Developing Treatment Pathways

TI 1

procedure-modified rehabilitation

rehabilitation plan is adjusted based on the surgical procedure.

surgical procedure influences the speed, volume, and intensity of rehabilitation and progression may be impacted by

Type of surgery performed

Tissue fixation strength

Healing rate of repaired or reconstructed tissue

Surgeon-specific precautions

Amount of stress the tissue can safely tolerate

rehab progression depends on

Tissue involved

Quality of the injured tissue

Intrinsic healing potential

Type and extent of injury

Repair/reconstruction and fixation

Amount of stress applied during rehabilitation

three categories of orthopedic surgical procedures

• repair

• reconstruction

• resection

surgical repair

Restores or reconnects the patient’s native injured tissue

Requires adequate healing potential

Goal: preserve the original structure

Examples: rotator cuff repair, Achilles tendon repair, meniscus repair, labral repair

surgical reconstruction

Replaces or recreates a structure that cannot be reliably repaired

Often uses a graft or substitute tissue

Used when native tissue has poor healing potential or is severely damaged

Examples: ACL reconstruction, UCL reconstruction, MPFL reconstruction

surgical resection

Removes damaged, diseased, or nonviable tissue

May involve partial or complete removal of a structure

Examples: partial meniscectomy, distal clavicle excision, removal of loose bodies or damaged cartilage

rigid fixation

provides high mechanical stability and may allow earlier loading

ex. plate-and-screw fixation of a fracture, compression screws for some fractures

semirigid fixation

provides stability but still allows or requires some protection

ex. suture anchors for rotator cuff or labral repair, interference screws used in ACL reconstruction

soft-tissue fixation

relies heavily on biologic healing and tissue incorporation

ex. tendon-to-bone healing after rotator cuff repair, graft incorporation after ACL reconstruction, tendon repair

fixation rehab progression should consider…

• mechanical stability and biologic healing

meniscus healing

• Better healing potential at the vascular periphery

• Holds sutures well

• Repair success depends heavily on tear location and tissue quality

tendon healing

• Generally good healing potential

• Torn ends may be irregular and difficult to approximate

• Requires protection until biologic healing develops

extra-articular ligament healing

• Generally favorable healing environment

• Example: MCL

• Still require protection during healing

intra-articular ligament healing

• Poorer blood supply and healing environment

• Successful primary repair is less predictable

• Reconstruction is often used instead

autograft

⚬Tissue obtained from the patient

⚬Generally incorporates more predictably

⚬No risk of donor tissue rejection

allograft

⚬Donor tissue

⚬Infection and rejection are uncommon

⚬Biologic incorporation may be slower than autograft tissue

bone healing

Generally has strong healing potential

Healing is usually predictable when:

Blood supply is adequate

Bone quality is healthy

Fixation is appropriate

Nonunion is less common under favorable conditions

articular cartilage healing

⚬Avascular

⚬Limited intrinsic healing potential

⚬Defects often heal with fibrocartilage, not normal hyaline cartilage

⚬Cartilage restoration procedures may require prolonged protection

influences on healing process

Age

Tissue quality

Comorbidities

Vascular status

Overall health

mild muscle injury timeline

days to several weeks

moderate/ severe muscle injury timeline

several weeks to months

ligament injury timeline

weeks to months depending on severity

tendon repture/ repair timeline

often months

ligament graft maturation timeline

may continue for many months

bone healing timeline

commonly several weeks to months

timelines are used to estimate…

When protection is needed

When loading may begin

How quickly stress should increase

When higher-level function may be appropriate

criterion based rehab progression

Pain and soreness

Swelling/effusion

Fatigue and response to loading

ROM and mobility

Strength and muscle activation

Functional performance

Patient-reported function

Tissue-healing time frames

time vs criteria

time: tells us what may be biologically appropriate

criteria: tells us whether this patient is ready

monitor response to loading

• pain

• swelling

• fatique

monitor patients responses during exercise

• Pain or altered movement

• Increasing fatigue

• Loss of movement quality

monitor patients responses after exercise

Increased pain or soreness

New or increased swelling/effusion

Symptoms that persist into the next day

No soreness from previous exercise

PROGRESS by modifying one variable

Soreness present but resolves with warm-up

MAINTAIN the current level

Soreness persists and does NOT resolve with warm-up

REGRESS to the previous level

if symptoms continue with regression of exercises

Consider additional recovery

Resume at the reduced level

Reassess the source of symptoms

what could new or increased swelling indicate?

Tissue irritation

Excessive loading

Ongoing inflammatory response

Inadequate recovery between sessions

For joints, assess effusion when appropriate.

before progressing to activities that require greater force production, control or load tolerance

strength should be assessed

Manual Muscle Testing (MMT)

clinician-applied resistance used to grade muscle strength, typically on a 0–5 scale

Handheld Dynamometry

portable device that provides an objective measure of force

Isokinetic Testing

computerized testing that measures force or torque while movement occurs at a controlled speed

Functional Strength Testing

evaluates strength during tasks such as squatting, step-downs, heel raises, pushing, or pulling

Side-to-Side Comparison

compares the involved limb with the uninvolved limb when appropriate

functional testing

assesses how well the patient integrates strength, balance, coordination, neuromuscular control, and endurance during purposeful movement

Single-Leg Hop

hop for maximum distance on one leg

Triple Hop

: three consecutive hops for maximum distance

Crossover Hop

three consecutive hops while crossing over a line

Timed Hop

measures how quickly a patient can hop a set distance

Jump/Landing Tests

assess force control, alignment, and movement quality

Change-of-Direction Tests

assess acceleration, deceleration, cutting, and directional control

Upper-Extremity Functional Tests

assess weight-bearing, stability, power, or sport-specific upper-extremity function

Timed Up and Go (TUG)

time to stand, walk 3 m, turn, return, and sit

Stair Test

assesses ability and/or time to ascend and descend stai

6-Minute Walk Test

distance walked in 6 minutes

a complete rehabilitation protocol typically includes

• protection

• mobility

• muscle function

• functional progression

• progression criteria, pain/swelling

progression criteria

ROM

strength

movement quality

functional testing

acute phase timeline and goals

• 4-6 days after injury

• Protect the injured structure

  
  

• Control pain and excessive inflammation

  
  

• Reduce edema/effusion

  
  

• Prevent unnecessary loss of motion

  
  

• Begin safe muscle activation

  
  

• Maintain conditioning of uninvolved areas

  
  

subacute/ intermediate phase timeline and goals

• 4-21 days

• exercise should cause no pain

• Restore motion, strength, and controlled loading

subacute exercise progression

ROM → resisted exercise

Isometric → dynamic strengthening

Simple → more functional movement

Controlled → increasingly challenging tasks

chronic/ RTP phase timeline and goals

• 21 days - 12 months

• prepare for unrestricted function

• Restore full or near-full ROM

  
  

• Maximize strength and endurance

  
  

• Develop power

  
  

• Restore coordination and agility

  
  

• Progress running, jumping, cutting, throwing, or other task-specific demands

  
  

• Complete appropriate functional testing

  
  

ROM exercises

Passive

Active-assisted

Active

strength and endurance exercises

Static/isometric

Dynamic/resisted

neuromuscular exercise

Proprioception

Balance

Coordination

power and functional exercise

Plyometrics

Progressive functional/sport-specific activity

passive ROM

Movement produced by an external force

Minimal patient muscle activation

active-assisted ROM

Patient contributes to movement

Assistance provided as needed

active ROM

Movement produced by the patient

Requires sufficient muscle activation and control

general progression of ROM exercises

Passive → Active-Assisted → Active

Static / Isometric

Muscle produces tension without joint movement

Useful when movement is limited or contraindicated

Dynamic / Resisted

Joint movement occurs against resistance

Incorporates:

Concentric: muscle shortens

Eccentric: muscle lengthens while producing force

proprioceptive exercise progressions

Stable → Unstable

Bilateral → Unilateral

Predictable → Reactive

Simple → Complex

plyometric exercise

Links strength and speed

Uses the stretch-shortening cycle

• Eccentric loading

• Rapid transition

• Concentric force production

open kinetic chain

distal segment is free to move

• often isolates a joint or muscle group

closed kinetic chain

distal segment is fixed or supported

• typically involves multiple joints

Continuing conditioning of uninvolved systems and regions when safe helps minimize

Cardiovascular deconditioning

Strength loss

Endurance loss

Overall decline in work capacity

prehab components

Improving baseline ROM

Improving strength and endurance

Maintaining cardiovascular conditioning

Addressing known deficits

Practicing postoperative exercises

Patient education and expectation setting

exercise dosage manipulates these five variables

intensity

duration

frequency

speed

specificity

specificity

Required movement patterns

Force demands

Velocity

Duration

Environment

Sport/work demands

rehab progression continuum

Protect

↓

Restore Motion & Activation

↓

Build Strength & Endurance

↓

Restore Neuromuscular Control

↓

Develop Power & Capacity

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Progress to Functional Demands

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Return to Activity