Red Flags for Potential Serious Conditions in Patients with Knee, Leg, Ankle or Foot Problems Medical Screening

for the Knee, Leg, Ankle or Foot Region
Condition Fractures1-4 Red Flag Data obtained during Physical Exam Joint effusion and hemarthorsis Bruising, swelling, throbbing pain, and point tenderness over involved tissues Unwillingness to bear weight on involved leg Unilaterally cool extremity (may be bilateral if aorta is site of occlusion) Prolonged capillary refill time (>2 sec) Decreased pulses in arteries below the level of the occlusion Prolonged vascular filling time Ankle Brachial index < 0.90 Calf pain, edema, tenderness, warmth Calf pain that is intensified with standing or walking and relieved by rest and elevation Possible pallor and loss of dorsalis pedis pulse History of blunt trauma, crush Severe, persistent leg pain that is intensified with injury - or stretch applied to involved muscles Recent participation in a rigorous, Swelling, exquisite tenderness and palpable unaccustomed exercise or tension/hardness of involved compartment training activity Paresthesia, paresis, and pulselessness History of recent infection, surgery, Constant aching and/or throbbing pain, joint or injection swelling, tenderness, warmth Coexisting immunosuppressive May have an elevated body temperature disorder History of recent skin ulceration or Pain, skin swelling, warmth and an advancing, abrasion, venous insufficiency, irregular margin of erythema/reddish streaks CHF, or cirrhosis Fever, chills, malaise and weakness History of diabetes mellitus Red Flag Data obtained during Interview/History History of recent trauma: crush injury, MVA, falls from heights, or sports injuries Osteoporosis in the elderly Age > 55 years old History of type II diabetes History of ischemic heart disease Smoking history Sedentary lifestyle Co-occurring intermittent claudication Recent surgery, malignancy, pregnancy, trauma, or leg immobilization

Peripheral Arterial Occlusive Disease5-9

Deep Vein Thrombosis10,11

Compartment Syndrome12-14

Septic Arthritis15

Cellulitis16

References: 1. Judd DB, Kim DH. Foot fractures misdiagnosed as ankle sprains. Am Fam Physician. 2002;68:785-794. 2. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2002;68:2413-2418. 3. Hasselman CT, et al. Foot and ankle fractures in elderly white woman. J of Bone Joint Surg. 2003;85:820-824. 4. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies, and recent developments. Injury. 2004;35:443-461. 5. Boyko EJ, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. Journal of Clinical Epidemiology. 1997;50:659-668. 6. McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158:1357-1364. 7. Halperin, JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002;106:V303-11. 8. Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral occlusive vascular disease. Scand J Prim Health Care. 1998;16:177-182. 9. Leng, GC, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ. 1996;313:1440-79. 10. Constans J, et al. Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in outpatients. Amer J Med. 2003;115:436-440. 1. Bustamante S, Houlton, PG. Swelling of the leg, deep venous thrombosis and the piriformis syndrome. Pain Res Manag. 2001;6:200-203. 2. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop. 1989;240:97-104. 3. Swain R. Lower extremity compartment syndrome: when to suspect pressure buildup. Postgraduate Medicine. 1999:105. 4. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder. Orthop Trauma. 2002;16:572-577. 5. Gupta MN, et al. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology. 2001;40:24-30. 6. Stulberg D, Penrod M, Blatny R: Common bacterial skin infections. Am Fam Physician. 2002; 66:119-124.

Joe Godges DPT

KP SoCal Ortho PT Residency

KNEE/LEG/ANKLE/FOOT SCREENING QUESTIONNAIRE
NAME: ________________________________________ Medical Record #: _________________________ DATE: _____________

Yes 1. Have you recently experienced a trauma, such as a vehicle accident, a fall from a height, or a sports injury? 2. Have you recently had a fever? 3. Have you recently taken antibiotics or other medicines for an infection? 4. Have you had a recent surgery? 5. Have you had a recent injection to one or more of your joints? 6. Have you recently had a cut, scrape, or open wound? 7. Do you have diabetes? 8. Have you been diagnosed as having an immunosuppressive disorder? 9. Do you have a history of heart trouble? 10. Do you have a history of cancer? 11. Have you recently taken a long car ride, bus trip, or plane flight? 12. Have you recently been bedridden for any reason? 13. Have you recently begun a vigorous physical training program? 14. Do you have groin, hip, thigh or calf aching or pain that increases with physical activity, such as walking or running? 15. Have you recently sustained a blow to your shin or any other trauma to either of your legs?

No

Joe Godges DPT

KP SoCal Ortho PT Residency

1

Knee Capsular Disorder "Knee Capsulitis" ICD-9-CM: 719.56 Stiffness in joint of lower leg, not elsewhere classified

Diagnostic Criteria History: Stiffness Aching with prolonged weight bearing ROM loss - more loss of flexion than extension Pain at end ranges

Physical Exam:

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

Knee Capsulitis
ICD-9: 719.56 stiffness in joint of lower leg, not elsewhere classified Description: This disorder is particularly disabling because of it results in difficulty with rising from a chair, climbing stairs, kneeling, and walking. The primary complains are pain, stiffness, instability, and loss of function and sometimes with impaired muscle function. Etiology: It is considered a sequela of traumatic and age-dependent changes which result in a loss of cartilage and impairment of function. Capsulitis has been essentially classified as primary (idiopathic) or secondary, that is a process related to infection, trauma, inflammation, metabolism, or aging. The portion of the capsule that becomes extended on joint sliding or rolling may thicken and act to restrict motion in that direction. This capsular thickening subsequent to synovitis accompanies the destruction of the articular cartilage, and thus the joint mechanism becomes gradually impaired.

Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition • • • • • Restricted knee motion Pain worse with end-range stretch positions Tibiofemoral accessory movements and joint play movements are considerable limited. Patellofemoral accessory and joint play movements may also be limited Quadriceps femoris muscles may be weak and painful due to the tension transmitted to an inflamed joint capsule by the contracting musculotendinous units that attach to the capsule Palpable tenderness around the joint capsule

Sub Acute Stage / Moderate Condition As above with the following differences • Resisted tests of the quadriceps femoris are strong and relatively painless when the tibio-femoral joint positioned in slight flexion (thus lessening tension on the capsule)

Now (when less acute) examine the patient for common coexisting lower quadrant impairments. For example: • • • Lumbar, hip and ankle movement abnormalities Muscle flexibility deficits – especially of the hamstrings, tensor fascia lata, iliotibial band and sartorius Nerve mobility deficits – especially tibial and common peroneal nerves in the knee area
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

3 • • Weak quadriceps femoris commonly vastus medialis Restricted knee extension

Settled Stage / Mild Condition As above with the following differences • • Pain with repetitive activities of the knee especially at end range Passive movements are painful only with overpressures at end range

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Prevent movement induced inflammatory reactions. Avoid muscle guarding Pain free with daily activities that use knee with low range and amplitude of movements Pain free sleep • Physical Agents Phonophoresis/iontophoresis or pulsed ultrasound to assist in reducing inflammation Ice and/or TENS for relief of acute pain as well as to reduce muscle guarding Elevation/compression of knee to assist in reducing inflammation External Devices (Taping/Splinting/Orthotics) Fit patient with knee support if pain relief requires temporary use of an external device Use of assistive device for unloading tissue Therapeutic Exercises Pain free active mobility exercises Pain free walking Pain free walking and swimming in a pool Re-injury Prevention Instruction Temporarily limit end range of flexion or stretches or activities that aggravate the patient’s condition.

Sub Acute Stage / Moderate Condition Goals: Improve tibiofemoral and patellofemoral mobility Prevent re-injury to the joint capsule Restore strength of the muscles around knee • Physical agents May use ultrasound to the joint capsule prior to active or passive stretching procedures/exercises. Manual Therapy Soft tissue mobilization to adaptive shortened myofascia around the knee Joint mobilization to restricted accessory and joint play motions of the tibiofemoral and patellofemoral articulations

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5

Therapeutic Exercises Provide stretching exercises to enhance carryover of manual stretching procedures Provide strengthening exercises to weak knee and hip muscles Neuromuscular Reeducation Provide proprioception exercises to facilitate correct knee position Therapeutic Exercise Initiate lumbar stabilization exercises (i.e., trunk flexor and extensor strengthening to maintain the lumbar spine in its neutral positions during performance of daily activities Initiate stretching exercises to myofascia with flexibility deficits (e.g., hamstrings) Initiate nerve mobility exercises the nerve with mobility limitations (e.g., sciatic nerve) Promote daily performance of low-stress aerobic activity (e.g., walking)

• •

Settled Stage / Mild Condition Goals: Normalize tibiofemoral and patellofemoral mobility Normalize lower quadrant muscle flexibility and muscle strength Progress activity tolerance • • Approaches / Strategies listed above Manual Therapy Increase intensity and duration of soft tissue mobilization and myofascial stretching to the maximal tolerable Increase intensity and duration of joint mobilization procedures to the maximal tolerable Therapeutic Exercises Progresses intensity and duration of the stretching exercises as tolerated. Maximize muscle performance of the relevant lower quadrant (hip, knee, ankle and lumbar) muscles required to perform the desired occupational or recreational activities Ergonomic Instruction Provide job/sport specific training

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities. • Approaches / Strategies listed above

Selected References Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. Ann Int Med. 2000;132:173181. Puett DW, Griffin MR. Published trials of non medicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Int Med. 1994;121:133-140. Rogind H, Bibow-Nielsen B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil. 1998;79:1421-1427.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Impairment: Limited and Painful Knee Flexion

Knee Flexion MWM Cues: Position the patient supine with the involved knee flexed and a strap around the patient’s ankle (approximately 80 degrees of knee flexion is required for this procedure) Place one palm on the anterior aspect of the distal femur and the other on the anterior aspect of the proximal tibia Posteriorly glide the tibia Sustain the posterior glide while the patient actively flexes his/her knee and assists the active flexion with a pull on the strap This procedure uses long levers so instruct the patient to apply the force cautiously The following reference provides additional information regarding this procedure: Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 101-103, 1995

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8

Impairment:

Limited Knee Extension Limited Tibial Anterior Glide

Tibial Anterior Glide Cues: Position patient with his/her involved thigh supported on the treatment table with the patella just distal to the end of the table – a strap securing the proximal femur and/or pelvis to the table adds to the stabilization A belt holding the involved knee in flexion instead of hanging off the edge of the table is a nice courtesy Use a “Chuck Berry” stance - hug the limb like a guitar and generate the force with a trunk weight shift and a slight knee bend Stand on the lateral side of the involved limb to do an anterior glide of the medial condyle – stand on the medial side of the involved limb to do an anterior glide of the lateral condyle The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 169, 1989

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee Muscle Power Deficits “Patellofemoral Pain Syndrome” ICD-9-CM: 719.46 Pain in joint - lower leg

Diagnostic Criteria History: Anterior knee pain Precipitated by trauma (subluxation), unaccustomed weight bearing activities, or prolonged sitting Worsens with bent knee sitting and activities – especially squatting, climbing stairs, or running Limited medial patellar glide and/or excessive lateral patellar glide – with pain at end range of one or both of these glides (may need to vary the amount of knee flexion to elicit symptoms) Biomechanical abnormalities (such as pronatory disorders, patella malalignment, VMO/quadriceps weakness, tight lateral retinaculum and myofascia excessive lateral tracking excessive Q angle, hip muscle length and strength imbalances

Physical Exam:

Patella Lateral Glide Cues

Patella Medial Glide

Assess glides at varying degrees of knee flexion - up to about 30° Determine motion availability Determine symptom responses at end range - be sure to use a strong force if mildmoderate forces are asymptomatic

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

"Patellar Tendinitis" ICD-9-CM: 726.64 Patellar tendinitis

Diagnostic Criteria History: Anterior knee pain. Pain associated with repetitive use of extensor mechanism (e.g., jumping, kicking) Symptoms reproduced with palpation to inferior pole of patella, or patella tendon insertion at the tibial tuberosity

Physical Exam:

Patellar Tendon Palpation/Provocation Cues: P= Patella 1= Inferior Pole 2= Superior Pole 3= Tibial Tuberosity

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3

Iliotibial Band "ITB Friction Syndrome" ICD-9-CM: 726.60 Enthesopathy of knee, unspecified Diagnostic Criteria History: Lateral knee pain Pain precipitated by unaccustomed weight bearing activities - such as stair climbing or running on unlevel surfaces Symptom reproduction with palpation and provocation of (1) Gurdy's tubercle, or (2) lateral femoral condyle with the knee slightly flexed

Physical Exam:

Iliotibial Band Palpation Cues: May need to utilize aggressive palpation to reproduce mild symptoms which develop after extensive repetitive movement. 1 = Gurdy's Tubercle (insertion of ITB) 2 = Lateral femoral condyle (common site of friction with ITB)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4

"Pes Anserinus Bursitis" ICD-9-CM: 726.61 Diagnostic Criteria History: Symptom precipitated by recent repetitive activity (e.g., long distance running) usually in the presence of some biomechanical abnormality (e.g., abnormal pronation) Medial knee pain Symptoms reproduced with palpation of pes anserine bursa Pes anserinus bursitis

Physical Exam:

Pes Anserine Palpation Cues: Bursa is located on the medial tibia flare adjacent to the insertion of the semitendinosis (follow tendon distally to locate bursa) 3 = Pes Anserine Bursa

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5

Patellofemoral Pain Syndrome
ICD-9: 719.46 pain in joint - lower leg Description: Patellofemoral pain syndrome (PFPS) is described as anterior knee pain during squatting, kneeling, stairs, walking and sitting (especially prolonged sitting) with the knee flexed. It is typically caused by poor mechanics of the patella as it travels in the femoral groove during flexion and extension of the knee. This poor tracking which typically causes the patella to deviate laterally, resulting in excessive stress on the medial patello-femoral compartment due to stretching and irritation, as well as increased lateral compartment compression. Etiology: The specific causes of this disorder can vary in individuals and typically lacks a mechanism of injury. Tight lateral structures including the iliotibial band and the lateral retinaculum are thought to be the primary causes. There are several biomechanical factors that contribute to poor tracking of the patella. These include excessive femoral anteversion and increased midfoot pronation with resultant tibial lateral rotation. **The depth, of the femoral trochlear groove also has direct bearing on the tracking of the patella. Another factor is the motor control/strength of the hip abductors and external rotators during weight loading activities. Intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking the patella medially during extension causing the patient to experience PFPS. This disorder is common in adolescent females due to the biomechanical changes occurring as their bodies develop, though is not limited to this population.

Physical Examinations Findings (Key Impairments) Acute Stage / Severe Condition • • • The patient’s reported symptoms are elicited typically with compressive forces about the involved knee during activities such as squatting and sitting for long periods of time The patella typically has limited medial gliding of the patella secondary to taut peripatellar structures The patient may present with any or all of the following biomechanical abnormalities: an increased Q-angle, femoral anteversion, lateral tibial torsion, and increased midfoot pronation, limited external rotation of the hip, limited tibiofemoral extension, decreased strength in the supinators of the foot during gait, and medial quadriceps weakness.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Sub Acute Stage / Moderate Condition As Above – except: • The patient’s reported symptoms are elicited intermittently with the activities noted above.

Settled Stage / Mild Condition • Pain may be elicited only in certain positions of excessive patellofemoral compression maintained over prolonged periods of time such as sitting, sustained stair climbing, running or biking with seat too low.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease inflammation Decrease pain • Physical Agents Ice Ultrasound (in conjunction with mobilization/manipulation) Acupuncture, acupressure or electroacupuncture for pain control Manual Therapy Soft tissue mobilization to tight lateral peripatellar structures Joint mobilization to the patella – medial patellar glides, sustained stretch and high velocity low amplitude manipulation Joint mobilization to the tibiofemoral joint – restoring normal knee extension Sacroiliac evaluation and manipulation External Devices (Taping/Splinting/Orthotics) Patellar taping procedures in conjunction with biofeedback and exercise program to promote proper patellar tracking Foot orthotics to correct excessive pronation if present Resistive brace (such as Protonics) to improve hamstring use and restore proper biomechanics Neuromuscular Reeducation Facilitory techniques to improve the contraction of the hip abductors and lateral rotators, foot supinators, and, the quadriceps muscle group, focusing, if possible, on the oblique fibers of the vastus medialis muscle Therapeutic Exercises Stretching exercises for the iliotibial band and hamstrings Initial exercises should be largely closed kinetic chain activities in the pain-free range only Re-injury Prevention/Instruction: Temporarily limit any deep squatting, heavy lifting, or through-range resistive training of the quadriceps

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Sub Acute Stage / Moderate Condition Goals: Normalize lower extremity flexibility muscle strength, motor control, and patellofemoral tracking • • Approaches / Strategies listed above Therapeutic Exercises Progress exercises to include training for return to a specific work, recreational, or sport activity Assess the biomechanics of aggravating activity (e.g. cycling with a seat too low can increase pain and cause pressure) Promote painfree, low resistance, repetitive exercises (e.g., cycling) that provide non-injurious compressive loads to the patellofemoral cartilage

Settled Stage / Mild Condition Goal: Return to desired activities • • Approaches / Strategies listed above Therapeutic Exercises Progress stretching, strengthening and coordination exercises – which includes training for return to a specific work, recreational, or sport activity

Intervention for High Performance /High Demand Functioning in Workers or Athletes
Goal: Return to desired occupation or sport • • Approaches / Strategies listed above Further biomechanical assessment during aggravating activity

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9

Selected References Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33(1):4-19. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993;73(2):62-8. Fulkerson JP. The etiology of patellofemoral pain in young, active patients: a prospective study. Clin Orthop. 1983;179:129-33. Lohman E, Harp T. A critical review of patellofemoral pain syndrome in rehabilitation. Crit Review in Phys Rehab Med. 2002;14(3&4):197-222. Powers CM. Patellar kinematics, part ii: the influence of the depth of the trochlear groove in subjects with and without patellofemoral pain. Phys Ther. 2000;80(10):965-78. Powers CM, Maffucci R, Hampton S. rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther.1995;22(4):155-60. Salsich GB, Brechter JH, Farwell D, Powers CM. The effects of patellar taping on knee kinetics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. J Orthop Phys Ther. 2002; 32(1): 3-10.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10

Patellar Tendinitis
ICD-9: 726.64 patellar tendinitis Description: Repetitive strain injury affecting the patellar tendon, resulting in anterior knee pain. Etiology: This condition is believed to be the result of repetitive mechanical stresses and is most commonly found in athletes whose sport involves repetitive, sudden, ballistic movements of the knee – such as jumping. Intratendinous changes can begin as microtears, which lead to collagen degeneration, and subsequent fibrosis. The result is usually pain well localized to a small area of the anterior knee region with specific tenderness at the inferior pole of the patella. Physical Examination Findings (Key Impairments) Acute Stage / Severe Condition • • • • • • Severe local tenderness on palpation at either the proximal or distal insertion of the patellar tendon Accessory movement deficits of patella medial/lateral/superior/inferior glide Pain with maximum stretching of the quadriceps Weak and painful quadriceps muscle when tested isometrically against resistance Symptoms can be reproduced 1) using the decline squat test, 2)with eccentric knee contractions, 3) with deep squats, or 4) with jumping/ sports activities Biomechanical abnormalities of the lower quarter may be present – such as excessive foot pronation; patella alta; femoral anteversion; flexibility deficits in the quadriceps, hamstrings, and calf muscles, as well as in the iliotibial band; strength deficits of the gluteal, lower abdominal, quadriceps, and calf muscles

Sub Acute Stage / Moderate Condition As Above – except: • • The patient tolerates more repetitions during functional strength tests before onset of pain (pain may hinder sport performance, but usually does not limit activities of daily living) Patellar tendon palpation is less tender

Settled Stage / Mild Condition As Above – except: • • Symptoms may be difficult to illicit unless repeated strenuous movements are performed Mild local tenderness with patellar palpation – note that mild patellar tenderness with palpation may be a normal finding in active athletes

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Alleviate pain Reduce aggravating and predisposing factors • Physical Agents Ice Phonophoresis Iontophoresis External Devices (Taping/Splinting/Orthotics) Patellar taping procedures may assist with promoting proper patellar tracking Foot orthotics may be useful to correct excessive pronation Taping or bracing to unload patellar tendon Manual Therapy Joint mobilization at the patella if hypomobility exists Therapeutic Exercise Initiate non-aggravating, stretching exercises for relevant muscles or fascial tissue – typically the muscles with trigger points Initiate non-aggravating, strengthening exercises for relevant weak musculature Re-injury Prevention/Instruction: Temporarily limit any deep squatting, heavy lifting, or resistive training of the quadriceps

• •

Subacute Stage / Moderate Condition Goals: Restore function Prevent future re-injury • • • Approaches / Strategies listed above Manual Therapy Friction massage to the patellar tendon Therapeutic Exercise Progress stretching and strengthening to the relevant myofascia and connective tissue Begin sport specific training as tolerated, although still avoiding maximal concentric and eccentric loads

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

12 Settled Stage / Mild Condition Goals: As above Progress activity tolerance Ability to resume sports activity and daily activities without pain • • Approaches / Strategies listed above Therapeutic Exercise Progress stretching exercises – provide a comprehensive lower quarter stretching program with emphasis on patient independence and carryover Progress strengthening exercises with an with eccentric emphasis (e.g., light jumping activities, progressive resistive exercises, sport specific training) Begin sport specific training as tolerated, although still avoiding maximal concentric and eccentric loads

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Full return to sport activity or occupation • • Approaches / Strategies listed above Therapeutic Exercise Review and correct biomechanics of desired activity, especially landing pattern of jumps, ankle/foot biomechanics, and hip/pelvic balance and stability Agility training specific to sports activity High-velocity ballistic training that is sport specific Single-leg exercises Progress with combinations of load (weight), speed, and jumping height

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

13

Selected References Bellemans J, Witvrouw, et al. Intrinsic risk factors for the development of patellar tendonitis in an athletic population. A two-year prospective study. Am J Sports Med. 2001;29:190-5. Benjamin HJ, Briner WW. Volleyball Injuries. Phys Sportsmed. 1999;27:48-58. Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 1: A New Paradigm for a Difficult Clinical Problem. Phys Sportsmed. 2000;28:38-48. Cook JL, Khan KM, et al. Overuse Tendinosis, Not Tendinitis. Part 2: Applying the New Approach to Patellar Tendinopathy. Phys Sportsmed. 2000; 28:31-46. Panni AS. Patellar Tendinopathy in Athletes. Am J Sports Med. 2000;28:392-397.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

14

Patellar Bursitis
ICD-9: 726.65 prepatellar bursitis Description: Inflammation and swelling of bursae over the patella. Etiology: Cause is typically trauma, either due to repetitive extremity movement or to acute trauma to patella. In active persons, bursitis can be induced by work activity, as seen by carpet layers, gardeners, and/or roofers. In athletes, patellar bursitis has been reported in football players, wrestlers, basketball players and dart throwers. Direct injury to the bursae comes from repetitive contact with the artificial turf, wrestling mat, hardwood floor, or exercise mat.

Physical Therapy Findings (Key Impairments) Acute Stage / Severe Condition • • • • Enlarged bursa, commonly the bordering the patellar surfaces The involved bursa are tender, may be slightly warm, and reproduce the reported symptoms with provocatory palpation Resisted knee extension also reproduce the reported symptoms Decreased range of motion of knee – pain with passive knee flexion at end range

Sub Acute Stage / Moderate Condition As Above – except: • • • Bursa not as tender to palpation – swelling and warmth are also decreased The pain is not as intense with active movement of knee Improved passive range of motion of knee due to decreased swelling and pain

Settled Stage / Mild Condition As Above – except: • • Full active and passive range of motion is available with slight pain at end ranges Muscles around knee may test to be weak, especially the quadriceps

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

15 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease swelling and pain • Physical Agents Ice Ultrasound/phonophoresis Patient Education/Re-injury Prevention Avoid activities that aggravate the symptoms Therapeutic Exercises Gentle mobility within painfree ranges

• •

Sub Acute Stage / Moderate Condition Goals: Restore normal knee and patellar and patellar mobility Return to moderate activity • • • Approaches / Strategies listed above Patient Education/Re-injury Prevention Add padding over bursa during kneeling activities Therapeutic Exercises Encourage painfree, low resistance activities such as bicycling or walking

Settled Stage / Mild Condition Goal: Return to pain free daily activity • • Approaches / Strategies listed above Therapeutic Exercises Provide strengthening to weak lower extremity musculature

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

16 Intervention for High Performance /High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure activities. • • Approaches / Strategies listed above Therapeutic Exercises Encourage participation in regular low stress aerobic activities to improve fitness, and strength.

Selected References McFarland EG, Mamanee P, Queale WS, Cosgarea AJ. Olecranon and Prepatellar Bursitis: Treating Acute, Chronic, and Inflamed. Phys Sportsmed. 2000; 68(3). Butcher, JD, Salzman, KL, Lillegard WA. Lower Extremity Bursitis. Am Fam Physician. 1996;53:2317-24. Almekinders, LC, Temple, JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998;30:1183-90.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

17

Iliotibial Band Friction Syndrome
ICD-9: 726.60 enthesopathy of knee, unspecified Description: The iliotibial band is a thickened strip of fascia lata that extends from the iliac crest to the lateral tibial tubercle. It serves as a ligament between the lateral femoral condyle and lateral tibia, stabilizing the knee joint. Iliotibial Band Friction Syndrome (ITBFS) is an overuse syndrome resulting from friction between the iliotibial band and the lateral knee. It occurs primarily in runners but is also prominent in cyclists. Characteristic symptoms are sharp pain or burning on the lateral aspect of the knee proximal to the joint line during exercise. For runners, the pain is often most intense during the deceleration phase of gait. Walking with the knee fully extended may lessen the symptoms. Activities start out pain free but symptoms develop after a reproducible time or distance. Pain subsides shortly after the activity but return with the next bout of running or cycling. Etiology: Classified as an over-use injury, Iliotibial Band Friction Syndrome occurs after continuous, steady long distance runs or cycling. It can also occur after unaccustomed change in training programs, i.e. cycling or running over hilly terrain, sprint training, increased training distances, or running on sloped surface (e.g., on the crown of the road always running in the same direction, such as against traffic). The main symptom is lateral knee pain proximal to the joint line during exercise. Other predisposing factors are sudden increase in training distances, cavus foot, genu varum, tibial varum, rearfoot and/or forefoot varus, and leg length discrepancy. There is also evidence that weak hip abductor musculature is a contributing factor.

Physical Examinations findings (Key Impairments) Acute Stage / Severe Condition • • • • • • • Antalgic gait “Stiff legged” walking in order to reduce knee flexion Aggravation of symptoms upon climbing or descending stairs or running downhill Pain elicited upon thumb pressure over lateral femoral condyle while active flexionextension of the knee is performed, with maximum pain at 300 flexion Positive Ober’s test – suggesting a “Tight” tensor fascia lata Soft tissue restriction along the iliotibial band Provocation of pain with palpation over Gurdy’s tubercle

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

18

Sub Acute Stage / Moderate Condition As above with the following differences • • • • Reduced antalgic gait. Increased knee flexion during walking Reduced aggravation of symptoms upon climbing or descending stairs or running downhill Decreased pain upon thumb pressure over lateral femoral condyle while active flexion-extension of the knee is performed, with maximum pain at 30o flexion Reduced pain after start of activity (running, cycling)

Settled stage / Mild Condition As above with the following differences • Mild pain after start of activity (running, cycling)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

19

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Control pain and inflammation Correct poor training habits or any other structural abnormalities • Physical Agents Ice packs, ice massage Ultrasound Phonophoresis Electrical stimulation Re-injury Prevention Instruction Temporarily limit any activity that aggravate symptoms

Sub Acute Stage / Moderate Condition Goals: Avoid continued irritation Prevent Re-injury • • Approaches / Strategies listed above Manual Therapy Soft tissue mobilization and manual stretching to the fascial adhesions to the ITB

• Therapeutic Exercises Stretching intended to elongate the iliotibial band, such as Half-kneeling diagonal stretch, Ober stretch, modified Ober stretch, Crossover toe touch, Lateral hip drop stretch The most tension on the ITB is created by having the patient standing and extending and adducting the leg to be stretched across and behind the other leg. The patient than sidebends the trunk away from the involved hip/thigh hands clasped overhead • Re-injury Prevention Instruction Instruction in proper footwear (including bicycle toe clip options) and orthotics may be helpful (a lateral sole wedge may be of help)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

20

Settled Stage / Mild Condition Goals: As Above Prevent recurrence of resolved symptoms. • • Approaches / Strategies listed above Therapeutic Exercises Provide stretching exercises to elongate shortened myofascial (e.g., hip flexors, calf muscles) and strengthening exercises to improve the motor performance in weak muscles (e.g., gluteus medius and gluteus maximus) Re-injury Prevention Instruction Instruction in proper footwear and orthotics may be necessary

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: To return to optimum level of function at work or sports. • • Approaches / Strategies listed above Therapeutic Exercises Continuation of gradual increase in distance and frequency of activities

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

21

Selected References Barber FA, Sutker AN. Iliotibial band syndrome. Sports Med. 1992;14:144-148. Drogset JO, Rossvoll I, Grontvedt T. Surgical treatment of iliobitial band friction syndrome: A retrospective study of 45 patients. Scand J Med Sci Sports. 1999;9:296-298. Fredericson M, Guillet M, DeBenedictis L. Quick solutions for iliotibial band syndrome. Phys Sports Med. 2000;28. Fredericson M, White JJ, MacMohon JM, Andriacchi TP. Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002;83:589-92. Holmes JC, Pruitt AL, Whalen NJ. Iliotibial band friction syndrome in cyclist. Am J Sports Med. 1993;21:419-424. Martens M, Libbrecht P, Burssens A. Surgical treatment of the iliotibial band friction syndrome. Am J Sports Med 1989;17:651-654. Noble CA. Iliotibial band friction syndrome in runners. Am J of Sports Med. 1980;8:232-234. Noble HB, Hajek RM, Porter M. Diagnosis and treatment of iliotibial band tightness in runners. Phys Sports Med. 1982; 10:67-74.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

22

Pes Anserine Bursitis
ICD-9: 727.9 unspecified disorder of synovium, tendon, and bursa Description: An inflammatory condition of the medial knee especially common in certain patient populations and often coexisting with other knee disorders. The term pes anserinus refers to the conjoined tendons of the sartorius, semitendinosus, and gracilis muscles as they cross the proximal aspect of the tibia to insert along its medial surface. The term originates from the Latin “pes” for foot and “anserinus” for goose and derives from the anatomic observation that the tendons form a structure reminiscent of a goose’s webbed foot. Etiology: Inflammation of the pes anserine bursa. This bursa is located 2” inferior to joint line at the medial tibial flare. Inflammation to this bursa is often a sequela to local trauma, exostosis and tendon tightness, pes planus (predisposes the patient to problems affecting the medial knee) or DJD affecting the knee especially in overweight middle-aged to elderly women . A female patient who is overweight can also experience referred pain to the knee from broad pelvic area with the resultant angulation at the knee joint putting more stress on the bursa.

Physical Examinations Findings (Key Impairments) • • • • • Tenderness over proximal medial tibia May have localized swelling at the insertion of medial hamstring muscles Negative valgus stress at 30° flexion lessens likelihood of medial collateral ligament strain Negative McMurray’s and painfree knee flexion overpressures lessens the likelihood of meniscal involvement Positive resisted knee flexion in prone position

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

23

Intervention Approaches / Strategies Goal: Decrease swelling and pain. • Physical Agents Iontophoresis with dexamethasone Ultrasound/ phonophoresis Electrical stimulation Ice Therapeutic Exercises Gentle stretching in pain free ranges of: sartorius (hip IR in hip and knee extension) gracilis (supine hook lying, gently spread knees apart) hamstrings (long sit, foot turned slightly in, loop towel or sheet around foot and pull gently while maintaining lumbar lordosis) triceps surae (standing one with knee extended and one leg flexed) Quadriceps, hamstring and calf strengthening External Devices (Taping/Splinting/Orthotics) Orthotics, where indicated, to correct pes planus Re-injury Prevention Instruction Instruct patient in appropriate exercises, stretches, application of ice and instruct in the use of orthotics Patient education for weight management

• •

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

24 Selected References Abeles M. Anserine bursitis. Arthritis Rheum. 1986;29:812-3. Brookler MI, Mongan ES. Anserina bursitis: a treatable cause of knee pain in patients with degenerative arthritis. California Medicine. 1973;119:8-10. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 1996;53:2317-2324. Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part II: Differential Diagnosis. American Family Physician. 2003;68:917. Forbes JR, Helms CA, Janzen DL.Acute Pes Anserine Bursitis: MR Imaging. Radiology. 1995; 194:525-527 Handy JR. Anserine bursitis: a brief review. South Med J. 1997; 90:376-7. Hemler DE, Ward WK, Karstetter KW, Bryant, PM. Saphenous Nerve Entrapment caused by Pes Anserine Bursitis mimicking Stress Fracture of Tibia. ArchPhys Med Rehabil. 1991;72:3367. Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arth Rheum 1985;28:1062-5. Magee, D. Orthopedic Physical Assessment 3rd ed. WB Saunders Co., Philadelphia, PA, 1997 Stuttle FL: The no-name and no-fame bursa. Clin Orthop. 1959;15:197-99. White, T. Pes anserine (knee) bursitis rehabilitation exercises. Sports Medicine Adviser 2002.1. http://www.med.umich.edu/1libr/sma/sma_pesanser_rex.htm

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Knee – Movement Coordination Deficits Anterior Cruciate Ligament “ACL Tear” ICD-9-CM: 844.2 Sprain of cruciate ligament of knee

“ACL Insufficiency” ICD-9-CM: 717.83 Old disruption of anterior cruciate ligament

Medial Collateral Ligament “MCL Tear” ICD-9-CM: 844.1 Sprain of medial collateral ligament of knee

Diagnostic Criteria History: ACL Tear: Trauma or strain - often accompanied by an audible snap or pop, followed by rapid onset of a large effusion/hemarthrosis ACL Insufficiency: Episodic giving way, effusion and pain with specific (usually pivoting) activities MCL Tear: Trauma involving a valgus stress (e.g., from a fall or a blow to the lateral knee) ACL Tear and Insufficiency: Excessive anterior tibial translation with Lachman’s Test MCL Tear: Pain - and possibly laxity - with valgus stress test at 30 degrees of knee flexion

Physical Exam:

Lachman’s Test Cues: Stabilize femur, pull tibia anteriorly in a line parallel to the tibial plateau - determine the amount of tibial anterior translation (0-2 mm is normal) Other tests (e.g., anterior drawer, pivot shift, KT – 2000) may also be used to assess ACL integrity Involuntary, protective muscle guarding by the patient lowers sensitivity of these tests

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

Valgus Stress Test Cues: Stand facing patient Allow thigh to rest on table, flex tibia off table Performing test at 30 degrees of knee flexion is more selective for MCL involvement Prevent rotational motion of femur and tibia when applying the valgus stress

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3

Medial Collateral Ligament Sprain of the Knee
ICD-9: 844.1 sprain of medial collateral ligament of knee Description: Tension injury to the medial collateral ligament of the knee commonly from a sudden application of valgus force to the knee. The MCL tenses to the point of micro or macroscopic injury to its structure. Etiology: The medial collateral ligament can be injured as the result of contact with a direct blow to the lateral aspect of the thigh/leg or noncontact with the sudden application of a valgus torque to the knee. The classic example is a direct blow to the lateral aspect of the athlete’s knee while the foot is planted to the ground. Physical Examination Findings (Key Impairments) Acute Stage/ Severe Condition • • • • • • May have the inability to walk or bear weight without pain in more severe cases Minimal to moderate effusion and warmth with an isolated MCL injuries; larger amounts of effusion are associated with ACL and PCL tears which must be ruled out Palpation of the MCL produces tenderness Knee extension and flexion may be limited due to joint effusion and pain. Abnormal laxity and the reproduction of symptoms are identified with valgus stress testing at 30 degrees of knee flexion. May have weakness and pain with knee extension and flexion manual muscle testing due to the close anatomical proximity of the MCL to vastus medialis, semitendinosis, and semimembranosis. In a contact injury, lateral structures such as vastus lateralis and biceps femoris may also be affected.

Sub Acute Stage / Moderate Condition As above with the following differences • • • Able to walk with minimal pain and without a significant limp Strong and painful knee extension and flexion with manual muscle testing Minimal to no effusion at the knee

Settled Stage/ Mild Condition As above with the following differences • • Knee motion may be limited by stiffness with non-painful spongy end feel or motion may not be limited at all May have difficulty with deep squatting, cutting (Zigzags), and sprinting
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

4 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain, swelling, and inflammation at the knee Maintain knee mobility Restore strength to hamstrings and quadriceps Encourage weight bearing of involved leg Maintain general conditioning • Physical Agents: Ice with compressive wrap or Cryo/Cuff applied to injured knee with elevation Ultrasound Electrical stimulation Manual Therapy Friction massage External Devices (Taping/Splinting/Orthotics) May use crutches as required to limit pain May consider a Neoprene sleeve or minimally restrictive lateral hinge brace Therapeutic Exercises Range of motion exercises of the knee (passive→active assisted→active) Quadriceps setting and straight leg raise exercises (isometric) Upper body ergometer or swimming to maintain general fitness level while MCL is healing Patient Education/Re-injury Prevention Avoiding activities that may stress the MCL

• •

Subacute Stage/ Moderate Condition Goals: Walk unassisted without a limp Achieve 90o of knee flexion Increase knee strength Maintain general conditioning • • Approaches / Strategies listed above Therapeutic Exercises Begin isotonic progressive resistive for quadriceps and hamstrings Begin isokinetic exercise if available Begin closed-chain exercises Bicycle ergometer, stair climber Exercises to increase knee flexion to 90o

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5

Settled Stage/ Mild Condition Goals: Achieve full knee ROM Begin running and functional exercise program Continue with general conditioning • Therapeutic Exercise Full active knee motion exercises Improve muscle performance required to participate in desired occupational or recreational activities. For example: Fast speed walking to gentle straight-line jogging Jumping Sprints Zig-zags

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goals: Return to desired occupational or recreational activities • • Approaches / Strategies listed above Therapeutic Exercise Maximize muscle performance to relevant leg muscles required to perform the desired occupational or recreational activities Progress job/sports specific training to increase mechanical demand. Examples of activities for athletes: Sprinting up to full-speed Zig-zags up to full-speed Jogging greater than one mile Figure-eights Noncontact drills to full-contact drills Acceleration/deceleration speed play External Devices (Taping/Splinting/Orthotics) May utilize standard MCL taping as needed prior to athletic participation Brace application may be used as needed – may provide psychological benefit

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6

Selected References Dersheid GL, Garrick JG. Medial collateral ligament injuries in football: nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9:365-368. Holden DL, Eggert AW, Butler JE. The nonoperative treatment of grade I and II medial collateral ligament injuries to the knee. Am J Sports Med. 1983;11:340-4. Reider B. Medial collateral ligament injuries in athletes. Sports Med. 1996; 21:147-56. Reider B, Sathy MR, Talkington J. Treatment of isolated medical collateral ligament injuries in athletes with early functional rehabilitation: a five-year follow-up study. Am J Sports Med. 1994; 22: 470-477.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7

Anterior Cruciate Ligament Sprain/Insufficiency
ICD 9: 844.2 sprain of the cruciate ligament of knee - or 717.83 old disruption of anterior cruciate ligament Description: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee. The ACL extends from the anterior aspect of the tibia to the inner aspect of the lateral femoral condyle and it helps stabilize the knee in the anterior-posterior and rotational planes. The main blood supply is provided by the synovial membrane and the ACL is innervated by the tibial nerve. Etiology: ACL sprains are caused by sudden decelerations, abrupt changes in direction, hyperextensions, cutting maneuvers on a planted foot, internal tibial rotation, and valgus stresses. Physical Examinations Finding (Key Impairments) Acute Stage / Severe Condition • • • • • • Pain Swelling Decreased range of motion Decreased strength Abnormal laxity produced with Lachman’s and anterior drawer tests Decreased weight bearing on involved lower extremity

Sub Acute Stage/ Moderate Condition As above with the following differences: • • • • • Minimal to no effusion at the knee Minimal limitations in ROM Strength testing of knee extension and flexion in mid range are relatively strong and pain free Able to walk with minimal pain and without a significant gait deviations Decreased proprioception

Settled Stage / Mild Condition As above with the following differences: • • • Full ROM Minimal to no gait deviations Difficulty with sport specific activities (i.e., fast change in directions)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Intervention Approaches / Strategies Acute Stage/ Severe Condition Goals: Decrease pain, swelling, and inflammation at the knee Maintain knee mobility Restore strength to hamstrings and quadriceps Encourage weight bearing of involved leg Maintain general conditioning • Physical Agents Ice with compression and elevation Electrical Stimulation Ultrasound External Devices (Taping/Splinting/Orthotics) Assistive device as needed to limit pain Bracing to provide stability and limit anterior tibial torsion Therapeutic Exercise* Range of motion exercises of the knee (passive→active assisted→active) Isometric exercises for quadriceps and hamstrings

*Caution: Open chain terminal knee extension exercises (from 60 degrees to 0) with resistance applied to the distal leg, and closed-chain squatting between 60 and 90 degrees may cause increased anterior translation of the tibia and excessive stress to the ACL. • Patient Education Activity modification, especially avoiding positions that lead to giving way, pain, and effusion.

Sub Acute Stage/ Moderate Condition Goals: Walk independently without gait deviations Increase knee strength Increase proprioception • • • Physical Agents: Same as those listed above External Devices Functional bracing to increase knee stability Therapeutic Exercise Isotonic progressive resistive for quadriceps and hamstrings Isokinetic exercise if available Closed-chain exercises

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9 Stationary bicycle Running on treadmill Proprioceptive training Perturbation exercises Settled Stage / Mild Condition Goals: As above Return to desired recreational activity or sport • Therapeutic Exercises Improve muscle performance required to participate in desired occupational or recreational activities. For example: Fast speed walking to gentle straight-line jogging Jumping Sprints Zig-zags Perturbation training Plyometric and agility training

Selected References Bagger J, Ravn J, Lavard P, Blyme P, Sorensen C. Effects of functional bracing, quadriceps and hamstrings on anterior tibial translation in anterior cruciate ligament insufficiency: A preliminary study. J Rehabil Res Dev. 1992;29(1):9-12. Colby S, Hintermeister RA, Torry MR, Steadman JR. Lower Limb Stability with ACL Impairment. J Ortho Sport Phys Ther. 1999;25(8):444-454. Cooperman JM, Riddle DL, Rothstein JM. Reliability and Validity of Judgments of the Integrity of the Anterior Cruciate Ligament of the Knee Using the Lachman’s Test. Phys Ther. 1990;70(4):225-232. Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc. 1999;31(2):210-215. Fitzgerald K, Axe MJ, Snyder-Mackler L. Proposed Practice Guidelines for Nonoperative Anterior Cruciate Ligament Rehabilitation of Physically Active Individuals. J Ortho Sport Phys Ther. 2000;30(4)194-203. Fitzgerald K, Axe MJ, Snyder-Mackler L. The Efficacy of Perturbation Training in Nonoperative Anterior Cruciate Ligament Rehabilitation Programs for Physically Active Individuals. Phys Ther. 2000;80(2):128-139. Roberts D, et al. Proprioception in People with Anterior Cruciate Ligament –Deficient Knees: Comparison of Symptomatic and Asymptomatic Patients. J Ortho Sport Phys Ther. 1999;29(10):587-594.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee Pain "Medical Meniscus Tear" or "Lateral Meniscus Tear" ICD-9-CM: 717.3 717.40 Unspecified derangement of medial meniscus Derangement of lateral meniscus, unspecified

Diagnostic Criteria History: Joint line or posterior knee pain Joint locking Inability to fully bend or straighten the knee Precipitating twisting/pivoting, hyperflexion, or hyperextension mechanism Joint line tenderness (symptoms reproduced) Guarding, clicking, or pain with hyperflexion, hyperextension or McMurray’s Test

Physical Exam:

Hyperflexion Test

Hyperextension Test

McMurray's Test Cues: Begin tests slowly and gently - increase the amount of overpressure force if gentle forces are easily tolerated Add tibial rotations and varus/valgus forces in an attempt to elicit symptoms

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

Meniscal Tears of the Knee
ICD-9: 717.3 unspecified derangement of medial meniscus ICD-9: 717.40 derangement of lateral meniscus, unspecified Description: Meniscal tears are very common sports injuries. Typical symptoms include pain, catching, and buckling. Etiology: The mechanism of injury often describes a twisting injury to the knee, or full flexion of the knee (as in kneeling) that leads to pain or locking. The twisting can lead to meniscal tearing through shear forces, whereas loading the knee in full flexion can overload the posterior horn leading to a meniscal tear. Physical Examinations Findings (Key Impairments) Acute Stage / Severe Condition • • • • Effusion usually accompanies a medial meniscus tear, but not always a lateral tear Weight bearing flexion-extension (i.e., squatting) is painful and difficult to perform If the knee is locked, a springy- rebound end feel will be noted moving into extension McMurray’s test may not able to be performed if considerable effusion restricts flexion, because it is applicable only from full flexion to 90 degrees. If flexion is possible, a painful click may elicited on combined external rotation and extension if a tear exists in the posterior portion of medial meniscus, or on combined internal rotation and extension if posterior lateral meniscus lesion exists Tenderness is present at the joint line where a sprain to the peripheral attachment has occurred

Sub Acute Stage / Moderate Condition As Above – except: • Passive overpressure reveals a muscle-guarding end feel at the extremes of flexion and extension.

Settled Stage / Mild Condition As Above-except • • Passive overpressures are reproductive of symptoms only with end range in either combined external rotation and extension or combined internal rotation and extension Rotation opposite the side of the lesion may be painful, especially during Apley’s test with compression applied. Distraction with rotation should relieve the pain. This movement should be relatively normal unless a ligamentous injury also exists

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Restore painfree active knee movement • Physical Agents Ice Electrical stimulation Therapeutic Exercises Submaximal, controlled, quadriceps and hamstring setting exercises through available painfree ranges External Devices (Taping/Splinting/Orthotics) May use crutches as required to limit pain

Sub Acute Stage / Moderate Condition Goal: Restore normal, painfree response to overpressure at end ranges flexion or extension. • • Approaches / Strategies listed above Manual Therapy May attempt manual traction and manual resistance using PNF patterns with an emphasis on the distraction portion of the facilitation. Therapeutic Exercises Progress knee mobility and strengthening exercises if tolerated Include exercises that focus on maintaining strength in hip musculature

Settled Stage / Mild Condition Goals: Restore normal, painfree response to overpressure to both flexion and extension and combined movements of external rotation and extension and / or internal rotation and extension. Normalize status on weight bearing Increase strength dynamic control, and endurance of the involved lower extremity • • Approaches / Strategies listed above Therapeutic Exercises Instruct in stretching exercises to address the patient’s specific muscle flexibility deficits

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 • Progress strengthening exercises to address the patient’s specific muscle strength deficits

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational on leisure time activities. • • Approaches / Strategies listed above Therapeutic Exercises Progress strengthening with isokinetic exercises using velocity spectrum rehabilitation Continue to improve general endurance and conditioning with aerobic activities such as bicycling, swimming and walking Progress strengthening, stabilization, and balance activities in functional position with marching, lunges, step-up and step-down exercises, and plyometric training or slide board and balance board exercises

Selected References Bernstein J. Meniscal Tears of the Knee. Diagnosis and Individualized Treatment. Phys Sportsmed. 2000;28:83-90. McCarty E. Meniscal Tears in the Athlete: Operative and Non operative Management. Phys Med Rehabil Clin N Am. 2000;11:867-879.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1 Knee and Leg Radiating Pain "Peroneal Nerve Entrapment" ICD-9CM: 355.3 Lesion of lateral popliteal nerve

Diagnostic Criteria History: Line of pain on lateral side of knee and calf Paresthesias, potential numbness and weakness Onset precipitated by trauma or pressure to lateral knee, constrictive garment, brace, or cast around upper calf Symptoms reproduced with peroneal nerve tension test Symptoms reproduced with palpation/provocation of common peroneal nerve

Physical Exam:

Peroneal Nerve Tension Test

Cues: Perform a SLR to the point of first resistance, then plantarflex and invert the ankle and foot - inquire regarding symptoms with hip extension and flexion while maintaining plantar flexion and inversion

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

Common Peroneal Nerve Palpation Cues: 5 = Fibular head/proximal tibiofibular joint Nerve is located posterior and medial to the superior tibiofibular joint Assess symptom response to palpation

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3

Peroneal Nerve Entrapment
ICD-9: 355.3 lesion of the lateral popliteal nerve Description: Defined as a state of altered transmission in a peripheral nerve because of mechanical irritation from related anatomical structures. Entrapment neuropathy of the common peroneal nerve across the knee can occur in different regions. It can occur as the nerve passes beneath the biceps femoris tendon in the popliteal fossa or over the bony prominence of the fibular head and in the fibular tunnel formed by the origin of the peroneus longus muscle and the inter-muscular septum. The updated name for the peroneal nerve is the fibular nerve. Etiology: Peroneal nerve entrapment usually is attributed to excessively thick fibrous arch and narrowing of the tunnel through which the nerve passes. The suspected causes of this disorder vary, but all causes relate to space occupying disorders of the peroneal nerve as it courses through the posteriolateral region of the knee and superiolateral region of the leg. Suspected causes of peroneal nerve entrapment are: trauma or injury to the knee; fracture of the fibula; use of a tight plaster cast (or other long-term constriction) of the lower leg; habitual leg crossing; wearing of high boots; pressure to the knee from positions during deep sleep or coma; or injury during knee surgery. Risk factors for developing this condition are the following: being extremely thin or emaciated, having diabetes, or having polyarteritis. The diagnosis is confirmed by a nerve conduction velocity - short segment stimulation technique.

Physical Examinations Findings (Key Impairments) Acute Stage / Severe condition • • • • • Positive Tinel's sign at the neck of the fibula Decreased sensations, numbness or tingling on the dorsum of the foot Weakness of the ankles or feet Pain with provocation of the entrapment site Gait abnormalities - such as: "Slapping" gait, foot drop (unable to hold foot horizontal), or toe drag during swing phases

Sub Acute Stage / Moderate Condition In this stage you will see symptoms similar to the acute stage except the symptoms might ease up and will be to a lesser extent.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Intervention Approaches / Strategies Acute Stage / Severe condition Goals: Remove or decrease structures causing entrapment Keep edema or pooling of blood to a minimum Increase movement of nerve in between tissue Maintain strength, endurance, and sensations in unaffected sites. • Manual Therapy Soft tissue mobilization to restricted fascia or myofascia near entrapment site Joint mobilization to restricted accessory motions in the superior tibiofibular, patellofemoral or tibiofemoral joint Physical Agents Electrical stimulation to maintain muscle functioning if a paresis is present Ultrasound for inflammation reduction Therapeutic Exercises Nerve mobility exercises External Devices (Taping/Splinting/Orthotics) An ankle-foot orthosis for the severely impaired with drop foot until return of function of ankle dorsiflexors Sub Acute Stage / Moderate Condition Goal: Remove entrapment structures and increase movement of peroneal nerve through entrapment sites. • Approaches / Strategies listed above

• •

Note that surgery to decompression of peroneal nerve entrapment site may be required in severe cases or when symptoms persist or recovery remains incomplete for three to four months

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5

Selected References 1. Kanakamedala RV, Hong CZ. Peroneal nerve entrapment at the knee localized by short segment stimulation. Am J Phys Med Rehabil. 1989;68:116-122. 2. Fabre T, Piton C, Andre D, Lasseur E, Eurandeal A. Peroneal Nerve Entrapment. J Bone Joint Surg. 1998;1:47-53 3. Vastamaki M. Decompression for peroneal nerve entrapment. Acta Erthop. Scand. 1986;57:551-554 4. Sridhara CR, Izzo KL. Terminal sensory branches of the superficial peroneal nerve: an entrapment syndrome. Arch Phys Med Rehabil. 1985;66:789-791 5. MEDLINE Plus Medical Encyclopedia Common peroneal nerve dysfunction http://www.nlm.nih.gov/medlineplus/ency/article/000791.htm

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6

Manual Therapy for “Peroneal Nerve Entrapment”
Examination: Superior Tibiofibular Accessory Movements Treatment: Joint Mobilization: Posterior-Medial Glide (supine w/ wedge) Anterior-Lateral Glide (tibia on chair - use pisiform) Soft Tissue Mobilization: Lateral Popliteal or Calf area (p. 57) Nerve Mobilization: AROM and PROM progression

Impairment:

Limited Superior Tibiofibular Posterior/Medial Glide

Fibular Posterior/Medial Glide Cues: Position the patient with slight knee flexion under a mobilization wedge - with the heel just off the edge of the table Stabilize the tibia into internal rotation The treatment plane runs posterior -medially, thus, the mobilization force is directed medially, or, it is directed straight posteriorly if the tibia is internally rotated Use a “soft” thenar eminence as the mobilization contract

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7

Impairment:

Superior Tibiofibular Anterior/Lateral Glide

Fibular Anterior/Lateral Glide Cues: Position the patient with the involved knee flexed and with the tibia resting on a low table or a chair (Provide a stationary table or chair for the patient to hold on to for balance) Stabilize the tibia with one hand Mobilize the fibula anterio-laterally with the hypothenar eminence of the other hand using a trunk lean Catch a large portion of the lateral gastrocnemius to cushion the pressure – careful not to compress the common peroneal nerve The following reference provides additional information regarding this procedure: Freddy Kaltenborn PT: Manual Mobilization of the Extremity Joints, p. 159, 1989

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

SUMMARY OF KNEE (TIBIOFEMORAL) DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER
Knee Mobility Deficit “Knee Capsulitis” Knee Muscle Power Deficit “Iliotibial Band Friction Syndrome”

HISTORY
Aching – worse with wt. bearing Stiffness Lateral knee pain Overuse MOI – precipitated by unaccustomed wt. bearing – e.g., stair climbing or running on unlevel surfaces Medial knee pain Overuse MOI – such as long distance running in the presence of a LE biomechanical abnormality (e.g., abnormal pronation) Trauma Swelling (often acute hemarthrosis) Giving way Trauma – involving a valgus stress Swelling

PHYSICAL EXAM
ROM deficits – esp. loss of flexion Pain at end ranges SR w/ provocation of Gurdy’s tubercle or Lateral Femoral Condyle

PT MANAGEMENT
PROM/Joint Mobs Ther Ex’s Reduce overuse Physical agents (Ice, US) STM, C/R, FM, to ITB and Lat thigh PF Taping Rx LE biomechanical impairments Reduce overuse and LE biomechanical impairments Physical agents (US/Phono) Gentle FM Physical agents if acute P.R.I.C.E. instructions Proprioceptive and functional strength training Physical agents if acute (Ice, US) P.R.I.C.E. instructions Proprioceptive and functional strength training Friction massage Painfree Ther Ex’s

Knee Muscle Power Deficit Pes Anserinus Bursitis

SR w/ palpation or provocation of the pes anserine bursa

Knee Movement Coordination Deficit “Anterior Cruciate Ligament Sprain/Insufficiency” Knee Movement Coordination Deficit Medial Collateral Ligament Sprain

Excessive anterior tibial translation with Lachman’s Test

Pain – and possibly laxity – with valgus stress test at 30o of flexion

Knee Pain “Medial or Lateral Meniscal Tear” Knee and Leg Radiating Pain “Peroneal Nerve Entrapment”

Twisting/pivoting MOI Joint line pain Locking Cannot fully bend or straighten knee Line of pain on Lat side of knee/calf Paresthesias, sensory & motor deficits Onset MOI – trauma or pressure to lateral side of knee (e.g., brace)

SR w/: Joint line palpation or provocation Hyperflexion, hyperextension, or McMurray’s maneuvers SR w/: Peroneal Nerve bias LLTT Palpation/provocation of the Peroneal Nerve

Rx entrapment (STM/JM to Sup. Tib-Fib area) Peroneal Nerve Mob (PROM and AROM Ex’s)

Joe Godges DPT

KPSoCal Ortho PT Residency

SUMMARY OF PATELLOFEMORAL DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES

DISORDER Muscle Power Deficits “Patellofemoral Pain Syndrome”

HISTORY Anterior Knee pain Onset related to overuse or trauma Sx’s worsen with bent knee/sitting positions Anterior knee pain Onset associated with repetitive use of Quads – i.e., jumping Recent blunt trauma to the anterior knee Repetitive weight bearing onto knee i.e., kneeling

PHYSICAL EXAM Lateral patella orientation Limited medial patellar glide SR w/end range of patella glide Biomechanical abnormalities of the LE are common

Muscle Power Deficits Patellar Tendinitis

Muscle Power Deficits “Patellar Bursitis”

SR w/: Resisted extension Palpation/provocation of the patellar tendon at the superior pole, inferior pole, or insertion on the tibial tuberosity Patellar effusion SR w/provocation of the suprapatellar, prepatellar, or infrapatellar bursa

PT MANAGEMENT Reduce overuse STM and stretching of the lateral PF/thigh structures Patellar joint mobs (medial glides) PF taping Normalize LE impairments related to PF symptomatology Reduce overuse Physical agents (Ice, US, Ionto) Friction massage Taping Progressive reloading/sports training Reduce weight bearing stress – allow healing Physical agents (Ice, US, Phono)

Joe Godges DPT

KPSoCal Ortho PT Residency

1

Patellar Dislocation – Conservative and Operative Rehabilitation
Surgical Indications and Considerations Anatomical Considerations: Patellar stability is dependent upon two components: bony (trochlear groove) and soft tissue structures. There are multiple soft tissue layers that surround the patellofemoral joint. Medially, the superficial layer is consists of the fascia over the sartorius muscle, the second layer contains the medial patellofemoral ligament (MPFL) and the retinaculum, and the third layer contains the medial collateral ligament and joint capsule. The MPFL provides 50-80% of total restraining force medially. Fascial interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps comprise the lateral retinaculum. Pathogenesis: Patellar instability can be correlated with one or more of the following anatomical risk factors: tightness of lateral structures, patella alta, patella or femoral dysplasia, increased Q-angle, increased sulcus angle, generalized laxity, increased femoral anteversion, increased external tibial torsion, lateral position of the tibial tuberosity, abnormal foot pronation, and a vertical vastus medialis oblique (VMO) insertion. Patella dislocation can occur from indirect, twisting or rapid change of direction with the foot planted, or direct trauma to patella. Epidemiology: A higher incidence of patellar dislocations occur in females ages 10 to 17 years of age and the athletically active, with less incidence over age 30. Lateral dislocations are very common and will be the topic of discussion in this guideline. Medially dislocations are typically rare and result from direct trauma, an excessive lateral release or overcorrection of a realignment procedure. Redislocations occur more frequently in patients younger than 20 and tend to decrease with advancing age. Diagnosis • • • • • History of dislocation with giving way Effusion Positive apprehension test (Fairbank sign) Medial retinacular tenderness Other clinical findings may include: Patellar mobility (Sage test for lateral retinacular tightness – positive if medial patellar excursion is less than ¼ of greatest patellar width) Patellar maltracking Abnormal Q angle (normal = males – 8-10 degrees, females – 10-20 degrees) Abnormal sulcus angle (normal = <150 degrees) Imaging studies help confirm the diagnosis

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Conservative treatment includes bracing and taping to restore proper patellar alignment and physical therapy to regain strength and range of motion. Conservative treatment is most often attempted first, especially with a first-time dislocation. Operative treatment is recommended in the presence of anatomical abnormalities or osteochondral fractures. It is more effective in preventing recurrence of dislocations and is often only considered after conservative treatment has been unsuccessful. Surgical Procedure: Many different procedures are performed to correct patellar instability. Proximal realignment procedures include lateral release, medial reefing, advancement of the vastus medialis oblique (VMO), and Galleazzi’s procedure. Lateral release involves an incision of the lateral retinaculum. Medial reefing involves tightening the medial structures and is often done in conjunction with a lateral release. VMO realignment involves reattaching the VMO insertion more distally and laterally on the patella. The Galeazzi procedure is seldom performed however involves attaching the semitendinosus tendon to the medial side of the patella. Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial collateral ligament. Evidence has shown that lateral release is more effective when combined with another procedure (i.e. proximal or distal realignment) and for many investigators would only be used it there was a residual patellar tilt after repair/reconstruction of the medial retinacular structures.

CONSERVATIVE REHABILITATION (Acute)

Note: The following rehabilitation progression after a first-time acute lateral patellar dislocation is a summary of the guidelines provided by D’Amato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk.

Phase I Goals: Decrease pain and swelling Limit range of motion and weight-bearing to protect healing tissues Return muscle function Avoid overaggressive therapy that may lead the patient into a patellofemoral pain syndrome Intervention: • • • • • Bracing: set at 0 degrees initially with ambulation, lateral buttress pad in brace Ice McConnell taping; light compressive bandage Instruction in partial weight-bearing with crutches Electrical stimulation for activation of the VMO

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 • • • Supine straight leg raise (SLR) with minimal to no pain Ankle pumps if edema is present Isometric hamstrings

Phase II Criteria: no significant joint effusion, no quadriceps extension lag, minimal to no pain with activities of daily living Goals: Full ROM – pain-free Improve quadriceps strength Low-level functional activities Initiate conditioning Avoid patellofemoral symptoms or instability Intervention: • • • • • • • Continue patellar bracing or taping Weight-bearing as tolerated; discard crutches when extension lag is no longer present Continue electrical stimulation and modalities as needed Continue supine SLR and add adduction and abduction SLRs Toe raises with equal weight bearing Closed kinetic chain exercises Low-level endurance and pool exercises

Phase III Criteria: full active ROM, good to normal quadriceps strength, full weight-bearing with normal gait pattern Goals: Improve function Gradual return to high-level activities Intervention: • • • • • • Bracing: wean from bracing and taping as quadriceps function improves Four-way hip exercises Pool therapy – walking with progression to running Sport and skill-specific training Proprioceptive training Patient education

Criteria for Return to Full Activity (8-12 weeks)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4

• • • • •

Equal ROM between lower extremities No pain or edema 85% strength compared with uninvolved limb Satisfactory 1-minute single leg hop test, two-legged hop test Patellar stability with clinical tests

Preoperative Rehabilitation: Acute Phase: PRICE - protection, rest, ice, compression, elevation (if acute) Maintain quadriceps strength and flexibility of the hamstrings Patellar bracing and taping to restore proper alignment

POSTOPERATIVE REHABILITATION Distal and/or Proximal Realignment Procedures

Note: The following rehabilitation progression is a summary of the guidelines after a distal and/or proximal realignment procedure provided by D’Amato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk. The same rehabilitation protocol is used for both distal and proximal realignment procedures, with a few exceptions noted below. For a combined distal and proximal realignment, the protocol for distal realignment is used.

Phase I for Immediate Postoperative – Weeks 1-6 Goals: Control inflammation Protect fixation Activation of quadriceps and VMO Full knee extension and minimize adverse effects of immobilization Intervention: • • • • ROM: 0-2 wks – 0-30 degrees of flexion, 2-4 wks – 0-60 degrees, 4-6 wks – 0-90 degrees Brace: 0-4 wks – locked in full extension 24 hours 7 days a week except for therapeutic exercises and continuous passive motion use, 4-6 wks – unlocked for sleeping, locked for ambulation Weight-bearing: Proximal realignment – as tolerated with two crutches, Distal realignment – 50% with two crutches Quadriceps sets and isometric adduction with electrical stimulation for VMO (* no electrical stimulation for 6 wks with proximal realignment procedure)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 • • • • • • Heel slides 0-60 degrees (proximal), 0-90 degrees (distal) Non-weight bearing gastrocnemius/soleus, hamstring stretches 4-way SLR with brace locked in full extension Resisted ankle ROM Patellar mobilization (when tolerable) Aquatic therapy at 3-4 wk – gait training

Phase II – Weeks 6-8 Criteria for progression: Good quadriceps set, ~90 degrees of flexion, no signs of active inflammation Goals: Increase flexion Avoid overstressing fixation Control of quadriceps and VMO for proper patellar tracking Intervention: • • • • • • • Brace: discontinue use for sleeping, unlock for ambulation as per physician's orders Weight bearing: As tolerated with crutches Progress to weight-bearing gastrocnemius/soleus stretching, full flexion with heel slides Aquatic therapy Balance exercises Stationary bike – low-resistance, high seat Wall slides 0-45 degrees of flexion progress to mini squats

Phase III Week 8-4 months Criteria for progression: No quadriceps extensor lag with SLR, nonantalgic gait, no evidence of lateral patellar tracking or instability Intervention: • • • • • • • • • Discontinue crutches when: no extensor lag with SLR, full extension, nonantalgic gait pattern Step-ups - 2 inches progress to 8 inches Stationary bike – moderate resistance Endurance – swimming, Stairmaster Gait training 4-way hip exercise Leg press 0-45 degrees of flexion Toe raises, hamstring curls Continue balance activities
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

6 • Hamstrings, gastrocnemius/soleus, add quadriceps and iliotibial band stretches

Phase IV 4-6 months Criteria for progression: Good to normal quadriceps strength, no soft tissue complaints, no evidence of patellar instability, clearance from physician to progress closed-chain exercises and resume full or partial activity. Intervention: • • • Progression of closed-kinetic chain exercises Jogging/running in pool with resistance Functional progression, sport-specific training

Selected References: Aglietti P, Buzzi R, De Biase P, Giron F. Surgical treatment of recurrent dislocation of the patella. Clin Orthop. 1994;308:8-17. Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. Philadelphia, 2003. Mosby, Inc. pp 327-342. Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121. Garth WP, Pomphrey M, Merrill K. Functional treatment of patellar dislocation in an athletic population. Am J Sports Med. 1996;24:785-791. Maenpaa H, Lehto MUK. Surgery in acute patellar dislocation – evaluation of the effect of injury mechanism and family occurrence on the outcome of treatment. Br J Sports Med. 1995;29:239-241. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-579. Scuderi G. Surgical treatment for patellar stability. Orthop Clin N Am. 1992;23:619-630. Vainionpaa S, Laasonen E, Silvennoinen T, Vasenius J, Rokkanen P. Acute Dislocation of the patella. J Bone Joint Surg. 1990;72:366-9.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Lateral Retinacular Release of the Patella and its relation with proximal and distal realignment procedures
Surgical Indications and Considerations Anatomical Considerations: Two components of knee extensor mechanism primarily affect the limits of medial and lateral patellar displacement: bony constraints and ligamentous tethers. Fulkerson and Gossling described the lateral retinacular structures from superficial to deep as: the fibrous expansion of the vastus lateralis muscle, the superficial oblique retinaculum (iliotibial band to lateral border of the patella and patellar tendon), the deep transverse retinaculum (from iliotibial band to lateral patellar border) bordered superiorly by the epicondylopatellar ligament and inferiorly by the patellotibial ligament, and the capsulosynovial layer. Fascial interconnections between fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps comprise the lateral retinaculum. The medial retinacular structures from superficial to deep are the fascia over the sartorius muscle, the medial patellofemoral ligament (MPFL), the vastus medialis oblique muscle (VMO) and the retinaculum, and the medial collateral ligament and joint capsule. The primary restraint to lateral displacement is the medial patellofemoral ligament (MPFL). Slips of the vastus medialis oblique muscle insert into the MPFL. Contraction of the VMO tensions the MPFL – providing (approximately) a 60% contribution of this ligament force limiting lateral patellar dislocation. Pathogenesis: The most common reasons for anterior knee pain are: overuse, patellofemoral malalignment, and trauma. Malalignment leads to instabilities (dislocations and subluxations), and overload of the retinaculum and subchondral bone. Patellar dislocations and subluxations can be categorized by chronicity (acute vs chronic), direction (medial vs lateral) and cause (traumatic vs non traumatic). Patellar instability can be predisposed by certain anatomic factors: patella alta, tightness of lateral structures, increased Q-angle (lateralization of the tibial tubercle), increased sulcus angle, excessive femoral anteversion, external tibial rotation, genu valgum, pes planus, hypoplastic lateral trochlear ridge, generalized laxity, weak or hypotrophic vastus medialis oblique, and hypertrophic vastus lateralis. Another factor is the altered motor control/strength of the hip abductors and external rotators during weight loading activities. Also, intra-articular effusion has been shown to lead to vastus medialis inhibition as well. With inhibition of this muscle, the oblique fibers of the vastus medialis are not effective in tracking the patella medially during extension predisposing the patient to experience patellofemoral pain. Chain of events in lateral instability: Patellar tilt resulting from a tight lateral retinaculum can exert over time lateral retinacular strain and increased pressure on the lateral facet of the patella leading to lateral patellar compression syndrome or even excessive lateral pressure syndrome, heralded by arthrosis of the lateral patellofemoral joint. The syndrome is then primarily the result of chronic lateral tilt, with subsequent lateral retinacular shortening and tightening. This continues the lateral facet overload, and articular cartilage degeneration results in osteoarthritis (chronic imbalance of facet loads). In addition, studies have demonstrated MPFL tears at the adductor tubercle in patients with lateral patellar dislocation.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Epidemiology: Historically, it has been considered a primarily female disorder, however some studies clearly show a male preponderance. Based on the research done, it cannot be said what the relative risk of patellar dislocation is among males and females. Subluxation and dislocation occur most frequently laterally, though medial instability can occur as a result of trauma or overaggressive surgical treatment. There is a higher incidence of acute instability in young active patients between the ages of 13-20, with less incidence over age 30, reoccurrence is higher in patients who dislocate at younger than 15. A recurrent rate up to 44% in non-operatively managed patients has been reported. Fourteen to forty-nine (14%-49%) percent of patients who sustain a primary acute dislocation will experience recurrent dislocation. Acute dislocation is seen predominantly in football and basketball players. Diagnosis • • • • • • • • History of dislocation with giving way Anterior knee pain with prolonged knee flexion, ascending or descending stairs. Peripatellar retinaculum tenderness Effusion Crepitus Postitive apprehension test (Fairbank sign) Positive quadriceps pull test Other clinical findings may include: o Patella alta: most consistent physical examination feature associated with patellar instability o Patellar hypomobility (positive on glide if medial patellar excursion is less than ¼ of greatest patellar width, positive on tilt if decreased) o Increased Q angle (10° ± 5° for men and 15° ± 5° for women) o Increased Sulcus angle (normal = <150 degrees) Imaging studies that help confirm the diagnosis: o X-rays: Axial view (tilt, patellofemoral incongruence), lateral view (rotational malalignment, trochlear dysplasia) o CT: Patellar tilt angles are taken from three midpatellar transverse tomographic images at 15, 20, 40, and 60 degrees of flexion o MRI Arthroscopy also has a role in confirming the preoperative diagnosis of patellofemoral malalignment

The diagnosis is best made on the basis of the history, physical examination and radiographic examination (X-rays, CT scan). Nonoperative Versus Operative Management: Consists of weight reduction, medial quadriceps and hip external rotator muscles strengthening, hamstrings and quadriceps stretching, mobilization of the tight lateral retinaculum, kinetic chain balancing, orthotic devices, correction of foot pronation, low impact loading exercises, taping and bracing and oral anti-inflammatory medication. It has been reported that 80% of symptomatic patellofemoral disorders respond to non-operative treatment.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Surgical Procedures: Arthroscopic lateral release is primarily indicated for patients with persistent anterior knee pain despite of supervised physical therapy with a tight lateral retinaculum clinically and radiographically documented by lateral patellar tilt, a tender lateral retinaculum, a medial glide of two or less quadrants, a normal Q-angle, and minimal or nonexistent patellofemoral chondrosis. The superomedial portal is established 3-6 cm proximal to the superior pole of the patella in line with the medial edge. Excessive superior extension should be avoided so as not to damage the vastus lateralis muscle. The entire retinaculum is released, paralleling the lateral edge of the patella. At the superior aspect of the patella, the release should stay posterior. The patella should be able to tilt 70 to 90 degrees. Goal: Allow the patella to seek a central position and prevent lateralization of the patella. Complications: Hemarthrosis, infection, medial patellar subluxation if excessive lateral release. An isolated lateral release has poor prognosis in patients with patella alta, an abnormal q-angle or a hypoplastic trochlea. Some studies reported better results when this release was combined with another procedure on the medial retinaculum. Many investigators suggest performing a lateral release if there is a residual patellar tilt after repair/reconstruction or reefing (tightening the medial structures) of the medial retinacular structures. Other proximal realignment procedures include reefing (mentioned above, open or via arthroscopy) and the advancement of the vastus medialis oblique (VMO), which involves reattaching the VMO insertion more distally and laterally on the patella. Goal: Restore patellofemoral alignment in recurrent subluxation or dislocation and to centralize the patella after a lateral retinacular release. Complication: Reflex sympathetic dystrophy (possible entrapment of the saphenous nerve). The lateral retinacular release and the other proximal realignment procedures do not address bone malalignment. Studies have reported a 86% return to previous level of activity within 3-4 months for individuals having a proximal realignment procedure. Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial collateral ligament. Osteotomy involves reorienting the tibial tubercle medially or anteromedially to reduce the Q-angle. Goal: correct patellar tracking on the skeletally mature patient with recurrent subluxation/dislocation, or an increased Q-angle, and unload damaged articular surfaces. Indications for surgical procedures are: failure of nonoperative care, osteochondral injury, patella instability, disruption of MPFL-VMO, high level athletic demands and risk factors. Surgical Outcomes: 79% obtain good to excellent functional outcome after lateral release with a combined VMO advancement and tibial tubercle transfer (Palmer 2004). Preoperative Rehabilitation: • Control pain and inflammation: protection, rest, ice, compression, elevation (if acute) • Maintain or improve strength and flexibility of the quadriceps and the hamstrings • Improve general lower extremity alignment • Patellar bracing and taping to prevent more damage

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 POSTOPERATIVE REHABILITATION Lateral Retinacular Release The following is a general guideline for the rehabilitation after lateral retinacular release. Advancement of the patient to the next phase should be considered on an individual basis taking also into consideration the surgeon’s directives. The overall goal of rehabilitation is to reestablish appropriate extensor mechanism function and reduce patellofemoral contact forces. Phase I: Immediate Postoperative – Weeks 1-2 Goals: Control postoperative pain and swelling Protect tissues in the process of healing limiting range of motion Improve muscle function of the lower extremity, specially quadriceps and VMO Improve range of motion: 0º- 115º knee flexion and full knee extension Full weight bearing if extension ROM is controlled by muscle Independent ambulation Intervention: • Pain, inflammation and hemarthrosis management: Cryotherapy, compression bandage, elevation and ankle pumps • ROM: Early range of motion is needed to ensure that the lateral structures are maintained in an opened or released position. * Knee flexion: 0-1 week: 0º- 90º flexion, 75º by day 3, 110º-115º by week 2. * Knee extension: full. • Brace: 0-2/4 wks – locked in full extension, removed for rehabilitation * Some do not recommend the use of immobilizers • Weight bearing: immediate post-operative ambulation with crutches, weight bearing as tolerated (WBAT). Full by 2 weeks • Therapeutic Exercise: Quadriceps sets at full extension progressing to multi angle isometrics Electrical stimulation for VMO Hip external rotators strengthening Heel slides and wall slides Non-weight bearing gastrocnemius/soleus, hamstring, ITB, hip flexors stretching 4-way SLR with brace locked in full extension. * Begin abduction at approximately 3 weeks to minimize lateral pulling of this muscle group on the patella. Patellar mobilization (when tolerable) Aquatic therapy at 2 wks (when wound is healed) with emphasis on gait training Stationary bike for ROM when sufficient knee flexion is achieved Phase II – Weeks 3-5 Criteria for progression: Well-controlled swelling and pain Good quadriceps strength and control
Loma Linda U DPT Program KPSoCal Ortho PT Residency

Ben Cornell PT, Joe Godges PT

5 ROM: 90º of active knee flexion and full active knee extension Full weight bearing Goals: Increase lower extremity strength and flexibility: 70% muscle reconditioning Control of quadriceps and VMO for proper patellar tracking Exercise swelling controlled Improve gait pattern, balance and proprioception. Establish home exercise program Independent activities of daily living Intervention: • Brace: if brace is used, discontinue use for sleeping, brace at 0º-60º when ambulating • Weight bearing: WBAT without crutches if: * Full active knee extension, active 90º- 100º knee flexion, non-antalgic gait pattern, and no extension lag with SLR. * Patient can progress from two to one crutches, and then ambulate without them. • ROM: Knee flexion: Week 2: 100º-115º Week 3: 115-125º Knee extension: 60º-0º • Therapeutic Exercise: 45º flexion with heel slides Complete lower extremity flexibility: Quadriceps, ITB and hip flexors stretching and progress to weight-bearing gastrocnemius/soleus stretching Calf raises 4 way hip exercises Wall slides progression (0-45º) to mini squats Closed chain kinetic terminal knee extension with resistive tubing or weight machine, and open chain reconditioning. Balance and proprioceptive activities Stationary bike Treadmill walking with emphasis on normalization of gait pattern Aquatic therapy Aerobic reconditioning Phase III Week 6 weeks return to activity Criteria for progression: Good to Normal quadriceps strength Non-antalgic gait No evidence of lateral patellar tracking or instability Pain is controlled and associated with activity only Clearance from physician to progress closed-chain exercises and resume full or partial activity Necessary joint range of motion, muscle strength, and endurance to safely return to athletic participation Knee extension: 70% of contralateral side.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Goals: Restore any residual loss of ROM Improve functional strength and proprioception Return to appropriate activity level Maintenance program development Intervention: • Brace: for activity only • Therapeutic Exercise: Endurance – swimming, stairmaster Complete lower extremity flexibility Continue balance activities and gait training Progression of closed-kinetic chain exercises and proprioception exercises Step-ups - 2 inches progress to 8 inches: forward and lateral Stationary bike – moderate resistance Leg press 0-45 degrees of flexion 0-70º wall squats Knee extension 90-0º Toe raises, hamstring curls Jogging/running in pool with resistance * Walk/jog progression, Jogging in pool with progression to land * Forward and backward running, cutting, figure 8’s Slide Board Plyometrics Emphasis on sport/work -specific activity development Return to sports when the knee is pain free, near full ROM has been obtained, and they have achieved at least 80% strength as compared with the opposite leg. Most patients are able to go back to sports by four to six months (Arendt, Fithian and Cohen 2002). POSTOPERATIVE REHABILITATION Proximal Realignment Procedures After a combined proximal and distal realignment, the protocol for distal realignment is suggested. Phase I: for Immediate Postoperative – Weeks 1-4 Goals: Control pain and inflammation Activation of quadriceps and VMO Full knee extension and reestablish 0º-110º knee flexion 75% weight bearing progression Reestablish patellar normal glide Note – with VMO advancement: Early flexion may stretch the advancement Delay quad strengthening for tissue healing

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 Intervention: • Pain and swelling management • ROM: 0-1 wk: 0-30ºof flexion, 2 wks:0-60º, 3 wks: 0-90º, 4 wks:0-110º (others recommend no more than 90º for 4 weeks) • Brace: 0-4 wks – locked in full extension and by 6 weeks unlocked for ambulation * Other studies: in full extension for 1 week then unlocked and by 3 weeks discontinued. * Some do not recommend brace locked, but brace as ROM limiting only • Weight-bearing: with two crutches, from toe touch to 75% WB by end of phase • Therapeutic Exercise: Muscle reeducation: initiate multi-angle exercises Heel slides 0-60º Non-weight bearing gastrocnemius/soleus, hamstring and ITB stretches 4-way SLR with brace locked in full extension Patellar mobilization (when tolerable) Aquatic therapy at 3-4 wk – gait training Phase II: – Weeks 4-10 Criteria for progression: Minimal pain No signs of active inflammation 0º- 110º of flexion Muscle control of extension to 0º 75% weight bearing

Goals: Improve ROM and muscle strength (70% of contralateral side) Avoid overstressing fixation Exercise swelling controlled Improve function to full activities of daily living Intervention: • Weight bearing: As tolerated with crutches • Therapeutic Exercise: Complete lower extremity flexibility and progress to weight-bearing gastrocnemius/soleus stretching, Balance exercises and gait training Aquatic therapy Stationary bike – low-resistance, high seat Wall slides 0-45º of flexion progress to mini squats Late phase: close chain/open chain reconditioning Patella mobilization Aerobic reconditioning after 6 weeks Phase III: Week 11 - 4 months

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 Criteria for progression: Full ROM achieved 70% of contralateral side Pain is associated with activity only Criteria for activity return must be met

Goals: Resume activity Maintain program development Intervention: • Therapeutic Exercise: Discontinue crutches when: no extensor lag with SLR, full knee extension, nonantalgic gait pattern Step-ups - 2 inches progress to 8 inches Stationary bike – moderate resistance Endurance – swimming Jogging/running in pool Gait training Progression of closed-kinetic chain exercises Continue balance activities Complete lower extremity flexibility: hamstrings, gastrocnemius/soleus, quadriceps and iliotibial band stretches Emphasis on sport specific strength Develop home exercise program Some studies considered the phase between 4 and 6 months the returning to activity level phase Phase IV: 4-6 months Goals: Return to appropriate activity level Improve functional strength and proprioception Intervention: • Progress close kinetic chain activities, jogging and running, sport specific activities. POSTOPERATIVE REHABILITATION Distal Realignment Procedures Phase I: 1-2 weeks Goals: Protect fixation Control pain and inflammatory process, and minimize effects of immobilization Re-gain quad and VMO control ROM: 0º-90º/110º flexion and full knee extension TTWB, two crutches (50% by end of phase) Good skin integrity Independent ambulation

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

9

Intervention: • Pain, swelling and hemarthrosis management • ROM: 0-90°/110º • Brace: 0-30º 0-4/6 weeks; for ambulation only * Brace only days 1-4 • Weight Bearing: 0-4 weeks: crutches progressing to 50% weight bearing • Therapeutic Exercise: Multi angle Quad sets with isometric adduction for VMO recruitment Full passive knee extension Passive and active-assisted ROM Calf, hamstring stretches (non-weight bearing) 4 way SLR (locked brace if extensor lag) Patellar mobilization Muscle reeducation, use EMS Begin aquatic therapy with emphasis on gait at 3-4 weeks Phase II: 3-4 wks Criteria for progression: 70% of contralateral side WB: 50% (X-ray verification of osteometry site healing) Approximately 90° flexion ROM No active inflammation Pain controlled Muscle control of extension

Goals: Increase flexion ROM: 0-110º Avoid overstressing fixation Muscle control of extension Control inflammation and pain Wound closure complete Minimal gait deviation Intervention: • Pain and inflammation management • Brace: for ambulation only Discontinue brace at 4 weeks • ROM: 0-75º (3rd week), 90º/110º 4th week Passive and A/A ROM Discontinue CPM Mobilize patella • Weight bearing: 4-6 weeks: wean from crutches • Therapeutic Exercise: Emphasis on extension exercises Flexibility: hamstrings and gastrocnemius Muscle reeducation utilizing EMS

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

10 SLR and multi angle submaximal isometrics knee extension Gait and balance training Phase III: 4 weeks - 8 weeks Criteria for progression: Approximately 110° flexion ROM 75% WB with 2-1 crutch Pain control with WB and ROM Independent in ADL’s

Goals: Increase flexion ROM: 0-135º Muscle control throughout ROM Control pain and inflammation One crutch to none (week 6) Intervention: • Continue modalities for pain and swelling • Weight Bearing: 1 to no crutch, by 6 weeks full WB. • Therapeutic Exercise: Continue Phase I exercise, progress to full flexion with heel slides Muscle reeducation using close chain program with 0-30º restriction Active extension with SLR Balance exercises and gait training Stationary bike - week 6 to 8 Pool program Phase IV: 9 weeks – Criteria for progression: Swelling controlled Full range of motion achieved Normal gait pattern Good dynamic patellar control with out evidence of lateral tracking or instability Criteria for specific activity must be met

Goals: Resume activity Maintain program development Intervention: • Pain is controlled and may be associated with activity only • Brace: for activity • Weight Bearing: full weight bearing • Therapeutic Exercise: Step-ups, begin at 2 inches and progress to 8 inches Stationary bike with moderate resistance

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

11 Squats, leg press, forward and lateral lunges Closed kinetic chain terminal knee extension with resistance Toe raises Hamstring curls Sports specific activity development Continue proprioceptive exercises Develop and assess home exercise program Some recommend a Phase V Phase V: 4 months - 6 months Goals: Continue improvements in quadriceps strength, improve functional strength and proprioception Intervention: • Progression of closed chain activities, Jogging in pool with progression to land, functional progression, sport/work specific training Late Phase Exercises for Postoperative Patellofemoral Conditions (Mangine et al proposed late phase exercises for postoperative patellofemoral conditions.) Criteria for progression: No effusion, painless ROM, joint stability, Patient performs ADL’s and can complete previous protocol ROM: minimum of 0-135º, minimal bilateral difference in muscle tone

Goals: Increase function to full activity level Return to previous activity level Establish maintenance program Intervention: • Warm up: jump rope, stretch, push-ups, sit ups. • Lifting: leg curls, squats, lunges, toe rises, triceps, bench press • Agility: plyoball sit-ups, dots, chest bands. Selected References Ahmad CS, Lee FY. An all-arthroscopic soft-tissue balancing technique for lateral patellar instability. Arthroscopy. 2001;17:555-557. Ahmad CS, Stein BE, Matuz D, Henry JH. Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. A review of eight cases. Am J Sports Med. 2000;28:804-10. Arendt EA, Fithian DC, Cohen E. Current concepts of patella dislocation. Clin Sports Med. 2002;499-519.
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

12

Brotzman SB , Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Ed. Philadelphia, Mosby, Inc.; 2003. Fithian DC, Meier SW. The case for advancement and repair of the medial patello femoral ligament in patients with recurrent patellar instability. JOTSM. 1999;7:81-89. Fithian DC, Paxton EW, Stone ML, Silva P, Davis D, Elias D, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114-1121. Fu FH, Maday MG. Atthorscopic lateral release and the lateral patellar compression syndrome. Orthop Clin North Am. 1992;24:601-612. Fulkerson JP, Gossling HR: Anatomy of the knee joint lateral retinaculum. Clin Orthop. 1980;153:183-188. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med. 2002;30:447-456. Halbrecht JL. Arthroscopic patella realignment: an all-inside technique. Arthroscopy. 2001;17:940-945. Hinton RY, Sharma KM. Acute and recurrent patellar instability in the young athlete. Orthop Clin North Am. 2003;34:385-96. Irwin LR, Bagga TK. Quadriceps pull test: an outcome predictor for lateral retinacular release in recurrent patellar dislocation. J R Coll Surg Edinb. 1998;43:40-42. Mangine RE, Eifert-Mangine M, Burch D, Becker BL, Farag L. Postoperative management of the patellofemoral patient. J Orthop Sports Phys Ther. 1998;28:323-335. Marumoto Jm, Jordan C, Akins R. A biomechanical comparison of lateral retinacular releases. Am J of Sports Med. 1995;23:151-155. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-579. Nam EK, Karzel RP. Mini open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation. a medium-term follow-up. Am J Sports Med [on line publication].December 2004; volume 32. Palmer SH, Servant CT, Maguire J, Machan S, Parish EN, Cross MJ. Surgical reconstruction of severe patellofemoral maltracking. Clin Orthop. 2004;419:144-148.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Distal Osteotomy For Patellar Realignment And Rehabilitation
Surgical Indications and Considerations Anatomical Considerations: Patellar tracking and stability rely on two restraining mechanisms: a transverse group and a longitudinal group. The longitudinal group consists of the quadriceps superiorly and the patellar ligament inferiorly. Transversely are the medial and lateral retinacula from the vastus medialis and vastus lateralis, which include retinacular thickenings acting as medial and lateral patellofemoral ligaments. Pathogenesis: Patellofemoral pain, patellar subluxation or dislocation can occur when abnormal tracking secondary to malalignment of the patella occurs. The origin of malalignment may be a result of obliquity in the pull of the quadriceps, unilateral tightness, unilateral weakness, trauma to any of the stabilizing structures, or structural abnormalities, i.e. increased Q-angle. Epidemiology: There is a higher incidence of acute instability in young active patients between the ages of 13-20; reoccurrence is higher in patients who dislocate at younger than 15. Female athletes are at a greater risk for recurrent instability than males, possibly due to anatomic differences (greater Q-angle). Subluxation and dislocation occur most frequently laterally, though medial instability can occur as a result of trauma or overaggressive surgical treatment. The following guidelines discuss lateral instabilities. Diagnosis: Patellofemoral instability is mainly a clinical diagnosis based on history and clinical examination. Diagnostic imaging can be utilized to rule out other pathologies. MRI may detect a disruption in the medial retinaculum, chondral lesions, and determine the angle of congruence. Non-operative Versus Operative Management: Conservative treatment is generally done initially which includes physical therapy, taping, and bracing. Surgical intervention is indicated when conservative treatment fails and recurrent instability and/or pain persists. Distal bony realignment procedures are indicated for the skeletally mature patient. Surgical Procedure: Distal realignment involves osteotomy reorienting the tibial tubercle medially to reduce the Q-angle. Distal osteotomy may be accompanied with proximal soft tissue procedures including lateral release, reconstruction of the medial patellofemoral ligament, or advancement of the vastus medialis. Currently, the most frequently used operations include a flat osteotomy cut with straight medialization of the tibial tubercle (Elmslie-Trillat procedure) or an oblique cut which uses anteriorization in addition to medialization of the tibial tubercle (Fulkerson’s procedure). Medialization is recommended for isolated instability, while anteromedialization is preferred with accompanying patellofemoral pain or chondral lesions to reduce compressive forces on the patellofemoral joint.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Preoperative Rehabilitation: • Control pain and inflammation • Utilize bracing to prevent further subluxation or dislocation • Maintain ROM and strength without promoting further instability

POSTOPERATIVE REHABILITATION

Note. The following rehabilitation guidelines are compiled from multiple sources (see references). A comprehensive plan of care should be individualized based on each patient’s presentation and depending on the operative procedure(s) used. Many surgeons have specific protocols for use in post-op rehabilitation.

Phase I: Post-op - 6 weeks Goals Protect fixation Control inflammatory process Re-gain quad and VMO control Minimize effects of immobilization Full knee extension Intervention: • • • • ROM: 0-90° Brace: 0-4 weeks; locked in extension except for therapy and CPM use 4-6 weeks; unlocked brace for sleeping Weight Bearing: 0-4 weeks; crutches with weight bearing as tolerated 4-6 weeks; wean from crutches, maintain locked brace Therapeutic Exercise: Quad sets with isometric adduction for VMO recruitment Heel-slides 0-90° Calf, hamstring stretches (non-weight bearing) 4 way SLR (locked brace if extensor lag) Resisted ankle ROM (non-weight-bearing) Patellar mobilization Begin aquatic therapy with emphasis on gait at 3-4 weeks

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Phase II: 6weeks - 8 weeks Criteria for advancement to Phase II: Good quad set Approximately 90° flexion ROM No active inflammation Goals: Increase flexion ROM Avoid overstressing fixation Increase quadriceps and VMO control Intervention: • Brace: Discontinue for sleeping, unlock with ambulation • Weight Bearing: as tolerated, no crutches • Therapeutic Exercise: Continue phase I exercise, progress to full flexion with heel slides Calf stretch in weight bearing Discontinue CPM Balance exercises Stationary bike: low resistance/high seat Short arc quadriceps extension in pain free ranges Wall slides 0-45° of flexion Phase III: 8 weeks - 4 months Criteria for advancement to Phase III: Good quadriceps tone without extensor lag with SLR Non-antalgic gait pattern Good dynamic patellar control with out evidence of lateral tracking or instability

Goals: Quad strength good to normal No patellar instability with exercise Normalize gait pattern Intervention: • Brace: may discontinue • Weight Bearing: full weight bearing • Therapeutic Exercise: Step-ups, begin at 2 inches and progress to 8 inches Stationary bike with moderate resistance 4-way hip for flexion, extension, adduction, abduction Leg press 0-45° Closed kinetic chain terminal knee extension with resistance Toe raises Hamstring curls

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Treadmill walking Continue proprioceptive exercises Phase IV: 4 months - 6 months Criteria for advancement to Phase IV: good to normal quad strength no evidence of patellar instability no soft-tissue complaints normal gait pattern physician clearance for more concentrated closed chain exercises and resume full or partial activity Goals: Continue improvements in quad strength Improve functional strength and proprioception Return to appropriate activity level Intervention: • Therapeutic Exercise: Progression of closed chain activities Jogging in pool with progression to land Functional progression, sport/work specific Selected References: Cosgarea AJ, Browne JA, Kim TK, McFarland EG. Evaluation and management of the unstable patella. Phys Sportsmee. 2002;30:1-11. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med. 2002;30:447-456. Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. Philadelphia, 1996, F.A. Davis Company. Klimkiewicz JJ. Proximal/distal patellar realignment rehabilitation guidelines. Georgetown University Hospital Orthopedic Protocols. 2003. Myers P, Williams A, Dodds R, Bulow J. The three-in-one proximal and distal soft tissue patellar realignment procedure. Am J Sports Med. 1999;27:575-587. Palmer SH, Servant C, Maguire J, Machan S, Parish E, Cross M. Surgical reconstruction of severe patellofemoral maltracking. Clin Orthop Relat Res. 2004;419:144-8. Shelbourne KD, Porter DA. Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle. Am J Sports Med. 1994;22:318-323.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Patellar Tendon Rupture and Rehabilitation
Surgical Indications and Considerations Anatomical Considerations: Rupture of the patellar tendon most often takes place at the osteotendinous (tibial tubercle) junction. Rupture of the tendon in this area causes complete derangement of the extensor mechanism of the knee. Destruction of the extensor mechanism may lead to an inability to actively obtain and maintain knee extension. Pathogenesis: Patellar tendon ruptures tend to occur during resisted knee flexion with violent quadriceps contraction (when landing from a jump). A force greater than 17.5 times body weight has been reported as the estimated force required to rupture the patellar tendon. The patellar tendon sustains greater stress than the quadriceps tendon during knee flexion. Since there is more tensile load on the tendon at its insertion sites than in the middle portion, the tendon tends to rupture just distal to its attachment to the patella. Etiology: Intrinsic factors that can lead to rupture of the patellar tendon include repetitive microtrauma, systemic inflammatory disease, diabetes mellitus, and chronic renal failure. Extrinsic factors include ruptures that may occur as a result of a corticosteroid injection near the inferior poll of the patella, sudden eccentric contraction of the quadriceps with the foot planted and the knee flexed while the person falls (most prevalent mechanism). Surgery to the knee can also cause rupture of the patellar tendon, these include total knee replacement, using the central third of the patellar tendon as an autograft (ACL repair) and excision of patellar tendonitis. Diagnosis: Rupture of the patellar tendon is usually associated with a “pop” or “tearing” sensation with immediate pain, immediate swelling, and an inability to rise and weight-bear will also be noted. Upon physical exam the patient will present with tenderness along the anterior knee and retinacula, patella alta and ecchymosis will also be observed. Lab values may be taken to rule out systemic disease. Plain film radiographs (AP, axial and lateral views), and/or MRI provide the confirmation. Nonoperative versus Operative Management: The type of treatment given to a patient with a rupture depends on the severity of the rupture. A patellar tendon rupture can be treated nonoperatively, but only in the case of a partial tear were the patient is able to maintain active full extension and has normal patellar height. In this case the patient would be immobilized until the tendon has fully healed and strengthening exercises should be delayed for at least 3 months. Operative management is typically the approach of choice, especially with a complete rupture. Surgical intervention is typically initiated as soon as possible to limit the amount of quadriceps contracture and atrophy. Surgical Procedure: Surgical repair of a ruptured tendon is usually delayed 4-7 days to allow a decrease in inflammation and decrease the risk of wound complications. For a patient with an acutely ruptured tendon the general surgical procedure would include suturing the torn tendon through bone tunnels in either the patella or tibial tubercle. The location of suturing depends on the location of the rupture. Debridement of viable tissue may also be performed along the patellar tendon, tibial tubercle and patella. In patients with chronic patellar tendon ruptures or

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 patients where repair may be impossible the surgeon may choose to do surgery in stages. This decision depends on the need to replace the patellar tendon with and autograft or allograft, the degree of patella alta, whether the repair requires augmentation or whether there is peripatellar scaring. Preoperative Intervention: • Discuss with the importance of postoperative rehabilitation • Identify appropriate patellar height for patient (Surgeon responsibility) • Identify possible injuries to associated structures: medial/lateral retinacula, menisci, ACL, PCL, MCL, LCL POSTOPERATIVE REHABILITATION Phase I for Immobilization and Rehabilitation: 4-13 days Goals: Control pain and inflammation Maintain patellar mobility Maintain hamstring strength of the ipsilateral leg and lower extremity strength of the contralateral leg Active knee flexion to 45o and passive knee extension to 0o Intervention: • Crutch training with toe-touch weight-bearing • Ice and elevation • Isometric ipsilateral hamstring exercise, contralateral LE strengthening • Gentle medial/lateral patellar mobilization (~25%) • AROM, AAROM and PROM • Hinged knee brace locked in extension Phase II for Immobilization and Rehabilitation: 2-4 weeks Goals: Control pain and inflammation Begin weight-bearing Maintain patellar mobility Active flexion to 90o and passive knee extension to 0o Maintain ipsilateral hamstring and contralateral LE strength Begin ipsilateral quadriceps retraining Intervention: • Crutch training with partial weight-bearing (25-50%) • Ice and elevation • Isometric ipsilateral hamstring exercise, contralateral LE strengthening • Gentle medial/lateral patellar mobilization (~25%) • AROM, AAROM and PROM • Hinged knee brace locked in extension

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 • Ipsilateral quadriceps sets (NO straight leg raises)

Phase III for Immobilization and Rehabilitation: 4-6 weeks Goals: Control pain and inflammation Progress weight-bearing (possibly discontinue crutch use) Active flexion progressed as tolerated and passive extension to 0o Maintain patellar mobility Maintain ipsilateral hamstring and contralateral LE strength Continue ipsilateral quadriceps retraining Intervention: • Progress to weight-bearing as tolerated, may discontinue crutch use if good quadriceps control is acquired • Gait training • Ice and elevation • Isometric ipsilateral hamstring exercise, contralateral LE strengthening • Gentle medial/lateral patellar mobilization (~25%) • AROM, AAROM and PROM • Hinged knee brace locked in extension • Ipsilateral quadriceps sets (NO straight leg raises) Phase IV for Immobilization and Rehabilitation: 6-12 weeks Goals: Control pain and inflammation Progress to full active ROM Maintain patellar mobility Maintain ipsilateral hamstring and contralateral LE strength Continue ipsilateral quadriceps retraining Intervention: • Weight-bearing as tolerated • Gait training • Hinged knee brace locked in extension until good quadriceps control and normal gait are obtained • Ice and elevation • Isometric ipsilateral hamstring exercise, contralateral LE strengthening • Gentle medial/lateral patellar mobilization (~50%) • AROM • Ipsilateral quadriceps strengthening (straight leg raises without resistance and stationary cycling at 8 weeks)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Phase V for Rehabilitation: 12-16 weeks Goals: Complete weight-bearing Progress ipsilateral quadriceps strength Begin neuromuscular retraining Intervention: • Gait Training • No immobilization • Ipsilateral quadriceps strengthening • Proprioception and balance activities (including single leg support) Phase VI for Rehabilitation: 16-24 weeks Goals: Begin running Sport/Job specific training Intervention: • Progress program as listed for Phase IV, with sport or job specific training Phase VII for Rehabilitation: >6 months • May begin jumping and contact sports when ipsilateral strength is 85-90% of contralateral extremity

Selected References: Marder RA, Timmerman LA. Primary repair of patellar tendon rupture without augmentation. Am J Sports Med. 1999;27:304-307. Casey MT, Tietjens BR. Neglected ruptures of the patellar tendon. a case series of four patients. Am J Sports Med. 2001;29:457-460. Enad JG, Loomis LL. Patellar tendon repair: postoperative treatment. Arch Phys Med Rehabil. 2000;81:786-788. Matsumoto K, Hukuda S, Ishizawa M, Kawasaki T, Okabe H. Partial rupture of the quadriceps tendon (jumper's knee) in a ten-year-old boy: a case report. Am J Sports Med. 1999;27: 521-525.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Patella – Open Reduction and Internal Fixation
Surgical Indications and Considerations Anatomical Considerations: The patella is a sesamoid bone that is embedded in the quadriceps tendon. Tensile forces are transmitted from the quadriceps to the tibia via the patella. The patella is also subjected to compressive forces at the articulation with the femur. At 45° the patella is under the most force (approximately between 2 and 10 newtons per millimeter squared). During development the patella most often originates from a single ossification center. In approximately 23% of patients two to three separate ossification centers exist. Two percent of the time these centers do not completely merge, the condition is called bipartite patella. Of these individuals approximately 2% develop symptoms secondary to trauma or chronic stress on the patella. Traumatic patellar fractures are identified as transverse, vertical, marginal or osteochondral. Transverse fractures occur horizontally across the patella. Vertical fractures run from the inferior pole to the superior pole. Marginal fractures occur at the perimeter of the patella and most often include small fragments. Osteochondral fractures are cracks or discontinuities of the covering of the patella. Pathogenesis: Fractures of the patella occur in when the force applied to the patella is stronger than the bone that constitutes the patella. This can happen when the patella receives a direct blow or as a result of indirect forces. If the patella is osteoporotic, much less force is required to fracture the patella. The patella can also be fractured during ACL reconstruction surgery when autogenous patellar tendon is used. The patella can be fractured while the proximal bone plug is being removed. Transverse fractures most often occur with indirect force (for example a forceful quadriceps contraction). Transverse fractures are the most common fracture to result from a traumatic patellar dislocation. Vertical and osteochondral fractures are rare and can occur with either direct or indirect force. Marginal fractures are usually due to a direct force to the side of the patella. Epidemiology: Patellar fractures make up approximately 1% of skeletal injuries. Males are more likely to have bipartite than females, but traumatic patellar fractures do not occur more commonly in men or women. Osteochondral fractures are more common in children than in adults. Diagnosis: • History of a direct blow to the patella • There may be a palpable ridge in the patella if the break is complete • Persistent patellar tenderness • Decreased function of the extensor mechanism (inability to extend the knee against resistance) • Radiographs confirm injury to the bone • MRI can be helpful to identify or rule out associated ligamentous injuries to the knee

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Fractures with 2mm or less separation are indicated for nonoperative treatment. This includes 4-6 weeks of immobilization in a splint or cast on the conservative side and as little as 2 weeks of immobilization on the aggressive side. Aggressive nonoperative treatment may include weight bearing as tolerated as early as 1-week post fracture. Surgical repair is typically recommended for all patellar fractures that demonstrate 3mm or more separation of fragments or a step off of 2mm or more. In the case of comminuted fractures or fractures of severely osteoporotic bone a synthetic patellar prosthesis can be used. Surgical Procedure: Surgical techniques include placing two or three wires or canulated screws perpendicular to the fracture line. In addition, wire can be used around the circumference of the patella. New procedures include arthroscopic techniques also using screws perpendicular to the fracture line as well as circumferential wiring. Fixation screws and wiring are not removed post operatively unless there are complications. Small fragments and loose bodies are removed if found. Preoperative Rehabilitation: Goals include gait with the appropriate assistive device, control of swelling/inflammation, maintaining maximum range of motion, strengthening of surrounding stabilizing musculature, and patient education. Physical therapy interventions include gait training, joint mobilizations, strengthening, and modalities.

POSTOPERATIVE REHABILITATION

Phase I: Weeks 1-4 Goals: Pain and edema control Improvement in muscle contraction PROM: 0°-30° Avoid excessive stress on the extensor mechanism Independent home program Intervention: • • • • • • • • Cryotherapy Electrical stimulation for muscle stimulation (remember to not stress extensor mechanism) Patellar mobilization PROM: heel slides Isometrics: Quadriceps sets at 20°-30°, hamstring sets Straight leg raises Immobilization for gait with WBAT (begin WBAT around week 4) Weight shifting

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Phase II: Weeks 5-8 Goals: Pain management Normalize gait pattern Increase lower extremity strength PROM: 0°-90° Intervention: • • • • • • • Modalities for pain control Progress PROM AAROM: therapist assisted and stationary bike AROM when cleared by physician (6-8weeks) Isometrics – continue progress from Phase I Open chain hip and ankle strengthening Gait training (progress weight bearing)

Phase III: Post Week 8 Goals: Self management of symptoms Increased ambulation distance Good sitting and standing tolerance Good patellar stability and tracking Intervention: • • AROM: 0°-120° Progress lower extremity strengthening: closed chain (squats, steps), continue hip and ankle strengthening, focus on stability, proprioception, balance, and extensor strengthening

Phase I for Aggressive Rehabilitation: Weeks 1-2 Goals: Pain and edema control Improvement in muscle contraction PROM: 0°-30° Avoid excessive stress on the extensor mechanism Independent home program

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Intervention Week1: • • • • • • • • Cryotherapy Electrical stimulation for muscle stimulation Patellar mobilization PROM: heel slides in hinged splint set at 0°-30° to be work constantly except for bathing. Isometrics: Quadriceps sets at 20°, hamstring sets NWB gait with crutches Relative immobilization with hinged splint set at 0°-30° Open chain hip strengthening: abduction, adduction, extension

Intervention Week 2: • • • Continue interventions from Week 1 AAROM in hinged splint set at 0°-30° Begin WBAT gait with splint and crutches

Phase II for Aggressive Rehabilitation: Weeks 3-4 Goals: Pain management Increase weight bearing with gait Increase lower extremity strength ROM: 0°-90° Intervention: • • • • • • Modalities for pain control AAROM: therapist assisted and stationary bike 0°-90° AROM: heel slides, short arc quad extension, begin closed chain strengthening Isometrics: continue progress from Phase I Closed chain hip and ankle strengthening Gait training: WBAT with hinged splint and crutches

Phase III for Aggressive Rehabilitation: Weeks 5-6 Goals: Pain management Normalize gait pattern Increase lower extremity strength ROM: 0°-120°

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 Intervention: • • • • • • Modalities for pain control Patellar and tibial/femoral mobilization AROM Closed chain strengthening: wall squats, supine leg press, stationary bike Proprioceptive and balance training Gait training: FWB with hinged splint

Phase IV for Aggressive Rehabilitation: Weeks 7-12 Goals: Self management of symptoms Increased gait distance and speed Good sitting and standing tolerance Good patellar stability and tracking 5/5 hip, knee and ankle strength Intervention: • • AROM: 0°-120° Progress lower extremity strengthening: closed chain (squats, steps, increase speed and force), continue hip and ankle strengthening, focus on stability, proprioception, balance, and quadriceps strengthening.

Selected References: Binder AJ. Spoken interview July 28th, 2004. Diagnosis – Patella ORIF. Medical University of South Carolina, Department of Physical Therapy. Online. www.muschealth.com/pt May 3, 2004. Donatelli R. Wooden M. Orthopaedic Physical Therapy. 3rd ed, Churchill Livingstone. 2001:471-473. Lamoureux C. Patella Fractures. eMedicine Online. http://www.emedicine.com/radio/topic528.htm May 3, 2004. Neumann, D. Kinesiology of the Musculoskeletal System. Mosby, Inc. 2002:456-461. Shabat S, Stern Y, Berner D, Morgenstern D, Mann G, Nyska M. Functional results after patellar fractures in elderly patients. Arch Gerentol Geriatr. 2003;37:93-98.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Anterior Cruciate Ligament Reconstruction
Surgical Indications and Considerations Anatomical Considerations: The anterior cruciate ligament (ACL) lies in the middle of the knee. It arises from the anterior intercondylar area of the tibia and extends superiorly, posteriorly, and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur. The ligament is intra-articular but extrasynovial. The ACL is described as being composed of 3 main bundles. These bundles include the anteromedial, posterolateral, and intermediate. The ACL really functions as a continuum, with a portion being tight through all ranges of knee flexion. It acts as the primary restraint to anterior tibial translation and guides the screw-home mechanism associated with knee extension. The ACL acts secondarily to prevent varus and valgus, particularly in the extended knee. Injury leads to abnormal kinematics of the knee. Subluxation episodes occur, creating abnormal shear forces on the meniscus and articular cartilage. Subsequent meniscal injury, therefore, is increased significantly. The major blood supply for the ACL comes from the synovium and fat pads. The vessels involved are middle geniculate and terminal branches of the inferior medial and lateral geniculate vessels. Sensory receptors and nerve fibers have been identified in the ligament, which suggests some sensory role and possible proprioceptive function. Pathogenesis: Ligaments tear when the mechanical load exceeds the physiological capacity of the tissue. ACL tears are most commonly due to extrinsic mechanical forces. It may be due to contact injuries where there is a blow to the side of the knee, such as may occur during a football tackle. Alternatively, non-contact ACL injuries can occur by coming to a quick stop combined with a direction change while running, pivoting, landing from a jump, or hyperextension of the knee joint. ACL injuries are often associated with other injuries. The “unhappy triad” is a classic example, in which the ACL is torn at the same time as the MCL and the medial meniscus. Basketball, football, soccer and skiing injuries are common causes of ACL tears. Epidemiology: Injury of the ACL is the most common ligamentous injury of the knee and accounts for about 30 injuries per 100,000 of the population, with greater than 100,000 new ACL injuries occurring each year. Women are more likely to suffer an ACL tear than men are. Females are at higher risk of ACL injury when considering sports participation numbers. This is believed to be related to both intrinsic factors (increased Q angle, decreased notch width, increased joint laxity, hormonal influences) and extrinsic factors (less muscle strength, different muscle activation patterns, altered cutting and landing patterns). Adults who tear their ACL usually do so in the middle of the ligament or pull the ligament off the femur bone. These injuries do not heal by themselves. Children are more likely to pull off their ACL with a piece of bone still attached, these may heal on their own, or may require the bone to be fixed.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Diagnosis • • • • • • • • • • • • Mechanism of injury Most patients describe a “pop” sound at the time of injury Immediate pain and swelling in knee Knee joint instability once swelling and pain resolves Limited ROM Joint line tenderness Positive Lachman Test /or Anterior Drawer Test Pivot-Shift or Jerk Tests (to assess rotational instability) Radiographs to exclude fracture, tumor, and osteoarthrosis Arthroscopy CT scan for associated fractures or avulsions of the cruciate MRI can be helpful in determining the presence, location, and severity of the tear(s) and to evaluate other injuries to the knee – with 98% accuracy

Nonoperative Versus Operative Management: Surgical repair depends on the extent of instability and level of activity. It is typically recommended for patients who expect to return to relatively high functional activities required of recreational athletics. In chronic cases, the major indication for surgical reconstruction is recurrent instability. Indications for nonoperative management include patients with active infection, soft-tissue abrasion, and reluctance to participate in the complex rehabilitation required. Conservative care includes a comprehensive rehabilitation program, a functional brace for sports, and activity modification. Relative contraindications are common and include the following: patient is less than 2 weeks from injury, low activity levels, preexisting osteoarthrosis, skeletal immaturity, and inflammatory arthropathy. Some people are able to live and function normally with a torn ACL. However, most people complain that their knee is unstable and may "give out" with attempted physical activity. Unrepaired ACL tears may also lead to early arthritis in the affected knee. Surgical Procedure: There are several surgical procedures available including mini-arthrotomy open technique, two-incision arthroscopically assisted techniques, and one incision endoscopic technique. Currently, ACL reconstruction is most often performed using an arthroscopically assisted technique. The most frequently used graft types for ACL reconstruction are the patellar tendon (PT) and the combined semitendinosis and gracilis tendons (HT). For the past two decades, the gold standard in ACL reconstructions has been the patellar tendon graft from the middle third of the tendon, but increasingly the hamstring tendon graft has been used. The shift in popularity is due to several reasons, including, concerns about damaging the knee extensor apparatus using the PT and the potential for subsequent anterior knee pain, patella fracture, ligament rupture, and infrapatella contraction. The HT techniques also have potential complications including tunnel widening and fixation and concerns of the affects on the muscle function.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Preoperative Rehabilitation • • • • • Patient education on expectation and likely outcomes of rehab Patient education on joint protection, to avoid deep squats and low chairs for 12 weeks Instructions on post-operative exercises Documentation of pre-operative strength and ROM Correction on any deficits in flexibility and soft tissue compliance

POSTOPERATIVE REHABILITATION

Note: The following rehabilitation progression is a summary of the guidelines provided by Bollen, Risberg, Shelbourne. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, goals, and rationales.

Phase I of Rehabilitation: Weeks 0-2 Note: Contact MD immediately if increasing pain, signs of infection, or signs of DVT. Goals: Control edema and pain Achieve full extension and 90° of flexion Weight bearing as tolerated Begin regaining muscle strength Quad activation Intervention: • • • • • • • • • • Local treatment of swelling with cryotherapy and elevation Soft tissue mobilization to hypomobile tissue in superficial fascia near surgery site Passive knee extension (heel propped up on pillows and let knee sag) Exercise for 5 minutes/hour to stimulate graft ligamentization Maintain flexibility with heel slides or prone hamstring curls Closed Kinetic chain exercises: hamstrings and quads strengthening, half squats (20-70 degree), cycling with seat high to avoid too much flexion Neuromuscular electrical stimulation (NMES), quad activation exercises Tibiofemoral mobilization with rotation, patellar mobilizations Begin introducing proprioception training with eyes closed Crutch training for the first few days

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4

Phase II of Rehabilitation: Weeks 2-6 Goals: Control any residual symptoms of edema and pain Full knee extension ROM to almost full flexion Progress strength training Normal gait Progressive weight-bearing Return to normal ADL Intervention: • • • • • Increase load to knee with squats and dips Cycling, step machine, leg press 0-90 degrees Theraband work to improve knee control and proprioception Increase hip adductor and abductor strengthening Gait training

Phase III of Rehabilitation: Weeks 6-12 Goals: Full range of motion Increasing functional activity level Improve proprioception Intervention: • • • • • • Proprioception training on unstable surfaces Wobble board work Progressive resistive exercises Begin open kinetic chain exercises, beginning range at 40-90° of flexion Introduce jogging when muscle strength and control allows Progress to jogging in and out of cones from about 10 weeks, changes in directions should be smooth vs. sudden

Phase IV of Rehabilitation: Weeks 12-26 Goals: Return to pre-injury level sport/occupation at 6 months Normal strength and speed Normal agility Patient fully educated about the future of the knee Intervention:

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 • • • • Progressive sport specific program Sport/work specific strength training Progressive sport specific agility and speed work (no sudden twisting/turning until 4 months) Plyometrics, quality not quantity

Selected References: Bollen SR. BASK Instructional lecture 3: Rehabilitation after ACL reconstruction. Knee. 2001;8:75-77. Bonamo JJ, Fay C, Firestone T. The conservative treatment of the anterior cruciate deficient knee. Am J Sports Med. 1990;18:618-623. Chmielewski TL, Stackhouse S, Axe MJ, Synder-Mackler L. A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925-30 . Herrington L, Wrapson C, Matthews M, Matthews H. Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery. Knee. 2005; 12:41-50. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? Physical Therapy Sport. 2004;5:125-145. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18:292-299.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Posterior Cruciate Ligament Reconstruction and Rehabilitation
Surgical Indications and Considerations Anatomical Considerations: Many authors describe the posterior cruciate ligament (PCL) as the primary stabilizer of the knee. It is about twice as strong as the anterior cruciate ligament. It is approximately 38 mm in length and 13mm wide. It runs from the medial femoral condyle to the posterior tibia. The PCL consists of two bands, the anterolateral and posterolateral. The anterolateral band is two times as large and is 1.5 times stronger. The anterolateral band is the band that gets tight on knee flexion, while the posterolateral band is the band that tightens with knee extension. The PCL as a whole gives the knee 95% restraint to posterior tibial torsion and is a secondary control to lateral rotation, varus stresses and hyperextension. Pathogenesis: Tears to the PCL by itself are uncommon. The cause of injury most often is when some force is applied to the anterior portion of the tibia while the knee is flexed, e.g., the anterior aspect of the flexed knee striking a dashboard. A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, causing a posterior force to the proximal tibia, may also result in injury to the PCL. Injury may also occur with forced hyperextension while the foot is planted in dorsiflexion. A force applied to the anteromedial aspect of the knee, as during a football tackle, results in a posteriorly directed force and a varus hyperextension force, may lead to PCL and posterolateral capsular ruptures. When the PCL is ruptured there is increased posterior translation and this translation increases as knee flexion increases and has maximum translation between 70-90 degrees, when the anterior cruciate ligament is fully relaxed. Epidemiology: Of all the patients seen in the emergency room for ligamentous injuries 37% are patients with severe knee injuries. Of that 37%, one third are related to sports injuries. The other two thirds are attributed to other types of injury such as falls and motor vehicle accidents. PCL injuries account for as many as 20% of all knee ligament injuries. Chronic PCL weakness can cause or predispose patients to the following pathologies: (1) medial compartmental osteoarthritis of the knee, (2) meniscal injury, and (3) patellofemoral arthritis. Diagnosis: The clinical examinations commonly used to assess for PCL instability are the posterior drawer test, Godfrey or posterior sag test, and the dynamic posterior shift test. • Positive Posterior Drawer Test with knee at 90° is 90% sensitive and 99% specific. The posterior drawer test with the knee at 90° is the most sensitive test for detecting PCL injury. Decreased range of motion may be observed, but may only lack 10-20° of flexion. Grading the injury upon examination is usually performed by using the following scale: Grade I injury, step off present but minimal (i.e., 0-5 mm); Grade II injury, 5-10 mm of posterior translation; and Grade III injury, greater than 10 mm of posterior translation. • Positive Godfrey or posterior sag test. 58% sensitive, 97% specificity. • Positive Dynamic Posterior Shift Test. 95% specific, but only 26% sensitive. Imaging such as MRI has high sensitivity and specificity in the diagnosis of PCL injury. MRI is found to be 99% sensitive and specific in the diagnosis of complete PCL tears. Arthroscopy can
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

2 be performed for further diagnoses of tears in the PCL. Operative vs. Non-operative Management: The decision to perform surgery or not is primarily based on the severity of the injury. It is common for non-operative rehabilitation to take place if the Grade is less than II. The key is to control the swelling, instability, and pain. If the patient, however, continues to experience pain and instability regardless of rehabilitation and bracing, a PCL reconstruction may be needed and performed. There are numerous factors that contribute to which route of treatment will be pursued. It depends on severity of the injury, whether the injury is to the PCL itself or if it is combined with other injuries to the ligaments or menisci, the activity level and goals of the patient, and the preference of the physician. Below is outlined the non-operative and the operative methods of rehabilitation. Note: the below rehabilitation protocols are derived from guidelines provided by McNeal, Lintner, Agesen, Ertl, Bhatti, and Kischner. Please refer to their publications for further information regarding progressions, limitations, expectations, and goals. Non-operative Rehabilitation: Day 1 to Week 2 Goals: Control the initial inflammation Regain ROM with muscle function as quickly as possible Intervention: • Rest, ice, compression, and elevation (RICE) several times a day, in addition to other modalities such as electrical stimulation, ice baths. • Assisted weight bearing. Patients with grade I and grade II injuries can bear as much weight as they can tolerate immediately. Some may need crutches initially. Crutches and a long leg brace are recommended only with severe grade III injuries with no other associated ligamentous laxity or intra-articular damage. • Electrical stimulation (ES) may be used to stimulate the quadriceps muscle, if the patient is having difficulty performing quadriceps contractions. • Exercises for quadriceps and hip strengthening. All open kinetic chain (OKC) hamstring exercises should be avoided since they promote posterior tibial translation at the knee. Non-operative Rehabilitation: Weeks 2-12 Intervention: • Bracing - Only patients with grade III injuries should still be wearing a brace (0-60°) until at least the third week of therapy. Then, the patient may be fitted for a functional knee brace. • Assistive Devices - Crutches can be discontinued and weight bearing as tolerated can be progressed • Exercises – At 2-3 weeks, exercises should be progressed with light resistance as tolerated. The stationary bike may be used for improving ROM. Aquatic exercises can be used for improving ROM and strengthening. At weeks 3-6, the exercises may be increased to include closed kinetic chain exercises (CKC) including: leg press, mini squats, stair stepper, step-ups. Resistance may be increased on the bicycle as tolerated. At 8-12 weeks, strengthening exercises should be progressed and a light jogging program

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 may be initiated. Non-operative Rehabilitation: 3 – 9 months • Exercises – Strengthening and proprioception exercises are progressed as tolerated. Plyometrics and sport-specific training should also be initiated and accelerated as tolerated. A running program is developed, and agility drills are integrated. An isokinetic test and a KT-2000 test should be performed at 3-month, 6-month, 9month, and 12-month follow-up visits. The athlete may return to sporting activities when isokinetic and functional tests are satisfactory according to the PT and the MD. The patient should not return to competitive sports until full quadriceps strength has been reestablished. POSTOPERATIVE REHABILITATION There are a number of different techniques used to reconstruct the PCL, so the treatment protocol is determined by the physician, the PT, and the type of graft used in surgery. The types of grafts used are the patellar tendon, quadriceps tendon, hamstring tendons, and the medial head of gastrocnemius. Phase I: Day 1 to Week 2 Goals: Protect the new graft – no active knee flexion. Gain full knee extension so patient can ambulate with normal gait. Improve quadriceps control Intervention: • Bracing – The patient will be in a post-op brace that is locked at 0 degrees. The brace is to be worn at all times. The brace will be progressed slowly to 30° depending on how stiff the patient may be getting. The patient needs to be educated that activities such as walking down a ramp/hill/incline, sudden deceleration, and squatting activate the hamstrings and should be avoided and that any weight-bearing exercises should be performed in brace. The patient can usually weight bear as tolerated on the affected limb with the use of crutches and a long leg brace. • Neuromuscular re-education – Improve muscular quadriceps control – consider using biofeedback or electrical stimulation on the quadriceps – including on vastus medialis oblique. • Mobility Exercises: Passive only 0-30° Seated heel slides using towel Hamstring stretch Gastrocnemius/soleus stretch • Strengthening exercise – Quad sets - if possible “1million/day,” straight leg raises, short arc quads • Manual Therapy – Manual patella mobs – especially superior/inferior. Patellar mobility is also very important, and the patient should be instructed in self-mobilization exercises

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 for the patella, scars, and soft tissues around the knee to prevent fibrosis. • Physical Agents – Ice can be used following exercise and initially every hour for 20 minutes

Phase II: Week 2 to Week 6 Goals: Protect the graft (note that it is at its weakest point in the healing process) Ambulate with normal gait Good quad control Improve strength and ROM Minimal to no swelling Able to ascend/descend stairs Intervention: • Exercises:

Brace:

Heel slides – seated and/or supine Continue quad sets until swelling is gone and quad tone is good Straight leg raises - add ankle weights when ready Active knee flexion – PRONE – 0-30/40° Shuttle/Total gym – 0-60° - bilateral and unilateral; focus on weight distribution more on heel than toes to avoid overload on patella tendon Closed chain terminal knee extension Leg Press Step-ups – forward Step-overs Wall squats 0-30° Calf raises Cycle when 110° of flexion is reached Continue with HS and calf stretching Balance/proprioceptive training - weight shifting - med/lat, single leg stance - even and uneven surface - focus on knee flexion, plyoball tossing Aquatic resistance training may be initiated during the later part of this phase. Continue to wear brace – unlocked to 90° at week 4

Phase III: Week 6 to Week 12 Goal: Perform everyday ADLs without difficulty Full knee ROM Intervention: • Bracing - Post-op brace will is often discontinued at 6 weeks – patient may then be fitted for functional brace

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 • Exercises: Continue with above exercises, increasing intensity as tolerated. Active knee flexion – prone – 0-90° Knee extensions – 0-90° Step-ups – forward and lateral; add dumbbells to increase intensity; focus on slow, controlled movement during the ascent and descent Squats - standing (at week 8) Lunges – forward and reverse; add dumbbells or medicine ball Theraband hip flexion Single leg squats Single leg wall squats Cycle – increase intensity; single leg cycle maintaining 80 RPM Balance/proprioceptive exercise - Plyoball tossing – even and uneven surfaces, squats on balance board/foam roll, Cycle – increase intensity

Phase IV: Week 12 to one year Goal: Perform everyday ADLs without difficulty Full knee ROM Increase strength, power, and endurance. Prepares the athlete for return to competition Intervention: • Exercises: Strengthening should continue with focus on high intensity and low repetitions (6-10) for increased strength. Hamstring and calf stretches should also continue Quad stretch should be implemented. Week 12: Light resisted hamstring work can be initiated Initiate lateral movements and sports cord exercises: lunges, forward, backward, or side-step with sports cord, lat step-ups with sports cord, step over hurdles. Jogging/Plyometrics: When cleared by the physician, the patient can begin light plyos and jogging at a slow to normal pace. Patient should be focusing on achieving normal stride length and frequency. Initiate jogging for 2 minutes, walking for 1 until this is comfortable for the patient and then progress the time as able. Jogging should first be performed on even surfaces such as a treadmill or track. Then it can be progressed to mild uneven surfaces such as grass and then asphalt or concrete. It is normal for the patient to have increased swelling as well as some soreness, but this should not persist beyond one day or the patient did too much. Jump rope and line jumps can be initiated when the patient is cleared to jog.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Jogging and plyos should be performed with brace on. Advanced Plyos can include squat jumps, tuck jumps, box jumps, depth jumps, 180 jumps, cone jumps, broad jumps, scissor hops. Leg circuit: squats, lunges, scissor jumps on step, squat jumps. Power skipping Bounding in place and for distance Quick feet on step – forward and side-to-side – use sports cord Progress lateral movements – shuffles with sports cord; slide board Ladder drills Swimming – all styles Focus should be on quality, NOT quantity Landing from jumps is critical – knees should flex to 30° and should be aligned over second toe. Controlling valgus stress and movements, will be a challenge at first, and unilateral hops should not be performed until this is achieved. Gradually initiate sprints and cutting drills. Progression: Straight line, figure 8, circles, 45° turns, 90° cuts and sports specific drills

Selected References: Agesen T, Ertl J; Kovacs G. Posterior Cruciate Ligament Injury. E-medicine. http://www.emedicine.com/sports/topic105.htm. Jan. 12, 05. Bhatti J; Kischner S; Sarmini M. Posterior Cruciate Ligament Injury. E-medicine. 12/19/03. http://www.emedicine.com/pmr/topic102.htm. McNeal M; Lintner D. PCL Protocol. http://www.drlintner.com/PCLrehab.htm Stapelton T. The Posterior Cruciate Ligament. Hughston Health Alert. 1996 http://www.hughston.com/hha/a.pcl.htm. Sekiya J, Kurtz C, Carr D. Transtibial and tibial inlay double-bundle posterior cruciate ligament reconstruction: Surgical technique using a bifid bone-patellar tendon-bone allograft. Arthroscopy. 2004;1095-1100. Wind W, Bergfeld J, Parker R. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med. 2004;32:1765-1775.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Medial/Lateral Meniscectomy and Rehabilitation
Anatomical considerations: The meniscus is an important load-bearing structure that supports 70% of the load transmitted through the lateral compartment and 50% medially, thus decreasing contact pressures on the articular cartilage. It is also an important secondary stabilizer of the knee, resisting anterior translation. The meniscus has nutritive as well as lubricating properties in the knee joint as well. The medial meniscus is C shaped and thicker posteriorly. It occupies 50% of the articular contact area of the medial compartment. The lateral meniscus is O shaped and of equal thickness throughout. It covers 70% of the lateral tibial plateau. The red zone or fibrous outer portion of the meniscus is vascular and therefore tears there will often heal. The inner 2/3rds or white cartilaginous zone of the meniscus does not have a good blood supply and therefore, tears are less likely to heal in this area. The lateral meniscus is not as firmly attached to the tibia as the medial meniscus and therefore is less prone to injury. Pathogenesis: The meniscus is most commonly injured by a compressive or weight bearing force, combined with tibiofemoral rotation in the transverse plane as the knee moves from flexion to extension. A tear may therefore occur during activities that require rapid cutting or pivoting. Epidemiology: The posterior medial meniscus is the most commonly injured portion of the menisci, secondary to it being less mobile and therefore, greater stresses occurring in this area. Athletes and younger individuals most often obtain meniscus tears via non-contact activities like rapid cutting, pivoting or deceleration movements. With increasing age, tears can often occur with trivial injury due to degeneration of the meniscus. Diagnosis • • • • • Injury followed by pain in area of medial or lateral joint lines Most patients describe pain especially when the knee is straightened. Following an injury, the knee may click, lock or feel weak Positive McMurray’s or Apley’s tests MRI may help to confirm the diagnosis

Nonoperative vs. operative management: The overall treatment goal is to preserve as much meniscal tissue as possible while addressing the clinical symptoms caused by the meniscal tear. Nonoperative treatment which consists of anti-inflammatory medications and careful strengthening exercises may allow for the menisci to heal, especially if the tear lies in the outer third of the structure. This treatment may take 6-8 weeks in order for meniscal healing to occur. If the patient continues to complain of symptoms following 6 weeks, arthroscopic meniscectomy may be considered. Non-operative treatment is usually more appropriate for patients who are less active or sedentary. Meniscal tears that extend beyond the outer third or vascular zone will not heal and therefore a partial meniscectomy is recommended. A complete meniscectomy may be performed especially with significant degenerative tears to the meniscus.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Both complete and partial meniscectomies result in a significant increase in the load across the joint and on the articular cartilage and reduce the shock absorption capacity of the knee. A partial meniscectomy leaves a rim of tissue in place, which maintains some stress protection for the articular cartilage, in contrast to a total meniscectomy, which (in the absence of regeneration) is associated with increased cartilage degeneration, joint narrowing, alterations in bone geometry, and osteophyte formation. Due to these factors, many surgeons choose to preserve the meniscus with a meniscal repair or in some cases reconstruction with an allograft. In addition to the location of the tear, the pattern of the tear may also indicate if surgery may be required. Longitudinal tears have a favorable healing potential except for a bucket-handle tear (a variant of a longitudinal tear) in which circumferential fibers are involved. Radial or flap meniscus tears also involve the circumferential fibers. These tears are more easily managed with debridement/ meniscectomy. Degenerative tears also respond better to meniscectomy than repair. Surgical procedure: Although meniscectomy was originally performed by open arthrotomy, the procedure is almost universally done today by arthroscopic means. Partial meniscectomy is indicated in unstable tears that are not repairable due to location or configuration and serves to preserve as much of the normal meniscus as possible. In this procedure, the surgeon removes only the damaged or unstable portion of the meniscus, and balances the residual meniscal rim. The procedure for a total meniscectomy, the entire meniscus may be removed. Preoperative rehabilitation: Pre operative rehab for a meniscal injury that is to undergo a meniscectomy may involve: (1) Swelling and pain control, (2) range of motion exercises, (3) quadriceps strengthening and (4) aquatic therapy for strengthening if pain is preventing strengthening with normal weight bearing

POSTOPERATIVE REHABILITATION

Rehab following a partial medial or lateral meniscectomy can usually progress as tolerated, with no contraindications or limitations due to the fact that there is no anatomic structure that must be protected. Goals are early control of pain and edema, immediate weight bearing, obtaining and maintaining full ROM and regaining proper quadriceps strength. The following is a rehab progression provided by S. Brent Brotzman and Kevin E. Wilk. Phase 1: Acute phase Goals: Diminish inflammation and swelling Restore ROM Reestablish quadriceps muscle activity

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Intervention: Days 1-3 • Cryotherapy • Light compression wrap • Electrical muscle stimulation to quadriceps • Strengthening Exercises: Straight leg raises, hip adduction and abduction, ¼ and/or ½ squats • Active assisted ROM stretching, emphasizing full knee extension (flexion to tolerance) • Weight bearing as tolerated (use of axillary crutches as needed) Days 4-7 • Cryotherapy and continued use of compression wrap • Electric muscle stimulation to quadriceps • Strengthening Exercises: Straight leg raises, quadriceps sets, hip adduction and abduction, knee extension 90-40 degrees, ¼ and/or ½ squats • Balance/proprioceptive drills • Active assisted, passive ROM, and stretching exercises (hamstrings, gastrocsoleus, quadriceps) • Weight bearing as tolerated Days 7-10 • Continue all exercises and add: Leg press (light weight), toe raises, and hamstring curls • Bicycle (when ROM 0-105 degrees with no swelling)

Phase 2: Internal Phase Goals: Restore and improve muscular strength and endurance Reestablish full nonpainful ROM Gradual return to functional activities Intervention: Days 10-17 • Bicycle, Stairmaster and/or elliptical trainer for motion and endurance • Strengthening and coordination exercises: Lateral lunges, front lunges, ½ squats, leg press, lateral step ups, knee extension (90-40 degrees), hamstring curls, hip adduction and abduction, hip flexion and extension, toe raises • Proprioceptive and balance training • Stretching exercises Day 17-Week 4 • Continue all exercises • Pool program (deep water running and leg exercises)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 • Compression brace may be used during activities

Criteria for progression to Phase 3: Satisfactory clinical examination (minimal effusion) Full/nonpainful ROM No pain or tenderness Satisfactory isokinetic test

Phase 3: Advanced Activity Phase – Weeks 4-7 Goals: Enhance muscular strength and endurance Maintain full ROM Return to sport/functional activities Intervention: • Therapeutic exercises:Continue to emphasize closed-kinetic chain exercises May begin plyometrics Begin running program and agility drills

Selected References: Brindle T, Nyland J, Johnson D. The meniscus: review of basic principles with application to surgery and rehabilitation. J Athl Train. 2001;36:160-169. D’Amato M, Bach B. Knee Injuries. In Brotzman B, Wilk K, eds., Clinical Orthopedic Rehabilitation. Philadelphia, Mosby,2003. Poole R, Blackburn T. Dysfunction, Evaluation, and Treatment of the Knee. In Donatelli R, Wooden M, eds., Orthopedic Physical Therapy. New York,Edinburgh, London, Melbourne, Tokyo, Churchill Livingstone, 1994. Rath E, Richmond J. The menisci: basic science and advances in treatment. Br J Sports Med. 2000;34:252-257. Weinstein S. Arthritis of the Knee. In Weinstein S, Buckwalter J, eds., Turek’s Orthopedics, Principles and their Applications. Philadelphia, J.B. Lippincott Co., 1994.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Meniscal Repair
Surgical Indications and Considerations Anatomical Considerations: The meniscus is a half moon shaped piece of cartilage that acts as force transmitter between the femur and the tibia. The meniscus has nutritive as well as lubricating properties in the knee joint as well. In a normal knee, there are two menisci, which sit on the tibia itself; the lateral and medial menisci. The meniscus itself is largely avascular, and therefore, cannot repair itself if the tear is in an avascular portion of the meniscus. The only time a meniscus will repair itself is if the injury is located in the periphery of the meniscus, where it has a vascular supply. A short (<1cm) stable tear that is limited to the outer 20% of the meniscus could heal itself with a period of immobilization. Descriptively, the anterior third of the meniscus is known as the anterior horn, the posterior third as the posterior horn, and the middle as the body. The complete removal of the meniscus can result in progressive knee arthritis. Pathogenesis: Traumatic tears are the result of a sudden load being applied to the meniscal tissue that is severe enough to cause the cartilage to fail. This trauma is usually the result of a twisting injury on a semi-flexed knee or a blow to the side of the knee that causes the meniscus to be compressed or levered against. Common examples of this injury are a fall backwards onto the heel with rotation of the lower leg or a football clipping injury. Degenerative tears are a result of the failure of the meniscus over time. There is a natural “drying out” of the center of the meniscus which progresses with age. Therefore, often the mechanism of injury is nothing out of the ordinary for the patient. An example of a possible mechanism would be a squat to pick an item up off of the floor. However, other times, there are no memorable injury that caused the tear. Epidemiology: A meniscus tear can be located in any location, and in any conceivable pattern. However, tears that are confined to the anterior horn are unusual. Tears typically begin in the posterior horn and progress anteriorly. Patients with sports injuries have a mean age of 33 years, and account for approximately 32% of cases. Patients with non-sporting injuries have a mean age of 41 years, and account for approximately 39% of cases. Patients with an indefinable injury have a mean age of 43 years, and account for about 29% of cases. There is a 4:1 male to female ratio in these tears, and approximately 2/3 of all cases occur in the medial meniscus. It should also be noted that associated ACL tears were found in 47% of the patients in sports injuries and in 13% of the non-sporting injuries. In the no-injury group, there were no ACL tears. Diagnosis • Pain on the side of the knee at the level of the joint line between femur and tibia • May observe swelling, but generally low grade, associated with stiffness and limping • Patient may report a “locking” of the knee in a bent position, associated with pain • Twisting, squatting or impacting activities cause pain • Positive McMurray’s, Apley’s grinding test and/or Bounce home test • Radiographs rule out bony injury • MRI is helpful in determining the presence, size, location and severity of the tear

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Nonoperative Versus Operative Management: Surgical repair is typically recommended for patients who are experiencing pain and/or locking of the joint. Arthroscopic surgery is the method of choice to treat a tear, as there are currently no medications, braces or physical therapy treatments that have been shown to promote healing in avascular tears. Arthroscopic surgery is performed on an outpatient basis, with the surgeon evaluating the tear. Upon this evaluation, the decision is made to either remove or repair the tear based on the location and size of the tear. If there is a vertical tear at the rim near the meniscal blood supply, it is desirable to repair the meniscus by approximating the torn edges of the meniscus to allow for healing and preventing these edges getting caught in the joint. Note that if the tear is located in an avascular portion of the joint, a meniscectomy will most likely need to be performed. The main surgical risk is wound infection and breakdown. Surgical Procedure: One arthroscopic technique is known as the inside-out method. It uses cannulas to direct a pair of long needles into the meniscus and out through a small incision in the back of the knee. The suture ends are then tied together on the outside of the knee capsule to firmly approximate the tear. This procedure does require a 1 ½” incision to access the area where the sutures are tied together. Other arthroscopic methods can avoid incisions completely. Some of these include bioabsorbable arrows and dissolving meniscal staples. T-Fix sutures are another option that provide a good repair. These sutures have an anchor that acts like a wall anchor and is deployed after placing the suture through the meniscus, the tear, and the peripheral rim. The sutures are then tied together from the inside using a knot pusher instrument that secures the meniscus to the rim.

POSTOPERATIVE REHABILITATION

Phase I: Weeks 1-4 Goals: Decrease swelling and pain Protect Repair Increase range of motion and strength Intervention: • • Physical Agents Electrical Muscle Stimulation Cryotherapy Therapeutic Exercises Isometric quadriceps, straight leg raises, active knee extension Non-weight bearing gait training (weeks 1-2) Toe touch weight bearing – ¼ body weight gait training (weeks 3-4) Progressive Strengthening Exercises (hamstrings, quadriceps, gastroc-soleus, iliotibial band) Closed Chain activities (gait, toe raises, wall squats, mini squats) in weeks 3 and 4 UBE for conditioning (weeks 1-2)

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 Stationary bike < 15 minutes (weeks 3-4) External Devices Post-operative bracing (immobilizer) Axillary Crutches Passive Range of Motion/Manual Therapy Goal of achieving 0-90 degrees in weeks 1-2; 0-120 degrees in weeks 3-4 Patellar mobilizations

• •

Phase II: Weeks 5-8 Goals: Restore normal, pain free full range of motion Ability to walk with full weight bearing by weeks 7 and 8, while wearing immobilizing brace Intervention: • • • Physical Agents Electrical Muscle Stimulation (stops after week 6) Cryotherapy Passive Range of Motion/Manual Therapy Goal of achieving 0-135 degrees Patellar and peri-patellar soft tissue and joint mobilizations Therapeutic Exercises Knee flexion (hamstring curls to 90o) Knee extension (quad sets 0-30o) 4 way hip exercises Leg press (70-10o) Step-Downs Proprioceptive/balance training (weight shifting, mini trampoline, BAPS board, KAT board, plyometrics) Conditioning with stationary bike Weeks 7/8 and on – stationary bike, aquatic therapy, swimming, walking, stair climber, elliptical machine, straight running • External Devices Axillary Crutches and immobilizing brace as indicated

Phase III: Weeks 9-12 Goal: Allow patient to return to most normal activities including community ambulation, unlevel surfaces and stairs without pain - and without brace

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 Intervention: • • Approaches / strategies listed above Functional training: Introduce running without brace, multi-plane single leg activities, cutting and full sport activities

Intervention for High Performance / High Demand Functioning in Workers and Athletes Goal: Return to unrestricted sport or work activity • • Therapeutic exercises Review desired activity and progress to ballistic activity specific exercises Patient education/ergonomics instruction Educate patient to recognize knee injuries Instruct in home/gym exercise and stretching program to prevent recurrence.

Selected References Asik M, Sen C, Taser OF, Sozen YV, Alturfan AK. Arthroscopic meniscal repair with the use of conventional suturing materials. Acta OrthopedicTraumatol Turc. 2002. Abstract (article is in Turkish) Cincinnati Sports Medicine and Orthopaedic Center. Rehabilitation Protocol Summary for Meniscus Repairs. www.cincinnatisportsmed.com, accessed 7/6/2004 Drosos GI, Pozo JL. The causes and mechanisms of meniscal injuries in the sporting and nonsporting environment in an unselected population. Knee. 2004;4:143-149. Greis PE, Bardana DD, Holmstrom MC, Burks RT. Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg. 2002;10:168-76. Magee, D. Orthopedic Physical Assessment 4th ed. WB Saunders Co., Philadelphia, PA, 2002 Nevsimal L, Skotak M, Mika P, Behounek J. Clinical examination of menisci in the era of arthroscopy. Acta Orthopedic Traumatol Cech. 2002. Abstract only as article is in Czech. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees. Am J of Sports Med. 2004;32:675-680.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Knee - Articular Cartilage Procedures
Surgical Indications and Considerations Anatomical Considerations: Articular cartilage covers the articular surfaces of synovial joints and provides a nearly frictionless surface for kinematics. It lacks blood supply and lymphatic supply, receiving its nutrients secondary to movement and stresses to the proteoglycans and collagen. Articular cartilage is composed of type II hyaline cartilage, which does not spontaneously reproduce and is naturally replaced with fibrocartilage following pathology. Fibrocartilage lacks the shock absorption and smooth characteristic of hyaline cartilage. Mechanical motion and loading have been found to increase chondrocyte activity and improve cartilage generation. Pathogenesis: Research suggest that it may stem from a variety of causes including: post traumatic avascular necrosis, idiopathic avascular necrosis, overuse and repeated impact, blockage of a small artery, unrecognized injury, tiny fracture leading to cartilage damage, genetic predisposition (if multiple joints involved or family history), abnormal ossification, and acute trauma or shear force. Osteochondral defects are divided into five stages. Stage 0 - normal, Stage 1 - softening and/or superficial fissures, Stage 2 - injury extending to less than 50% of cartilage depth, Stage 3 - injury through 50% of cartilage depth and to subchondral bone, Stage 4 - Subchondral bone exposed, injury to subchondral bone or through to trabecular bone. Epidemiology: Osteochondral defect is a common disorder of unclear etiology. Predisposing factors include high impact athletic activities, muscular weakness and instability, malalignment, and endocrine imbalance. The pathology is historically more common in males (thought to be secondary to activity level) with prevalence increasing in females, ages 10-40 years, and is known to occur in the knee, dome of the talus, capitellum, femoral head, and trochlea. Occurrence is greater in the weight bearing joints and may occur in the upper extremities with falling onto an outstretched arm. Diagnosis: • • • • • • • Patients present with varying pain levels from no complaints to non-relieving pain following trauma, sudden onset (loose body), gradual onset, or intermittent pain Pain is primary complaint, dull ache, poorly localized, rest alleviates, increases with activity. Swelling is often intermittent, increases with activity Grating in the joint Decreased range of motion, stiffness. Inconsistent range of motion could be indicative of a loose body Locking in the joint and giving way Plain film radiographs confirm lesion. MRI, CT, and US are used to diagnose stage of lesion. Arthroscopy is gold standard evaluation tool

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2

Nonoperative Versus Operative Management: Treatment of osteochondral lesions depends on the size, location, stability of the fragment, and skeletal maturity (epiphyseal plates). Research and history has shown that articular cartilage will not spontaneously heal. Stage 1 and 2 lesions are often treated conservatively because the surgery is invasive and reliability of techniques is indifferent. Surgical intervention is recommended for stage 3 and 4 lesions and occasional stage 2 lesions depending on level of activity of patient and physician's choice. Surgical Procedures: Several surgical intervention options are available and chosen depending upon the condition of the lesion and goals of the patient. Arthroscopic debridement consists of removal of loose bodies, spurs, loose cartilage, and the cartilage surface is made smooth. Arthroscopic abrasion is utilized following debridement to expose bleeding surface of bone in order to stimulate cartilage healing – however, healing occurs with a less than optimal fibrocartilage layer. Arthroscopic micro fracture or drilling consists of drilling holes into the subchondral bone with the intention of stimulating articular cartilage formation from the subchondral bone. Drilling can be done either retrograde (does not touch the remaining cartilage) or antegrade (through the remaining cartilage). More invasive options include osteochondral autograft transfer (OAT) procedure that involves removing a graft and bone plug from a non weight bearing surface of the knee, usually the patella groove of the medial condyle. Holes are drilled into the osteochondral lesion and the plugs are then placed in the lesion. The articular surface is then hyaline cartilage from the plugs, but the space between the plugs is filled with fibrocartilage. The latest option is Autologous Chondrocyte Transplantation/Implantation (ACI) that requires a biopsy of healthy articular cartilage from a non weight bearing surface to be gathered and sent to the lab to culture hyaline cartilage. Cartilage is sent back to the physician. A periosteal graft is then taken from the tibia and inserted into the lesion with the new cartilage cells injected below it. The graft is sutured in place with flat sutures. Preoperative Rehabilitation: • • • • • Conservative treatment to return patient to highest level of function. If conservative fails to meet the desired outcomes and/or expectations, then surgery is implicated Lower extremity strengthening and arm bike to maintain cardiovascular strength Patient education in use of crutches and weight bearing status as appropriate A controlled motion brace may be appropriate with symptoms of instability Instructions and review post-operative plan and educate on long recovery period

POSTOPERATIVE REHABILITATION Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Fitzgerald and Irrgang and published in Clinical Orthopaedic Rehabilitation by Brotzman and Wilk. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

3 ARTHROSCOPIC DEBRIDEMENT

Phase I: Early post-operative protection phase: 0-6 weeks Goals: Protection of healing tissue from shear forces Restoration of full passive knee extension Gradual improvement of full knee flexion Re-establish voluntary quadriceps control Adhere to weight bearing status Intervention: • • • • • • • • • • Full extension at 1 wk Full flexion at 3 wks Initiate isometric exercises Open chain resisted exercises as tolerated Closed chain exercise as tolerated in accordance to weight bearing status Weight bearing as tolerated crutch training Initiate walking program: 3-6 weeks Stationary bike: 3-6 weeks Swimming program: 3-6 weeks Elevate and ice

Phase II: Intermediate Phase: 6-12 weeks Goals: Full active range of motion should be achieved by this time Return to full activities. Intervention: • • • • • Exercises to maintain full active range of motion Progress to open and closed chain resisted exercises as tolerated Agility and sport specific skill training at 50% effort is initiated, progress to full effort as tolerated Initiate return to full activity as these activities do not induce pain or effusion Elevate and ice as needed

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

4 OSTEOCHONDRAL AUTOGRAFT PROCEDURE Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan. Phase I: Protection Phase: 0-6 weeks Goals: Protection of healing tissue from shear forces Restoration of full passive knee extension Gradual improvement of knee flexion Re-establishment of voluntary quadriceps control Intervention: • • • • • • Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks Weight bearing- toe touch for 2 weeks, 25% body weight 3-4 weeks, 50-75% 5-6 weeks Immediate motion Patellar mobilization Full passive knee extension Passive knee flexion, active assisted range of motion: 0-90o week 1 0-100o week 2 0-110o week 3 0-115o week 4 0-125o week 6 Isometric quadriceps sets Straight leg raises Isometrics in multiple angles for quads Electrical muscle stimulator to quads if poor recruitment Bicycle as range of motion permits Active knee extensions: Week 3 Mini squats 0-50 degrees: Week 3 Leg press: Week 3 Gradual return to daily activities as tolerated, reduce if symptoms occur

• • • • • • • • •

Phase II: Transition Phase: 6-12 weeks Goals: Gradual increase range of motion Gradually improve lower extremity strength and endurance Gradually increase functional activities Intervention:

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5

• • • • • • • • •

Full weight bearing: Weeks 6-8 Knee range of motion: 0-125o Progress resistive exercises Initiate closed chain exercises including step ups and wall squats to 70 degrees Stationary bike Balance and proprioception drills Pool program Initiate isotonic strengthening program: Weeks 6-8 Gradual increase in walking and standing, as swelling and pain allows

Phase III: Maturation Phase: 12-20 weeks Goals: Improve muscular strength and endurance Increase functional activities Intervention: • • • • • • • • • • Leg press 0-90o Bilateral squats 0-60o Unilateral step ups and step downs, 2”-8” Forward lunges Walking program Stationary bike Balance and proprioceptive drills Pool program Stairmaster Initiate light running program – DETERMINED BY PHYSICIAN

Phase IV: Return to Activity Phase: 20-26 weeks Goals: Gradual return to full unrestricted functional activities Intervention: • • • • • • • • • Progress exercise program Squats 0-65o Leg press 0-90o Step ups, step downs Front lunges Bike Gradual increase to running and agility drills Low impact sports 4 months Moderate impact sports 5 months

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 • High impact sports 6-7 months

AUTOLOGOUS CHONDROCYTE IMPLANTATION Note: The following rehabilitation protocol is a summary of guidelines for post-operative articular cartilage procedures provided by Kevin Wilk and was presented at a Northeast Seminars symposium in Los Angeles in 2003. Please refer to the publication for details on the progression, potential impairments, and goals of the rehabilitation plan. Phase I: Protection Phase: 0-6 weeks Goals: Protection of healing tissue from load and shear forces Restoration of full passive knee extension Gradual improvement of knee flexion Regain quad control Intervention: • • • • • • • • • • • • • • • • • Brace locked at 0 degrees during ambulation for 4 weeks, sleep in brace 2-4 weeks. Weight bearing: non weight bearing for 2 weeks, toe touch 3-4 weeks, 25% 5 weeks Immediate motion CPM first 4-12 hours: 0-40o for 2-3 weeks, increase as tolerated 5-10 degrees per day Patellar mobilization Full passive knee extension Passive knee flexion 0-90o at 2 weeks, 0-105o at 4 weeks, 0-120o at 6 weeks Stretch hamstrings, calf, quads Theraband resisted ankle pumps Isometrics for quads Active knee extension 90-40 degrees, no resistance Straight leg raises Stationary bike Biofeedback as needed Isometric leg press at week 4 Gradual return to daily activities Elevation and ice

Phase II: Transition Phase: 6-12 Weeks Goals: Gradual increase in range of motion Gradually improve quad strength and endurance Gradual increase in functional activities Intervention: • Discontinue brace at 4-6 weeks

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

7 • • • • • • • • • • • • Progress knee flexion to 125o Patella mobilization and soft tissue work Continue stretching Mini-squats 0-45o Closed chain exercises, leg press Calf raises Open chain resistance, 1#/week Stationary bike Balance Front and lateral step ups Increase functional activity as pain and swelling allow Walking program

Phase III: Maturation Phase: 12-26 weeks Goals: Improve muscular strength and endurance Increase functional activities Intervention: • • • • • • • • • • • • Range of motion to 0-125/135 Leg press 0-90o Squats 0-60o Unilateral step ups 2”-8” Forward lunges Walking program Open chain extension 0-90o Bike Stairmaster Swimming Nordic track Light running at end of phase

Phase IV: Functional Activity Phase: 26-52 weeks Goals: Gradual return to full unrestricted activities Intervention: • • • Progress resistance as tolerated Progress agility and balance drills Impact and loading program to build to patients requirements

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

8 • • • • Progress sport programs as necessary Low impact sports at 6 months Moderate impact sports at 8-9 months High impact sports at 12 months

Selected References: Barber FA, Chow JCY. New frontiers in articular cartilage injury. Arthroscopy. 2003;19:142146. Bentley G, Biant LC, Carrington RWJ. A prospective, randomized comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg. Br.2003;85:223-230. Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd ed. Philadelphia, Mosby Inc.,. 2003: 350-355. D’Lima DD, Hashimoto S. Osteoarthritis and cartilage. Journal of the OsteoArthritis Research Society International. 2001;9:712-719. Ellenbecker T. Knee Ligament Rehabilitation: New Techniques for Cartilage Repair and Replacement. Churchill Livingston; 2nd edition. 2000. Mendicino RW, Catanzariti AR. Mosaicplasty for the treatment of osteochondral defects of the ankle joint. Clin Podiatr Med Surg. 2001;18:495-511. Milbrandt T, Berthoux L, Christenson V. Tracing transduced cells in osteochondral defects. J Pediatr Orthop. 2003;23:430-436. Nakagawa Y, Matsusue Y. Osteochondral grafting for cartilage defects in the patellar grooves of bilateral knee joints. Arthroscopy. 2004;20 Suppl 2:32-38. Wilk K. Surgical treatment options for articular cartilage defects. Northeast Seminars. Los Angeles 2003.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

1

Total Knee Arthroplasty Rehabilitation
Surgical Indications and Considerations Anatomical Considerations: The knee is composed of the distal end of the femur, proximal portion of the tibia, and the patella. It has a medial and lateral meniscus in between the femur and tibia to cushion the joint, absorb and transmit weigh-bearing forces. Four ligaments, the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL) provide anterior-posterior and medial-lateral support. The knee is an unstable joint, relying on ligaments, menisci, and balanced muscles on all sides of the joint, particularly the hamstrings and quadriceps, for cushioning and stability. It is more than a simple hinge joint, as the bone surfaces roll, glide, and rotate on each other. Pathogenesis: Wear and tear of the knee joint is part of the normal aging process, however, osteoarthritis (OA) accelerates the degenerative wear of the meniscus. This form of arthritis usually results from some predisposing factor, such as an injury or deformity. Whether of unknown origin or secondary to trauma or disease, poor alignment of the leg bones may cause unequal weight distribution. This leads to excessive wear on one side of the joint surface versus another, and any irregularity of the knee joint results in wear and tear of the menisci. Over time, the menisci no longer function as an effective shock absorber/transmitter for the knee. Excessive localized pressure and damage to the joint result, possibly leading to bone-on-bone contact, causing symptoms of increased knee stiffness and pain. Remodeling of bone may also occur due to bone-on-bone contact, causing bony spurs. These spurs contribute to increased pressures within the joint, leading to pain and decreased function. Rheumatoid arthritis is an inflammatory joint disease that is destructive to articular cartilage lining the surfaces of the knee joint. The inflammatory process can cause joint instability and deformity, muscle atrophy and weakness, swelling, stiffness, and pain. Epidemiology: Total knee arthroplasty (TKA) is one of the most common orthopedic procedures: 171,335 primary total knee replacements occurred in 2001. Nearly 90% of patients who elected to have TKA had OA of the knee, 2/3 were female, and 1/3 were considered obese. Although patients as young as late-40’s and as old as mid-90’s have received total knee replacements, the “ideal” knee replacement candidate is between the ages of 65-75, as patients are healthy enough to recover well from surgery, yet old enough so replacement most likely lasts the rest of their lives (15-20 years). Obesity is the most modifiable risk factor, but prior knee injuries/trauma, and extreme physical or repetitive activity can also contribute to increased incidence of knee OA. Other causes of knee dysfunction leading to TKA include rheumatoid arthritis, trauma, congenital/acquired joint deformity, and tumors.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

2 Diagnosis/Indications For Surgery • Severe joint pain with weight bearing or motion that compromises functional activities (severity of pain correlates poorly with radiographic and structural changes in the joint) • Extensive destruction of articular cartilage of the knee secondary to advanced arthritis • Gross instability or limitation of motion • Marked deformity of the knee such as genu varum or valgum • Knee pain that does not respond to conservative therapy (medication, injections, physical therapy > six months) • Previous failed surgical procedure Nonoperative Versus Operative Management: There are typically four major groups of nonsurgical treatments: 1) Health and behavior modification, including weight loss and patient education about behavior changes to reduce impact of disease, physical therapy and exercise to stretch, strengthen muscles surrounding the knee. Deyle et al concluded that a combination of manual physical therapy and supervised exercise is more effective than no treatment in improving walking distance and decreasing pain, dysfunction, and stiffness in patients with OA of the knee, possibly deferring or decreasing the need for surgical intervention. Vad et al proposed a progressive five-stage rehabilitation program for managing knee OA that ranges from protected mobilization to exercises to improve neuromuscular coordination, timing, and joint protection. Taping and bracing to support and protect the knee joint, foot orthoses to correct imbalances contributing to unequal weight bearing forces across the knee joint, and use of TENS for pain control are also included under this category. 2) Drug treatments, including simple pain relievers, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, opiates, and glucosamine and/or chondroitin sulfate are several types of drugs used to treat knee OA. 3) Intra-articular treatments involve one or more injections into the knee joint. Corticosteroid injections, limited to four or less per year, are helpful for significant swelling causing moderate to severe pain. Typically corticosteroid injections are not helpful if arthritis affects joint mechanics. Viscosupplementation with hyaluronic acid, a molecule that is found in joints of the body, is a way of adding fluid to lubricate the joint and make it easier to move. It can be helpful for people whose arthritis does not respond to behavior modification or basic drug treatments. Three to five weekly shots are needed to reduce the pain, but relief is not permanent. 4) Alternative therapies include the use of acupuncture and magnetic pulse therapy. Acupuncture is adapted from a Chinese medical practice. It uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Because the body produces electrical signals, proponents think that magnetic pulse therapy may stimulate the production of new cartilage. Many forms
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

3 of therapy are unproven but reasonable to try provided they are through a qualified practitioner and the primary physician is informed of the patient’s decision to try these therapies. Elective total knee replacement is, more often than not, the last effort in managing joint pain and dysfunction caused by arthritis when non-operative treatment of knee pain is not effective. When erosion of articular joint surfaces becomes severe, TKA is the surgical procedure of choice to decrease pain, correct deformity, and improve functional movement. Surgical Procedure: An incision is made down the front of the leg from mid-thigh to several inches below the knee. The quadriceps muscles are either split down the middle or shifted, along with the patella, to the side of the thigh. The distal end of the femur and proximal end of the tibia are sawed off; the menisci and ACL are excised as well. The PCL may also be cut; the pros and cons of sparing the PCL is currently of debate in knee replacement surgery. The knee replacement consists of three components that help the surgeon tailor the device to the patient. A curved femoral component is usually made of shiny chrome alloy; it is attached to the femur and “replaces” the femoral condyles. The metal tibial component has a flat top with a spike that goes into a 2” hole that the surgeon drills into the tibia. A disc, made of polyethylene, is cemented to the top of the tibial component. Depending on its condition, the patella is either left intact or the inside resurfaced- the patella is never totally replaced. If the patella is resurfaced, polyethylene is also used to cover the inside. Total knee arthroplasty components are either held in place with bone cement (cemented fixation), utilize bone ingrowth via a porous prosthesis (uncemented fixation), or combine cemented fixation of the tibial component and uncemented fixation of the femoral component (hybrid). Uncemented fixation has been used primarily for the active patient in whom the risk of prosthetic loosening over time is most likely, however, the ultimate decision rests with the attending surgeon. Preoperative Rehabilitation • Ensure adequate strength of trunk and upper extremities for support during use of assistive devices • Instruction in use of walker/crutches/or cane to maintain desired postoperative weight bearing status (touchdown weight bearing for uncemented or hybrid replacements, weight bearing as tolerated for cemented replacements) • Review of post-operative exercises, bed mobility and transfers, use of continuous passive motion (CPM) machine as indicated per physician • General strengthening, flexibility, and aerobic conditioning While it seems reasonable to believe patients undergoing TKA would benefit from preoperative strengthening exercises, there is no evidence to support this assumption, either in improving functional outcome or shortening hospital stay (D’Lima et al., Rodgers et al.). However, a study by Jones et al showed that patients who have greater preoperative dysfunction may require more intensive physical therapy intervention after surgery because they are less likely to achieve similar functional outcomes to those of patients who have less preoperative
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency

4 dysfunction. POSTOPERATIVE REHABILITATION Note: The following rehabilitation progression is a summary of the guidelines provided by Kisner and Colby. Refer to their publication to obtain further information regarding criteria to progress from one phase to the next, anticipated impairments and functional limitations, interventions, and goals. *Use of a CPM device is often initiated by the first day after surgery, per physician protocol. It has been suggested that CPM decreases postoperative pain, promotes wound healing, decreases incidence of deep venous thrombosis (DVT), and enables the patient to regain knee flexion more rapidly during early postoperative days. However, Kumar et al conducted a randomized prospective study that found no statistically significant difference in range of motion gains using a CPM device versus active movement. Continuous passive motion units may be recommended as an adjunct to, not a replacement for, a supervised postoperative rehabilitation program.

Phase I: Maximum Protection: Weeks 1-2 Goals: Control postoperative swelling Minimize pain Knee ROM 0-90° Muscle strength 3/5-4/5 Ambulation with or without use of an assistive device Establish home exercise program Intervention: • • • • • • • • • • • • Passive range of motion (PROM)-CPM as indicated per physician Ankle pumps to decrease risk of DVT Bed mobility and transfers usually initiated 24-48 hours post-surgery, depending on surgical procedure and co-morbidities Heel slides in supine or sitting to increase knee flexion Muscle-setting exercises of the quadriceps, hamstrings, and hip adductors, possibly coupled with neuromuscular electrical stimulation Assisted progressing to active straight-leg raises in supine, prone, and sidelying positions Gravity-assisted knee extension in supine by periodically placing a towel roll under the ankle and leaving the knee unsupported Gentle inferior and superior patellar glides Neuromuscular inhibition techniques such as agonist-contraction techniques to decrease muscle guarding, particularly in the quadriceps, and increase knee flexion Gentle stretches for the hamstrings, calf, and iliotibial band Pain modulation modalities Compressive wrap to control effusion

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

5 • Gait training

Phase II: Moderate-Minimum Protection: Weeks 3-6 Goals: Diminish swelling and inflammation Increase ROM 0-115° or more Increased dynamic joint stability/full weight bearing per implant status Muscle strength 4/5-5/5 Return to functional activities Adhere to home exercise program Intervention: • • • • • • • • • • • • Interventions listed in Phase I Patellar mobilizations Tibiofemoral joint mobilization if appropriate and needed Soft tissue mobilization to quadriceps or hamstrings myofascia Incision mobilization after suture removal, when incision is clean and dry Progressive passive stretches to hamstrings, gastrocnemius, soleus, quadriceps within a pain-free range Stationary bike or peddler without resistance to increase flexion ROM Pain-free progressive resisted exercises using ankle weights, theraband/tubing Proprioceptive training such as weight shifting, tandem walking, lateral stepping over/around objects, obstacle courses, lower extremity proprioceptive neuromuscular facilitation (PNF), front and lateral step-ups, closed-kinetic chain activities Closed-kinetic chain strengthening, such as ¼ squats, ¼ front lunges Gait training as needed to decrease limp, wean off assistive device Protected, progressive aerobic exercise, such as cycling without resistance, walking, or swimming

Phase III: Return to Activity: Week 6 and beyond Goals: Progress ROM 0-115° as able, to a functional range for the patient Enhance strength and endurance and motor control of the involved limb Increase cardiovascular fitness Develop a maintenance program and educate patient on the importance of adherence, including methods of joint protection Intervention: • • • Continue interventions of previous phases; advance as appropriate Implement exercises specific to functional tasks, such as transferring from sit-to-stand, lifting, carrying, push/pulling, squat/crouching, return to work tasks, return to sport tasks Improve cardiorespiratory and muscle endurance with activities such as bicycling, walking, or aquatic programs

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

6 Selected References: Avramidis K, Strike P, Taylor P, Swain I. Effects of electrical stimulation of the vastus medialis muscles in the rehabilitation of patients after total knee arthroplasty. Arch Phys Med Rehab. 2003;84:1850-1853. D’Lima D, Colwell C, Morris B, Hardwick M, Kozin F. The effect of preoperative exercise on total knee replacement outcomes. Clin Orthop. 1996;1(326):174-182. Deyle G, Henderson N, Matekel R, Ryder M, Garber M, Allison S. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A randomized controlled trial. Ann Intern Med. 2000;132:173-181. Fitzgerald G, Oatis C. Role of physical therapy in management of knee osteoarthritis. Curr Opin Rheumatol. 2004;16:143-147. Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia, W.B. Saunders Company, 1998. Jones C, Voaklander DC, Suarez-Almazor ME. Determinants of function after total knee arthroplasty. Phys Ther. 2003;83:696-706. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. Philadelphia, F.A. Davis Company, 2002. Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop. 2003;1(410):225-234. Kumar PJ, McPherson EJ, Dorr L, Wan Z, Baldwin K. Rehabilitation after total knee arthroplasty: A comparison of 2 rehabilitation techniques. Clin Orthop. 1996;1(331):93-101. Moore K, Dalley A. Clinically Oriented Anatomy, 4th ed. Baltimore, Lippincott Williams and Wilkins, 1999. Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol. What makes the difference? J Arthroplasty. 2003;18(3):27-30. Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J, Bedard J. Preoperative physical therapy in primary total knee arthroplasty. J Arthroplasty. 1998;13:414-421. Vad V, Hong HM, Zazzali M, Agi N, Basrai D. Exercise recommendations in athletes with early osteoarthritis of the knee. Sports Med. 2002;32(11):729-739.

Ben Cornell PT, Joe Godges PT

Loma Linda U DPT Program

KPSoCal Ortho PT Residency

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times