12)

Thomas Stretch Hold for 30 seconds repeat 3 times

Adductor Stretch Hold for 30 seconds repeat 3 times

Quadriceps Hold for 30 seconds repeat 3 times

Patellar Glides 3-5 minutes

Calf Stretches Hold for 30 seconds repeat 3 times

Posterior Tibial Glides 3-5 minutes

IT Band Stretch Hold-Relax repeated 3 times

Hamstring Hold-Relax repeated 3 times

Strength Exercises(Week 7-9)

Calf Raises (Body Weight)

3 sets, 10 reps

Mini Squats-use stick(0-40 degrees)

3 sets, 10 reps

PNF Knee Pattern 3 sets, 8 reps

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(Through a greater range)

Monster Walks(Light Resistance Band)

3 sets, 5 yards back and forth

4 Way Hip (Increase resistance, move

resistance placement to ankle and now performed weight

bearing)

3 sets, 8 reps

Step Ups 2 sets, 10 steps each leg

Lunges(Bodyweight)

3 sets, 10 reps on each leg

Gluteus Maximus Lift with cuff weight

3 sets, 15 reps

Strength Exercises (Week 10-12)

Wall Slides 3 sets, 10 reps

Terminal Knee Extensions 2 sets, 15 reps

Leg Press (Light Weight)

2 sets, 20 reps

Hamstring Curls 3 sets, 10 reps

Squats(Resistance Tubing working

to weights)

3 sets, 8 reps

Lateral Step Ups (hold bar/stick)

2 sets, 1 minute

Core Exercises Quadruped Opposite Arm/Leg

2 sets, 10 reps on each side

Supine Twist 2 sets, 10 reps on each side

Abdominal Draw on a Bosuball

2 sets, 10 reps, hold for 5 seconds

Crunches 2 sets, 50 reps

Plank 3 sets, 45 seconds

Plank with hand on Swiss Ball

3 sets, 45 seconds

Oblique Crunch with Swiss Ball between Legs

2 sets, 25 reps both sides

Supine Bridge 2 sets, 25 reps

Neuromuscular Control Single Leg Stance 3 set, 20 seconds

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(Week 7-9)All Exercises start with eyes open and progress to eyes

closed

(On stable surface)Double Leg Stance(On stable surface)

3 sets, 20 seconds

Tandem Stance (On stable surface)

3 sets, 20 seconds

Neuromuscular Control(Week 9-12)

All Exercises start with eyes open and progress to eyes

closed

Single Leg Stance(On airex pad)

3 set, 15 seconds

Double Leg Stance(On airex pad)

3 sets, 15 seconds

Tandem Stance (On airex pad)

3 sets, 15 seconds

Squats on BOSU Ball (hold a stick/bar)

3 sets, 10 reps

Plyometric Exercises(Week 10-12)

Ankle Jumps 3 sets, 20 seconds

Lateral Sliding 3 sets, 30 seconds

Front Back Hops 3 sets, 30 seconds

Side-to-Side Hops 3 sets, 30 seconds

Single Leg Jumps 2 sets, 10 jumps

Double Leg Jumps 2 sets, 10 jumps

Cardiovascular Exercises Stationary Bike (Interval Training)

10 sec high intensity, 20 seconds low intensity (20-25

min)Walking/Jogging on Treadmill/Outside

Speed of 3.0-3.5 mph at a 2% grade (20 minutes)

Pool Exercise Jogging with Light resistance(20 minutes)

Elliptical Moderate Intensity (25 minutes)

Rationale:

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Utilizing the knowledge of the bone healing process dictates the use of passive

movements to increase ROM. After 6 weeks, the bones is healed to the point where more

stresses are put on the knee to increase the range of motion.12 To gain even greater ranges of

motion in the knee, joint mobilization of the patella continues, along with adding posterior tibial

glides to increase flexion of the knee. Throughout the phase, interval training on a stationary bike

is utilized to help maintain cardiovascular fitness, as well as move the knee through more of a

functional ROM.8,12

In addition to focusing on restoring full ROM, the open-kinetic-chain exercises must

progress to closed-kinetic-chain exercises. The athlete begins to perform minisquats to about 40

degree to get the lower extremity accustomed to holding his body weight. Performing calf raises

with body weight, lunges, and step ups start to increase forces along the bone, helping the bone

tissue lay down in appropriate patterns.9 Monster walks, four way hip, and gluteus maximus lifts

are essential in making sure the muscle of the lower leg are strengthening to support the function

of the kinetic chain.

PNF exercises perform through more range of motion helps provide the maximal

response for increasing strength and neuromuscular control. With diagonal 1 and 2 patterns, the

clinician provides resistance while the athlete performs the PNF patterns.12 Having the clinician

provide resistance, the intensity of exercises increases, helping the athlete become stronger

throughout larger functional ROM than linear strengthening provides.

In addition to PNF exercises, single leg, double leg, and tandem stances on static

surfaces and on airex pads help reestablish neuromuscular control, while the athlete is weight

bearing. Performing these exercises without the hinge brace helps with dynamic stability of the

knee. The athlete starts of on a static surface to begin establishing proprioception.12

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To provide a thorough rehabilitation to the athlete and to make the transition back to

participation easier, core strengthening is trained during this phase. Now that the athlete is full

weight bearing, he performs a variety of core exercises. Doing the core exercises on a Swiss ball

provides a challenge to the athlete. The challenge is creating an unstable environment for the

athlete to strengthen abdominals. Side crunches on the Swiss ball between the legs provides the

challenge to the oblique muscles.12 To increase the difficulties of the isometric contraction

exercises of the TA and multifus, they are performed in the quadruped position. The supine

bridge also helps activate the TA and multifidus in a tougher position.12

Along with maintaining core strength, the cardiovascular fitness is also essential in

helping the athlete return to participation smoothly. With the athlete weight bearing, more

cardiovascular exercises are utilized. The athlete now progresses to a jog in the pool with

resistance. Stationary bike exercises use an interval training technique to allow for increased

work and increase intensity.12 The athlete now starts at a walking pace on a treadmill or outside

to get the athlete used to a proper gait pattern that may have been forgotten while non-weight

bearing.8 The elliptical provides an alternative method to the athlete for the cardiovascular

exercises.

As cardiovascular training is important during rehabilitation, plyometric training is also

important. The main purpose of plyometrics is to increase the excitability of the nervous system

for improved reactive ability of the neurovascular system. To utilize benefits of plyometric

training, the athlete needs to first start getting used to the movements required in the exercises.12

The athlete starts with ankle jumps, front and back hops, and side to side hops. These exercises

begin towards the end of the phase when an adequate amount of strength has been established.12

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Progressing into single leg and double leg prepares the athlete for increased loads of plyometrics

in phase III.

In order to progress the athlete into the final stage of this plan of care, the athlete must

have full range of motion at the knee (0 degrees extension and around 140 degrees of flexion).6,12

The athlete must have the sets and repetitions completed for each strength exercise outlined

within this phase. All exercises are pain free. The exercises must be done without the hinge brace

with no compensation.12

Phase III (13-18 weeks):8

At this point in rehabilitation, the athlete has full range of motion at the knee. The athlete

is also strong enough to sustain close-chain exercises such as squats and calf raises, movements

essential for pole-vaulting. Throughout this phase, the athlete increases plyometric exercises to

help build explosive power and dynamic stability needed to complete the athlete’s sport. All

exercises are performed without the athlete’s hinge brace. On the last day of week 18, the athlete

completes the Vail Sport Test and the Carolina Functional Performance Index (CFPI).12,13

The athlete does warm-ups with their teammates and complete functional activities. If he

passes both of the functional test, the athlete fully returns to practice 18 weeks after sustaining

the tibial plateau fracture. The main goal of this phase is to return the athlete to practice strong

enough to feel confident that the risk of re-injury of his knee without a brace is minimal.

Exercise Sets and Repetitions

Knee ROM

(Dynamic Stretching)

Walking Hamstring Stretch 25 yards

Knee to Chest Stretch 25 yards

Walking Adductor 25 yards

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Walking Quad 25 yards

Butt Kicks 25 yards

Open and Close Gate 25 yards

High Knees 25 yards

Strength Exercises Squats(With bar and weight)

3 sets, 10 reps

Calf Raises on Step 3 sets, 15 reps

Reverse Squats while holding a bar/stick

5 sets, 10 reps

Monster Walks(Increase Resistance Band)

5 sets, 10 yards

Dead Lift 3 sets, 10 reps

Single-Leg Squat 2 reps, 1 min

Lateral Bounding (working up to resistance bands through the 6 weeks)

3 sets, 30 seconds

Forward Walking with resistance (can holding

bar/stick)

3 sets, 30 seconds

Backward Walking with Resistance (can holding

bar/stick)

3 sets, 30 seconds

Core Exercises Prone Walk-Out on Swiss Ball

3 sets, 15 reps

Prone Bride “Around the World”

3 sets, 10 reps

Russian Twist with Medicine Ball

3 sets, 25 reps

Quadruped Opposite Leg/Arm on Half Foam

Rollers

3 sets, 15 reps

Hanging Windshield Wipers 3 sets, 20 reps

Neuromuscular Control Single Leg Squats on BOSU Ball while holding a broom stick in position of running

with a pole-vault

3 sets, 15 squats each leg

Throw Backs Standing on airex pad single leg

3 sets, 20 throws on each leg

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Lateral Bounding over BOSU Ball

3 sets, 30 sec

Plyometric Three Hurdle Jumps 2 sets, 10 jumps

Two Leg Lateral Hop Overs with stick

2 sets, 10 jumps

Box Jumps 2 sets, 15 jumps

Alternate-leg Power Step-ups while holding a stick/bar

3 sets, 10 steps each leg

Standing Long Jump 10 jumps

Single Leg Long Jump 10 jumps

Depth Jump to Vertical Jump 10 jumps

Cardiovascular Exercises

(Week 13-14)

Jogging 5 mph at 5% grade(20 minutes)

Pool Exercise Running with resistance (20 minutes)

Cardiovascular Exercises (Week 15-18)

Running Moderate Intensity for 25 minutes

Sprints (with/without pole) 40 meters

Interval Training 10 second sprint, 30 second jog (20 minutes with 2 min

rest every 5 minutes)

Rationale:

The first part of this phase focuses on dynamically stretching the lower extremity. A

dynamic stretch is when the muscle contracts and is moved through the ROM. It is important to

incorporate a dynamic stretch in a rehabilitation program to prevent re-injury. There are many

instances in sports when a muscle is forced beyond its active limits, and if there is not enough

elasticity, the muscle is injured.12 During pole-vaulting, the athlete needs to prepare for

appropriate flexibility in order to get down the track and over the beam with no injury.

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As flexibility is important, increasing strength and endurance prepares the athlete for

competition. The strength and plyometric exercises focus on increasing the power and

coordination of the muscles needed during pole-vaulting. All of the exercises incorporated in

phase III are used to prepare the athlete for the stresses that are placed on the athlete’s body

during competition. Both sides of the body need to be equal in strength and conditioning to

reduce the risk of injury.13

As strength is increasing, neuromuscular control is also increasing. Neuromuscular

control is important to refocus the athlete’s awareness of peripheral sensation and process the

signals in coordinated motor strategies. Making the athlete stand on an airex pad while doing

throw backs causes the muscle to stiffen which heightens the stretch sensitivity of the receptor.12

The body processes multiple stimuli from balancing on the BOSU ball while standing on a

single-leg. This helps improve neuromuscular control.12 All exercises are done close-chained to

enhance the joint congruency and the neurosensory feedback and minimize shear forces.12

In addition to regaining full strength and power, it is also essential to regain full

cardiovascular endurance in order for the athlete to perform. This phase focuses on running and

sprinting to get the athlete ready to be quick down the track. Utilizing sprints in different patterns

helps the athlete with agility and speed.12

Throughout this phase the core needs to be trained. A pole-vaulter needs to have an

excellent, well-rounded strength in his core. The athlete needs to be able to control their core,

which in return controls forces along the extremities, to achieve proper biomechanics to perform

at their best ability.13 When the team is doing any of their core exercises, the athlete may

participate.

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When this phase is completed the athlete complete two functional tests to return to

competition: Vail Sports Test and Carolina Functional Performance Index (CFPI). Criteria of

passing these tests are further discussion in the “Return To Play Criteria” section. If criteria to

passing these functional tests met, then approval from the physician shows the athlete he is ready

to return to competition safely.

Contraindications/Precautions:

The main precaution with tibial plateau fractures is knee stiffness and joint contracture

that can occur if immobilization lasts too long. Both of these prevent the athlete from achieving

normal knee extension.1 With that being said, being over aggressive trying to obtain range of

motion too quickly can cause instability in the affected knee.12 Furthermore, beginning passive

range of motion stretching early in the rehabilitation is detrimental to obtaining an excellent

rehabilitation outcome.2 Malunion also results from inadequate initial treatment or late collapse

of fracture. To prevent malunion, the patient is non-weight bearing for 6-8 weeks.1,2,12

Return to Play Criteria:

The first requirement in order to return to play successfully is the athlete must be able to

progress through each phase of this plan of care. This includes regaining full range of motion and

completing all of the outlined sets and repetitions for all strength exercises. Second, he must pass

the Vail Sport Test and the CFPI. Finally, in order for the athlete to return to competition, the

physician must approve the athlete is healed and ready to compete.

The Vail Sport Test is effective at evaluating the athlete’s power, neuromuscular control,

muscle endurance, and movement quality. The test is out of 54 point, and in order for the athlete

to pass, he must score a 46 or higher.14 There are four components to the test: single-leg squat for

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3 minutes, lateral bounding for 90 seconds, and forward/backward jogging for 2 minutes. The

athlete is scored based upon the capability of them to establish strength and muscular endurance,

absorb and produce force, while maintaining appropriate movement at the trunk and lower

extremity.14

Utilizing the CFPI helps the athletic trainer evaluate the lower-extremity functional

performance. The test includes the co-contraction test, carioca test, shuttle run test, and one-

legged timed hopping test.12 CFPI is best used pre-injury so the results are compared to current

testing to ensure the athlete is progressing in the rehabilitation. The CFPI has reliable criteria for

functional performance testing and return to play.12

Both of these functional assessments are highly reliable and have research behind them to

prove their value to determine whether an athlete is ready to return to play after a tibial plateau

fracture. With this plan of care being based entirely on evidence-based research, completing this

rehabilitation plan should put the athlete in a position to successfully pass the Vail Sport Test and

the CFPI. Utilizing these resources, the input of the physician, and the input of the athletic trainer

allows the athlete to return to competition with a low risk of re-injuring the knee.

Conclusion:

Tibial plateau fractures only account for a small percentage of fractures being more

relevant in the elderly. Since this injury is not a prevalent injury, it is important to have a strong

understanding of the injury and a quality based plan to provide the best outcome for injured

athletes. This plan focuses on decreasing inflammation, begin active range of motion early in

rehabilitation, and providing strengthening exercises to strengthen all muscles that affect the

knee in a manner to allow the athlete to return to competition with enough strength to safely

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pole-vault. Additionally, the plan of care includes an objective functional assessment tests in

returning the athlete to play when they have regained full function of the affected limb, thus

decreasing the risk of re-injury in the fracture knee.

References

1. Fenton P, Porter, K. Tibial Plateau Fractures: A review. Trauma. 2011; 13(3): 181-187.

2. Agnew SG. Tibial Plateau Fractures. Operative Techniques in Orthopedics. 1999; 9(3): 197-205.

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3. Rubin A. Standard of Care: Tibial Plateau Fracture. The Brigham and Women’s Hospital. Boston, MA; The Brigham and Women’s Hospital, Inc Department of Rahbilitation: 2007

4. Siegel J, Tornetta III P, Tibial Plateau Fractures. Orthopedic Traumatology: An Evidence-Based Approach. New York, NY: Springer New York; 2013

5. Kraus TM, Martetschlager F, Muller D, Braun KF, Ahrens P, Siebenlist S, Stockle U, Sandmann GH. Return to Sports Activity After Tibial Plateau Fractures: 89 Cases with Minimum 24-Month Follow-Up. The American Journal of Sports Medicine. 2012; 40(12):

6. Starkey C, Brown SD, Ryan J. Examination of Orthopedic and Athletic Injuries. Philadelphia, PA: F.A. Davis Company; 2010.

7. Shah N. Increasing Knee Range of Motion Using a Unique Sustained Method. North American Journal of Sports Physical Therapy. 2008; 3(2): 110-113.

8. Lind CC. Tibial Plateau Fracture Post-Operative Protocol. Park City, UT: Rosenburg Cooley Metcalf; 2013.

9. Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. Baltimore, MD: Lippincott Williams & Wilkins; 2013.

10. Flautt, W. Lateral Tibial Plateau Fractures. The Journal of Orthopedic and Sports Physical Therapy. 2012; 42(9): 819.

11. Nicholas JJ, Taylor FH, Buckingham RB, Ottonello D. Measurment of Circumference of the Knee with Ordinary Tape Measure. The EULAR Journal. 1976; 35(3): 282-284.

12. Prentice WE. Rehabilitation Techniques for Sports Medicine and Athletice Training. New York, NY:McGraw-Hill Companies Inc; 2011.

13. Newton RU, Gerber A, Nimphius S, Shim JK, Doan BK, Robertson M, Pearson DR, Craig BW, Hakkinen K, Kraemer WJ. Determination of Functional Strength Imbalance of the Lower Extremities. Journal of Strength and Conditioning Research. 2006; 20(4): 971-977.

14. Garrison JC, Shanley E, Thigpen C, Geary R, Osler M, DelGiorno J. The Reliability of the Vail Sport Test as a Measure of Physical Performance Following Anterior Cruciate Ligament Reconstruction. The International Journal of Sports Physical Therapy. 2012; 7(1): 20-27.

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