Exercise Rx RA #1

Indications for surgical intervention

- incapacitating pain at rest or with functional activities

- marked limitation of AROM and PROM

- gross instability of a joint or bony segments

- joint deformity or abnormal joint alignment

- significant structural degeneration

- chronic joint swelling

- failed conservative (nonsurgical) or prior surgical management

- significant loss of function leading to disability as the result of any of the preceding factors

indications for surgery

benefits of preoperative management

benefits of preoperative: ability to assess their preoperative functional status, discuss goals/expectations, develop rapport, educate patient regarding postop rehab

elements to preoperative management

elements to preop management: examination, evaluation of preop status, patient education, time for pt to ask Qs about procedure, postop care, preop exercise program

Preoperative examination and evaluation goals

- determine patient's impairments and functional status prior to surgery

- identify patient's needs and goals

Preoperative examination specific factors important for developing goals/outcomes of surgery/postop rehab

- pain

- ROM and joint integrity (AROM and PROM, passive mob tests)

- skin integrity

- muscle performance

- posture

- gait analysis

- functional status

benefit of Preop education and instruction

gives patients an opportunity to learn about factors associated with surgery like wound care, special precautions, use of assistive/supportive equipment (crutches, sling, etc), learn and practice postop exercises without postop pain/side effects of meds

components of preop patient education

- overview of plan of care

- postop precautions

- bed mobility and transfers

- initial postop exercises (deep-breathing and coughing exercises, active ankle exercises (ankle pumps - reduce DVT), gentle muscle-setting exercises of immobilized joints)

- gait training

- wound care

- pain management

Benefit of implementing a preop exercise program

- to limit further progression of impairments (strength, ROM deficits) resulting of MSK condition

- performing exercises correctly prior

- especially beneficial if postop rehab is a prolonged period of immobilization or reduced weight bearing after surgery

Inspection of the Surgical Incision

- check for signs of redness or tissue necrosis along the incision(s) and around sutures

- palpate along the incision and note signs of tenderness and edema

- palpate to determine evidence of increased heat

- check for signs of drainage; note color and amount of drainage on the dressing

- note the integrity of an incision across a joint during and after exercise

- as the incision heals, check mobility of the scar

common structural and functional impairments in postop rehab

- postop pain b/c of disruption of soft tissue

- postop swelling

- potential circulatory and pulmonary complications

- joint stiffness or limitation of motion b/c of injury to soft tissue an necessary postop immobilization

- muscle disease atrophy because of immobilization

- loss of strength for functional activities

- limitation of weight-bearing

- potential loss of strength and mobility of non-operated joints

maximum protection phase

- The initial postop period when protection of operated tissues is paramount in the presence of tissue inflammation and pain

- ranges from a few days to 6 weeks

Maximum protection phase plan of care:

Educate the patient in preparation for self-management

What is the intervention for this?

instruction in safe positioning and limb movements and special postop precautions and contraindications

Maximum protection phase plan of care:

Decrease postop pain, muscle guarding, or spasm

What is the intervention for this?

relaxation exercises

- use of modalities such as TENS, cold or heat

- continued passive motion (CPM) during early postop period

Maximum protection phase plan of care:

Prevent wound infection

What is the intervention for this?

instruction or review of proper wound care (cleaning and dressing the incision)

Maximum protection phase plan of care:

Minimize postop swelling

What is the intervention for this?

- elevation of the operated extremity

- active muscle pumping exercises at the distal joints

- use of compression garment

- gentle distal-to-proximal massage

indications for surgical ACLR

- disabling instability of the knee from partial acute ACL tear or chronic ACL laxity

- frequent episodes of knee giving way during routine ADLs as a result of significantly impaired knee stability despite a course of nonop management

- a positive pivot-shift test indicating rotational instability associated with concomitant injury to other knee structures like MCL

- injury to MCL at time of ACL injury to prevent lax healing of MCL

- increased risk of re-injury because of participation in high-demand work, sports, or recreational activities

contraindications for surgical ACLR

- relatively inactive individual with minimal exposure to work, sport, and recreational activities that place high demands on the knee

- inability to make lifestyle modifications that eliminate high-risk activities

- inability to cope with episode of instability

- advanced arthritis of the knee

- poor likelihood of complying with postop restrictions and adhering to a rehab program

Surgical approach of ACLR

- arthroscopic assisted or endoscopic techniques using an autograft

Autograft 2 types for ACLR

bone-patellar tendon-bone graft

semitendinosus-gracilis tendon graft

Harvesting Autograf: bone-patellar tendon-bone graft

- harvested through a small, longitudinal incision over the patellar tendon from patients involved knee (sometimes other knee)

- central 1/3 of patellar tendon w/small bone treatments from patella and tibial tubercle is harvested

- fragments serve as bone plugs fro graft fixationA

Harvesting Autograf semitendinosus-gracilis tendon graft

- harvested through an incision over the tibial inset in of the semitendinosus and gracilis tendons

- hamstring tendon grafts harvested with bony attachment to allow faster ligament incorporation are becoming more common

Advantages of Bone-patellar tendon-bone graft

- high tensile strength/stiffness, similar or greater than ACL

- secure and reliable bone-to-bone graft fixation with interference screws

- rapid revacdularization/biological fixation (6 weeks) at the bone-to-bone interface permitting safe, accelerated rehab

- ability to return to pre injury high-demand activities safely

Disadvantages/Possible Complications of Bone-patellar tendon-bone graft

- anterior knee pain in area of graft harvest site

- pain during kneeling

- extensor mechanism/patellofemoral dysfunction

- long-term quadriceps muscle weakness

- patellar fracture during graft harvest (rare, but significant adverse effects)

- patellar tendon rupture (rare)

Advantages of Semitendinosus-gracilis tendon graft

- high tensile strength/stiffness greater than ACL with quadrupled graft

- no disturbance of epiphyseal plate in skeletally immature patient

- evidence of hamstring tendon regeneration at donor site

- loss of knee flexor muscle strength remediated by 2 years postop

Disadvantages/Possible Complications of Semitendinosus-gracilis tendon graft

- tendon-to-bone fixation devices (particularly tibial fixation) not as reliable as bone-to-bone fixation

- longer healing time (12 weeks) at tendon-bone interface

- hamstring muscle strain early in rehab

-short and long-term knee muscle flexor weakness (not associated with functional limitation)

- possible increased anterior knee translation (not associated with functional limitations)

Complications with ACLR

- inappropriate placement of the graft or bone tunnels

- problems with graft harvesting like inadequate graft length (more coming in hamstring), improper graft tension can affect joint stability and mobility

- insufficient graft fiction, graft slippage and early failure can occur

- bone plug in patellar tendon graft can fracture during harvesting and implantation, resulting

- graft failure need to revision reconstruction (common in early months after surgery), common cause is poor adherence to postop rehab when returning to high-risk high joint-load activities

Immobilization and bracing for postop ACLR reasoning

- protects the draft from excessive strain and prevent loss of full knee extension

- use of this now is no longer universally recommended

Factors to consider about immobilization and bracing

- surgeon's philosophy

- type of graft used

- comorbidities and concomitant surgical procedures

- assessment of patients expected level of adherence to post op rehab program

types of postop bracing

- Rehabilitative bracing

- Functional bracing

Rehabilitative bracing

- uses a hinged orthosis without a locking mechanism that restricts available ROM

- typically worn first 6 weeks after surgery

Rehabilitative brace use and progression of knee ROM

- initially locked to maintain full knee extension, including during ambulation and used with crutches

- unlocked for exercise

- worn throughout the day first 6 weeks, sometimes during sleep

- with ROM initiate, the brace is set to incremental ranges of knee flexion during exercise and functional activities

- progression might be slower is ACLR is combined with another procedure

How much knee extension and flexion is expected by 4-6 weeks post op?

- full active knee extension

- 90-110 degrees of flexion ROM

Functional bracing

- worn when returning to high-demand sports or work-related activities to potentially reduce the risk of re-injury

- worn during the advanced phases of rehab

- effectiveness of functional brace is unclear

weight-bearing considerations for postop ACLR management

- range from restricted weight bearing the first 2 weeks to weight bearing as tolerated with use of crutches immediately after surgery

- WB is increased in next 2-3 weeks based on patient's symptoms

- full WB and ambulation w/out crutches or w/out unlocked brace by 4 weeks if WB is pain free and has full active knee extension/quad strength to control knee

*found that immediate weight bearing did not compromise knee joint stability or function and resumed in lower incidence of anterior knee pain

*WB recommendations aren't based on type of graft or fixation

exercise progression for ACLR preop exercise

- surgery delayed until acute symptoms have subsided

- restore bull knee ROM, especially extension

- prevent atrophy and weakness of leg

- address strength and flexibility of hip and ankle

exercise progression for ACLR postop exercise

- exercise begins on 1st postop day

- CPM can be used

- research that both types of grafts saying one heals faster than the other

factors that affect rate of progression for ACLR

- age

- pre injury health status

- younger, healthier patients progress more rapidly

Maximum protection phase for ACLR

- during first 5 weeks post surgery

- early motion generates stress that benefits graft during first 6-8 weeks

Maximum protection phase goals for ACLR

- prevent reflex inhibition of knee muscles

- prevent adhesions

- restore knee mobility

- regain kinesthetic awareness and neuromuscular control of LE

- improve strength and flexibility of hip and ankle muscles

- achieve 90 degrees flexion, full passive extension by en of first 1-2 weeks

- reach 110-125 flexion by 3-4 weeks

Maximum protection intervention for ACLR

- exercises begin a day or day after postop emphasis on:

1) preventing vascular complications (DVT)

2) activating knee musculature

3) reestablishing knee mobility

*if in brace, WB exercises are perfumed in brace, low-intensity closed-chain exercises and proprioceptive/neuromuscular control training are initiated as soon as WB is permissible

Exercises for maximum protection phase ACLR

- ankle pumping exercises (reduce DVT risk)

- voluntary isometric and dynamic activation of knee muscles: (quad sets, e-stim/biofeedback (Russian, Mtrigger), 4 position SLRs, low-intensity multi-angle knee isometrics, low-intensity eccentric quad training on ergometer, heel-slides, standing knee flexion, scooting for hamstring activation)

- ROM and patellar mobility (A-AROM and PROM, patellar mobs, to increase passive knee ext: supine with heel on rolled towel, to increase knee flexion: supine wall slides or dangle leg while sitting, stretch hip and ankle is flexibility is limited

- neuromuscular control/responses, proprioception, stability, and balance (trunk/LE stab in bilateral stance, weight shifting and minisquats, nonreststed multipoint movements (cycling and seated leg press at 3-4 weeks, pool exercises)

Criteria to progress to the next phase

- minimal pain and swelling

- full, active knee extension (no extensor lag)

- at least 110 knee flexion

- quadr strength at least 50-60% of contralateral side (measured isometrically at 60degrees)

- no evidence of excessive joint laxity

Resistance training precautions after ACLR

- progress exercises more gradually with hamstring graft than patellar tendon graft

- progress knee flexor strengthening exercises cautiously if hamstring graft was harvested and knee extensor strengthening if patella tendon graft was harvested

Closed-chain training precautions after ACLR

- when squatting/upright position, make sure knees don't move anterior to the toes as hips descend b/ this increased shear forces on tibia and could stress graft

- avoid close-chain strengthening of quads between 60-90 degrees knee flexion

Open-chain training precautions after ACLR

- place resistance above the knee until knee stability and control is established when strengthening hip muscles

- avoid resisted, open-chain knee extension (SAQ) between 45-30 degrees to full extension for at least 6 weeks or as long as 12 weeks

- avoid applying resistance to distal tibia during quad strengthening