Rehabilitation of Common Knee Conditions

Common Conditions

• conservative treatment of ligament injuries

• meniscal pathology

• knee fractures

• anterior knee pain

• osteoarthritis

• rehab of surgical knee:

  • TKA

  • ligament repairs

• return to sport

• protocols for reference

Knee Rehab musts

• control swelling ASAP — may elevate with knee in some flexion

• no pillows under post surgical knees or acute knee injuries (unless with elevation)

• get the extensor mechanism facilitated - QUADS!!!

• get full knee extension - ASAP
  get at least 90 degrees flexion - ASAP

• above and below - often controls middle

• normalize gait mechanics ASAP

• match your progression with healing time tables

• get functional fast

• DEFLATE STRAIGHT to 90 = FULL WEIGHT GAIT

How to get rid of knee swelling

RICE (which is the best)

How to get full knee extension (and fire up the extensor mechanism)

• mobilize, stretch, exercise (example)

• mobilize

  • patella mobs, femur dorsal glides/tibial anterior glides (**if indicated**) soft tissue/scar mobilizations

• Stretch

  • hamstrings, gastrocs/soleus, hip flexors

• exercise

  • promote desired movements

  • use synergist

  • knee and hip exteners

  • standing TKEs

How to get knee flexion

• MOBILIZE, STRETCH, EXERCISE

• protect the incision

• mobilize

  • patella mobs, tibial dorsal glides, soft tissue/scar mobilizations

• stretch

  • quadriceps, hip flexors

• exercise

  • promote desired movements

  • use synergist

  • knee and hip flexors

• CPM’s - Controversial (patient values)

Exercise Progression Guidelines

• if no soreness from prior visit, progress by modifying one variable

• if soreness is present, but decreases with warm-up, stay put

• if soreness remains, increased swelling, etc. back off progression

Remember the Hip and trunk

• 3 way SLR’s — yes… but are they functional?

• standing impulse drills for extension, abduction, and flexion

• hip ER exercises — T-band — multiple ways

Functional is Fun

Normalize Gait mechanics

• motion before strength

• precursor to all other ambulatory movements (ie. running)

• no pain, no limp, no swelling, match assistive device

• sagittal, frontal, and transverse planes

Balance/proprioceptive training

• awareness of joint position in space

• react to various movement and forces

  • mass and momentum

  • gravity and ground reaction forces

• aide in restoration of biomechanics and normal

• should be performed from day one

  • often until the end

• perturbation training

Hip and Ankle mobility and stability

use multiple moving parts:

• arm and leg drivers

• aides in restoration of global biomechanics

Copers - May not require Surgery

• < 1 episode of giving way - NO INSTABILITY FUNCTIONALLY

• > 80% 6m timed hop test

• >80% KOS ADL subscale

• >60% global rating of knee function

• less active, not planning on high activity/cutting sports

• no other injuries, meniscal, cartilage

ACL Non-operative

• control swelling

• gain ROM

• optimize Quad function

• address hamstring activation as secondary restraint

• neuromuscular rehab - best copers improve the most in this!

• progress in stages similar to operative protocol

Medial Collateral Ligament Injury

Location of tear

• proximal, mid-substance — heal better, but more scare tissue formation = progress ROM early

• distal tear — more-laxity, poor healing = progress ROM slower - may be immobilized in hinged brace up to 3 weeks

MCL Injury - ROM restrictions

• perform exercises in sagittal plane

• progress with tibial IR during resisted exercises

MCL Injury

Key Concepts:

• avoid valgus stress early

• quad control and knee extension attained early

• progress with functional activities when good quad control and good static leg balance

Lateral Collateral Ligament Injury

• progress slower than MCL Injuries

  • full weightbearing at 4 weeks

• Key concepts:

  • quad, knee motion attainment

  • control swelling

  • avoid early varus stresses

Posterior Cruciate Ligament Tear

• progress conservatively with flexion, limit posterior translation by avoiding excessive isolated hamstring strengthening

• weightbearing depending on other injuries

• if unstable with gait, consider a hinged brace for 3-6 weeks

• focus on quads

• follow criterion based progression for ACL with PCL reconstruction surgery

Acute Meniscus Tears

• manage pain and inflammation (hemarthrosis)

  • relative rest (introduce gentle ROM and can begin isometric exercises after 72 hours)

  • ice

  • compression

  • elevation

• activity limitation

• progressive and graded exercises with a return to activity plan

Acute Meniscus Tears: Exercises

• Limit excessive endrange knee flexion (especially with high load)

• Minimize tibial rotation

• Watch progression in weight-bearing, start exercises open chain, progress to closed chain

• Regular force on the meniscus is necessary for proper healing

• Six week return to activity program minimum

Chronic Meniscus Tears

• Likely that they also have osteoarthritis, or greater likelihood of developing osteoarthritis

• Manage like OA

  • “sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result.”Uthman, 2013

• Focus on improving motor control and muscle stability in order to decrease stress on the meniscus

Meniscus Treatment

Manual Therapy

• painfree

• tibiofemoral distraction

• anterior tibial glides

• posterior tibial glides progress in flexion

• oscillations in flexion or extension

Knee Fractures

Fracture Care

• movement and muscle activation dependent upon stability of fracture

• ALWAYS CONSULT PHYSICIAN

  • precautions — weightbearing

  • stability

  • motion allowed

Knee Fractures: Immobilization Phase

• immobilized 4-6 weeks for most fractures

• patient education, prevent DVT’s protection of fracture, Compliance

Knee Fractures: Mobilization Phase

• WBAT progress to full weightbearing

• manual therapy — check with physician

• exercise progression

Anterior Knee Pain

Contributions of:

• Hip

  • excessive IR

  • weak external rotators/extensors

• Foot/ankle

  • navicular drop

  • tight gastrocs

  • poor footwear/training

• muscular tightness

  • lateral quads, IT band

• patellar mal-alignment - Alta, baja, medial, lateral tilts, rotation

Knee OA

The Evidence- What we know:

• obesity affects outcome

• interferential current for pain relief

• manual therapy plus exercise better than home program

• alignment affects pain and disability

• psychosocial - self efficacy improves function

• adherence - improves long term outcomes

OA Knee

• What We Do?

• Encourage weight loss- Be nice

• Reduce reactivity- Ice, IFC

• Normalize Gait- Crutches, (Cane-or not)?

• Assess mobility- Get accessory mobility back-Soft tissue, capsular, flexibility

• Alignment- Foot wedge, orthotics, bracing if severe

  • If knee varum, lateral foot wedge

  • If knee valgum, medial foot wedge

• Psychosocial- Encourage activity, progress without pain

• Exercise- Open and Closed Chain both OK, keep them OUT OF INCREASED PAIN with activity

  • (Lin DH, et al. JOSPT 2009)

• Follow up- Booster- Phone Call, re-assessment

Management of Common Surgical Conditions

• total/partial knee replacement

• ACL reconstruction

• multi-ligament considerations

Types of Arthroplasty

• unicompartmental arthroplasty

• patellofemoral arthroplasty

• total knee arthroplasty

Uniarthroplasty

• used for isolated medial

• > lateral compartment disease

• all ligaments must be intact

• <8% of all arthroplasties

• good candidates are normal weight, elderly

Patellofemoral replacement

Total knee arthroplasty

3 types: All types REMOVE ACL

• CR = Cruciate retraining (PCL retained)

• PS = posterior stabilized

• RP = rotating platform

rotating platform

• special type of PS TKA design to increase surface area to reduce contact stresses

• the poly piece can rotate side to side separate from tibia

• increased conformity of tibiofemoral articulation

• mobile bearing used to diminish any kinematic conflicts

Total Knee Arthroplasty

• monitor incision for signs of infection

• DVT - Wells criteria

  • take girth measurements

• move the patella

• WBAT - Good gait

• progress ROM as tolerated

• too much WB = too much swelling = stiffness

  • stop the madness

• stiffness of <70 degrees 2 weeks post-op

  • may require manipulation

    • best 8-12 weeks post

    • risk of fracture increases over 12 weeks

• pre-op stiffness = post op ROM loss

• if unusual amount of unrelenting pain, SOMETHING IS WRONG

Total Knee Replacement: Road to Recovery

To Cope or Not to Cope

• Few Studies have actually shown the ACL reconstruction restores dynamic knee stability

• No clear evidence that Repair or non-Repair is any different on degenerative changes later in life

• Screening Exam has poor predictive value of determining copers and non-copers

Copers

• Movement consistent with good knee stability

• Less episodes of giving way of knee

• Less anterior joint laxity

• Higher Knee Outcome Survey

• Higher Activity level

• Hop Testing > 90%

Non-Copers

• Poor movement patterns, alternate strategies

• More episodes of Giving way of knee

• More anterior joint laxity

• Lower Knee Outcome Survey

• Modified activity levels

• Hop Testing < 90%, but after one year equal to copers

ACL Reconstruction Guidelines

Isolated tear, versus concomitant injury

• meniscus debridement, repair, replacement

• other ligament disruption

• chondral defects

Isolated ACL Reconstruction

• control swelling

• get extension — gradually gain flexion, but don’t push early

• patellar mobility

• quad activation

• restore normal gait

ACL Reconstruction Rehab Guidelines

Soreness Rules

Multiligament Reconstruction: DELAY

• Usually ACL and PCL, and either MCL, LCL or Posterolateral Structure Involvement

• Follow more conservative PCL protocol

• 3 Ligaments, 3 Delays: weightbearing, mobilization, functional progression

  • Usually Non-Weightbearing for 6 weeks

  • Immobilizer up to 8 weeks

  • Functional Progression

    • Running progression no earlier than 12 weeks

    • Functional Testing no earlier than 16 weeks

Return to Sport

ACL or PCL: 9-12 months

• earlier than this runs risk of reinjury or INJURY TO OTHER SIDE

Rule of 90s

KNOWWW

Return to Sport PROGRESSION

• Walk, stairs, run, hop, cut, PREVENTION

  • Walk- good gait, full ROM

  • Stairs- step up/down with good alignment, control, painfree

  • Run- same as walking but faster

  • Hop- Hop Tests

  • Cut- Cutting drills

  • Prevention- FIFA 11, etc

Hop Tests - 90% of uninvolved

• Single leg hop

• Timed hop

• Triple hop

• Cross over hop

• Practice, 3 trials, average

• For timed hop take Uninvolved/Involved 100

• For others Involved/Uninvolved100