Background and Purpose

The tibial plateau is a secure bony structure made up of the medial and lateral condyles of

the tibia divided by the intercondylar eminence. Tibial plateau fractures account for 1% of all

fractures and are typically the result of a high-energy impact mechanism of injury.1 The median

age of this resulting injury is 52.6 years of age, with men under 50 years of age commonly

obtaining this injury via a high-energy mechanism, while women over 70 years of age are more

likely to accrue this injury via a fall.2 Incidence rates involving tibial plateau fractures range from

116-427/100,0003 and only 39% of patients that experience this type of fracture return to work

within the first year of injury.4 In the United States, it is estimated that this surgical procedure per

occurrence costs an average of $82,328.00.5(p1688)

The tibial plateau is home to multiple attachment points for the periarticular structures of

the tibiofemoral joint, including the medial collateral ligament (MCL), anterior cruciate ligament

(ACL), posterior cruciate ligament (PCL), and medial meniscus, as well as many other

neurovascular structures.6 The degree of displacement of the tibial plateau, when fractured, is

largely determined by the resulting magnitude of force produced by the mechanism of injury.7

The medial tibial condyle is a concave structure that is thicker than its counterpart, the convex

lateral tibial condyle.6 Due to the increased thickness and more distal location of the medial tibial

condyle, it bears 60% of the knee’s weight during ambulation.6 The typical course of action after

suffering a tibial plateau fracture is to undergo a surgical procedure called an open reduction

internal fixation (ORIF).8 The “open reduction” refers to the surgeon creating an incision in the

skin to access the fractured bone and realign it for optimal healing, while the “internal fixation”

statement refers to piecing the fragments of bone together with objects such as pins, plates, rods,

1
screws, or a combination of these.9 Patients will typically undergo general anesthesia, an agent

used for temporary loss of sensation, for an ORIF surgical procedure.9

Currently, there are no clinical practice guidelines for treatment post bicondylar tibial

plateau fractures, but there are protocols that surgeons use for patients that have experienced a

tibial plateau fracture. A protocol conducted by Crall et al10 included a NWB protocol for the

first 6 weeks after surgery, allowing for quadriceps strengthening to gain full knee extension,

global lower extremity stretching, closed-kinetic-chain (CKC) hip strengthening of the

uninvolved side, core strengthening, and other suggested therapeutic exercises for the first 6

weeks. This protocol has guidelines for therapy after 6 weeks and takes into account tissue

healing principles and when to implement physical therapy interventions. Brigham and Women’s

Hospital, an affiliate of Harvard Medical School, also has published a standard of care protocol

for managing a tibial plateau fracture.11 This protocol focuses on edema and range of motion

(ROM) management early in the acute phase of recovery, utilizing a continuous passive motion

(CPM) machine and a knee brace to prevent varus and valgus forces at the knee joint.11 While

varying post-surgical protocols exist, it is difficult to provide research supported interventions to

this population.

Henkelmann et al12 completed a prospective randomized study examining the efficacy of

the anti-gravity treadmill compared to a standard rehabilitation protocol in patients with tibial

plateau fractures with 6 weeks of partial weight bearing of 20 kg. The participants included a

total of 110 patients, including men and non-pregnant women, aged 18-65 years old. The control

group (n=50) received treatment according to this clinic's standard, including manual lymphatic

drainage, cryotherapy, and physical therapy all performed by the physical therapist. Manual

lymphatic drainage and cryotherapy were performed for 20 minutes total until swelling in the

2
affected area had decreased before each session. The patient then completed 30 minutes of

physical therapy 2-3 times a week for 6 weeks. Physical therapy interventions included

coordination training, balance training, fine and gross motor training, and a continuous passive

motion machine all within the 30 minutes allotted. The experimental group (n=60) received a

similar treatment of 20 minutes of manual lymphatic drainage and cryotherapy to decrease

swelling of the affected area, but had different physical therapy interventions. Interventions were

performed using an anti-gravity treadmill (alterGⓇ)13 2-3 times a week for 6 weeks, with

sessions lasting 30 minutes. The pressure inside the chamber of the anti gravity treadmill is

above the external pressure, and an air compressor is used to limit the effects of gravity during

ambulation. Parameters for the amount of gravity that was reduced for this study was not

included. Outcome measures used for this study included the Knee Injury and Osteoarthritis

Outcome Score (KOOS), circumference measurements above and below the patella, range of

motion (ROM), the Short Form Health Survey (SF-36), and the Dynamic Gait Index (DGI).

Findings of this study concluded that there were no significant differences in outcome measures

when comparing the experimental anti-gravity treadmill group to the control group at 6-weeks

post-intervention.

Thewlis D et al14 conducted a retrospective analysis investigating rehabilitation following

tibial plateau fractures related to postoperative weight-bearing protocols. This study investigated

the association between early loading within the first 12 weeks post surgery and its effects on

outcome measures at 26- and 52 weeks post-surgery. This retrospective analysis included a total

of 17 patients (8 male, 9 female) that would be followed for 52 weeks status-post ORIF of the

tibial plateau. The KOOS was collected for all participants, and subdomains of the assessment

were reported including symptoms of pain, activities of daily living (ADL), and knee-related

3
quality of life. Ambulation 2-days post-surgery was performed by patients with crutches or a

standard walker under the supervision of a physical therapist, with the average of patients using

an assistive device for 13 ± 11 weeks post-surgery.14 Patients loaded the affected limb to 20 kg

max over the initial 6 weeks of ambulation and continued with quadriceps strengthening and

unrestricted CKC knee range of motion exercises. A digital scale was used to give the patient an

understanding of loading their lower limb to a maximum of 20 kg, with weight-bearing

restrictions being lifted after the 6-week follow-up session. At 2 weeks and 6 weeks post-

operation, 77% (13/17) and 94% (16/17) of patients exceeded the weight-bearing limitation of 20

kg during ambulation.14 Trends showed a significant increase in loading ratio between week 2

and week 6, as well as week 6 and week 12. Results of this study concluded that early weight

bearing is not detrimental to the outcomes of tibial plateau fractures and that most patient-

reported outcome improvements occurred during the first 26 weeks status-post ORIF. Patients

who loaded their fractured limb excessively more compared to the unaffected limb at 2 weeks

post-operation had inferior knee-related quality of life (QoL) scores at 26 weeks. The KOOS

revealed significant improvements in pain, symptoms, ADLs, and knee-related QoL for patients

between weeks 12 and 16. In summary, the authors concluded that WBAT does not negatively

effect the results of tibial plateau fractures and may; therefore, be safe for postoperative

management and improving knee-related QoL scores.14

Chauhan A. et al15 examined the effects of bracing versus not bracing the lower extremity

after ORIF procedures for tibial plateau fractures. This prospective, comparative trial included a

total of 49 patients, with the experimental group (average age 50 ± 16 years; 14 women and 10

men) being fitted with a knee brace, and the control group (average age 51 ± 12 years; 9 women

and 16 men) not being fitted for a knee brace. Functional, subjective, and radiographic outcomes

4
were used to track progress after 6 weeks. These outcomes included knee flexion and extension

ROM, as well as patient health-related quality of life utilizing the SF-36 questionnaire. The SF-

36 questionnaire is a validated general health outcome measure used to assess mental and

physical components of outcomes through eight subscales. The findings of this study concluded

no statistical differences between the experimental group and the control group in terms of

functional, subjective, and radiographic outcomes 6-weeks status post ORIF. Therefore, it is

shown that bracing does not improve patient outcomes compared to individuals that are not fitted

with a brace.

Any type of fracture in the geriatric population has the potential to affect their daily life

tremendously. As individuals age, the body’s ability to produce more osteoblast cells, or bone

tissue-forming cells, decreases.16 This leads to a decrease in bone mineral density (BMD), which

has the potential to increase their susceptibility to a fracture.16 This loss of BMD, if severe

enough, can lead to osteoporosis which affected over 10 million people nationwide in 2017.16

The most common form of testing for BMD is known as dual-energy X-ray absorptiometry

(DEXA), with a T-score of -2.5 or more indicating a diagnosis of osteoporosis.16 Some men are

at an increased risk of developing osteoporosis due to their increased bone mass, with about 4-

6% of men above the age of 50 meeting this diagnostic criterion.17 A fracture of a lower

extremity has the potential to lead to a loss of independence, potentially putting the patient at an

increased risk of impairments following a sedentary lifestyle.

Currently, there are no clinical practice guidelines to follow status-post ORIF of a

bicondylar tibial plateau fracture for physical therapy, but there are varying rehabilitation

recommendations for this population. The reason for varying rehabilitation recommendations is

due to the fact that tissue healing factors differ among individuals. The surgeon must take into

5
account any patient comorbidities, the patient’s chronological age, the mechanism of injury, the

patient’s premorbid status, and other related factors that all contribute to the patient’s body’s

ability to heal. The studies reviewed have shown the importance of physical therapy

interventions and their impact on the recovery process. The purpose of this case report was to

describe the impact of physical therapy interventions on improving independence for a geriatric

patient status-post ORIF of a bicondylar tibial plateau fracture prior to discharge home from

subacute rehabilitation.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed under the direction of the Department of Physical Therapy and

with the oversight of the College of Graduate Studies at Central Michigan University.

Case Description

Patient History and Review of Systems

The patient was a 79-year-old male who was admitted to the emergency room

immediately following a bicondylar tibial plateau fracture on the right LE secondary to a low-

energy impact fall down a flight of 3 steps. The patient was fitted and placed in an external

fixator the same day to decrease the chances of obtaining an infection, keep tissues and bone

segments aligned, and to protect from further deviation. The patient was then transferred to

subacute rehabilitation to increase his independence and strength of his contralateral lower

extremity. After 2 weeks of therapy, the patient developed cellulitis and purulence around the

superior aspect of his external fixator. The patient was transferred to acute care where the

cellulitis was treated before he underwent an ORIF surgical procedure on the right tibial plateau

6
to repair the structural integrity of his right lower extremity. After surgery, the patient was

transferred back to subacute rehabilitation for improving independence and returning to

premorbid status. During the initial examination, the patient was awake and oriented to person,

place, and situation, as well as able to answer all subjective information. The patient stated that

he lived alone with 3 steps to enter the house with a railing on the left while ascending. His

bathroom included a shower bench, a standard-height toilet, and grab bars inside the walk-in

shower. Prior to the fall resulting in the bicondylar tibial plateau fracture, he reports being

independent with ADLs such as cleaning and cooking, as well as instrumental activities of daily

living (IADLs) such as grocery shopping and running errands. He was independent with

household and community ambulation, requiring no assistive device, as well as with transfers

and bed mobility prior to sustaining the bicondylar tibial plateau fracture.

Upon initial examination, the patient’s main complaint was increased pain in the

diaphysis of the right tibia. Other patient complaints included decreased independence, lower

extremity weakness, confidence, and quality of life. The patient was fitted with a total range of

motion (TROM) knee brace on the right lower extremity with ROM restrictions of 0-90° knee

flexion, as well as a non-weight-bearing (NWB) restriction.

His past medical history included sleep apnea, allergic asthma, chronic kidney disease

(CKD), type II diabetes mellitus, hyperlipidemia, hypertension (HTN), gastroesophageal reflux

disease (GERD), cardiomyopathy, pneumonia, and diverticulitis. The patient reports no history

of smoking. Past surgical history included a colectomy, as well as excision of a benign tumor

both in the cervical and abdominal region. See Table 3 for the patient’s list of medications. The

patient reported that they liked to spend time with their cats, as well as work on small house

projects with their stepson. The patient was accompanied by their stepson during the initial

7
examination, stating that he lives within walking distance from his house. The patient stated their

goals were to decrease pain in the right lower extremity, improve their independence with

transfers, return to modified independent ambulation, and return to their home environment

safely.

Given the findings identified from a computerized tomography (CT) scan conducted after

the external fixator was placed with pins in the right mid-femoral diaphysis, it was expected that

this patient had become debilitated. These findings included a comminuted fracture with

involvement of both the medial and lateral tibial plateau, intercondylar eminence, and

metaphysis of the right tibia. Musculoskeletal involvement included a medial meniscus fracture

of the fibular head and mild degenerative involvement of the right femoroacetabular and

tibiofemoral joints. Vascular involvement included moderate right hemarthrosis; and mild lateral

predominant subcutaneous edema in the right thigh. These complicating factors have the

potential to delay tissue healing responses generated by the recipient of injury. Multiple studies

have shown how vascularization that occurs inside the healing bone is necessary for hemostasis,

development, and repair of bone formation.18

Clinical Impression #1

Given these findings concluded from the CT scan and history of injury to date, it was

expected that the patient would have an increased level of pain which may limit passive range of

motion (PROM) and AROM of the right lower extremity, as well as have an increased fall risk

compared to the age-appropriate population. These will be assessed with objective measurements

of perceived pain through the Numeric Pain Rating Scale (NPRS), pain-free AROM through

goniometric measurement, and the Five-Time Sit-To-Stand (FTSTS) test for fall risk. It was also

expected that transfers, mobility, and patient independence would be decreased compared to their

8
premorbid status. These will be assessed with objective measurements of functional

independence with transfers and mobility utilizing the Functional Independence Measure (FIM)

and strength of the contralateral lower extremity will be assessed through manual muscle testing

(MMT). Baseline assessments were obtained to track improvements in these measurements

throughout the plan of care. The KOOS was not utilized with this patient due to not having a

diagnosis of osteoarthritis.

The patient’s diagnosis of a bicondylar tibial plateau fracture, combined with the weight-

bearing restrictions and level of independence makes this patient an interesting case report

subject. Of the 1% of fractures that occur at the tibial plateau,1 about 10-30% of these involve

bilateral tibial condyles.19 The patient’s past medical history including type II diabetes mellitus

combined with cardiomyopathy may have the potential to delay the healing process of bone

remodeling with impaired vascularization.20 This is a unique case report when compared to the

average patient with a bone fracture, with their ability to participate in therapy varying compared

to the average population that sustained this injury.

Examination

Active Range of Motion. Right lower extremity pain-free AROM was assessed utilizing the

parallel lines method21 with a universal goniometer, with ranges shown below in Table 2.

Currently, there is no research examining the reliability and validity of ROM measurements of

the knee joint using a standard goniometer and the parallel lines method. The parallel lines

method utilizes a standard goniometer, lining up the indicator and reference segments with the

respective bony segments that are being measured in a parallel line. The axis of rotation is placed

at the joint line, or the point in which an object rotates. Right knee flexion and extension, ankle

dorsiflexion and plantarflexion were measured at the second physical therapy session, 1 week

9
after ORIF, and at discharge 2 weeks after surgery. All ROM measurements were taken with the

patient wearing the total range of motion (TROM) knee brace for reliability and validity

purposes. AROM measurements were taken with the patient lying in the supine position on his

hospital bed, with the ipsilateral hip in the neutral position. Knee flexion pain-free AROM was

assessed by asking the patient to perform a heel slide while supine. After the measurement was

recorded, the patient was instructed to activate his quadriceps muscles to perform knee extension

while still lying in the supine position. Ankle dorsiflexion and plantarflexion pain-free AROM

was assessed by asking the patient to perform an ankle pump while lying supine. Pain-free

AROM of the right lower extremity (RLE) was recorded at the second physical therapy session

due to uncertain surgeon protocol, week 1, and at discharge. Overall, the patient demonstrated a

decreased AROM in right knee flexion and extension, as well as ankle dorsiflexion. See Table 2

for RLE pain-free AROM measurements. The left lower extremity (LLE) was noted as within

normal limits (WNL).

Strength testing. Formal manual muscle testing (MMT) of the RLE was not completed due to the

surgeon not allowing manual resistance to this affected lower extremity, but the strength of the

contralateral lower extremity was assessed as the edge of the hospital bed. Left lower extremity

strength was assessed through manual muscle testing (MMT) by following procedures and

testing protocols identified by Reese.22 Research regarding MMT has been shown to have

adequate to excellent overall interrater reliability of lower extremity muscles (ICC = 0.66-1.00).23

Left hip flexion and abduction, knee flexion and extension, ankle dorsiflexion and plantarflexion

were assessed using a break test. A “break” test involves having the patient move their extremity

into its mid-range with the examiner applying a force that counteracts the patient's desired

movement. This force starts as minimal resistance applied by the therapist and progresses to

10
maximal resistance to assess the strength of a muscle or group of muscles. The grading scale for

strength is based on a 5-point scale defined by Reese.22 A score of 0 indicates the inability of the

patient to contract a muscle in a gravity-eliminated position, while a score of 5 indicates the

ability of the patient to withstand maximal resistance applied by the examiner in a gravity-

resisted position. Left hip flexion strength was assessed at the edge of the bed with resistance

applied at the distal aspect of the femur once the patient was in mid-range. Left hip abduction

strength was assessed at the edge of the bed with the patient’s hip flexed to 45°, abducted to 20°,

and knee flexed to 90°. Resistance was applied at the lateral aspect of the distal left femur with a

medially directed force. The procedure to test left hip abduction strength differed from protocols

stated by Reese,22 therefore; reliability and validity data does not apply to this strength grade.

Left knee flexion and extension strength were assessed at the edge of the bed, asking the patient

to move through their available AROM against gravity. The left knee was then positioned in its

mid-range and the examiner applied resistance to the distal lower extremity, not crossing the

talocrural joint. Left ankle plantarflexion and dorsiflexion strength were assessed at the edge of

the bed, with the left knee flexed to 45°. The hospital bed was raised to allow the patient to move

throughout their full available range of motion. Resistance was applied by the examiner at the

distal aspect of the metatarsals. Overall, the patient demonstrated a slight decrease in

contralateral LE strength. See Table 4 for contralateral LE strength grades and an analysis of

each strength grade.

Pain. Pain assessment was recorded based on subjective information verbalized by the patient.

The patient’s level of perceived pain was objectively measured utilizing the NPRS.24 The NPRS

is an objective outcome measure created by Dr. Ronald Mezack and Dr. Warren Torgerson25 and

is used to assess the patient’s progression of pain for a wide range of patient populations it can be

11
applied to. This measurement is an 11-point scale that requires the administrator to ask the

patient to numerically assess their current level of pain on a scale of 0, meaning no pain at all, to

10, meaning the emergency room level pain. This objective measure has been reported to have

excellent interrater reliability (100% agreement) in the age brackets of 22-55- and 65–94-year-

old people in the non-specific patient population.26 This measure has excellent criterion (r=0.86)

and construct validity (r = 0.94, 95% CI = 0.93-0.95).26 For post-operative patients, the

minimally clinically important difference (MCID) was found to be 1.3 points in patients with

acute pain in the emergency department.26 Overall, the patient demonstrated a severe pain level

(NPRS = 7) score utilizing the NPRS as is reported in Figure 2.

Transfers and mobility. Transfer and mobility assessments were observed and recorded utilizing

the Functional Independence Measure (FIM).27 FIM scores are an objective way of measuring a

patient’s level of assistance needed for a particular task or activity.27 FIM scores have been

shown to have excellent test-retest reliability (ICC = 0.90) in the elderly population and excellent

overall consistency (median interrater reliability = 0.95) between raters across patients with

different diagnoses and levels of impairment.28 Each task was scored based on the level of

assistance required to complete the activity. See Table 1 for FIM scores for transfers and

mobility at different therapy sessions and definitions related to the level of assistance definitions.

The stand pivot transfer and ambulation were assessed with the patient utilizing a front-wheeled

walker (FWW) for an assistive device, while bed mobility was assessed without using an

assistive device. With the stand pivot transfer, the patient was instructed to pivot to his left, or

unimpaired lower extremity, to decrease the chances of a subsequent fall. Ambulation was taught

using a 3-point gait to adhere to the NWB surgeon protocol for the first week after surgery, with

weight-bearing restrictions being lifted after the first week to toe-touch weight bearing (TTWB).

12
The car transfer was assessed at the end of week 1 due to the patient being transported to his

referring physician, and at discharge to his home. The same car was used at week 1 and at

discharge. Stair ascension/descension was assessed at the second to the last session and at

discharge due to surgeon protocols and weight-bearing restrictions. The patient’s first initial

scores for the level of assistance required utilizing the FIM were scored at moderate to minimal

assistance. The full FIM was not used due to task-specific purposes that are relevant to this

subject. See Table 1 for additional details on the patient’s FIM score for transfers and mobility,

as well as operational definitions related to the level of assistance required.

Fall risk. A formal strength assessment of the right lower extremity was unable to be completed

due to the surgeon's protocol, but functional strength was assessed utilizing the Five Times Sit to

Stand Test (FTSTS).29 The FTSTS test provides the ability to quantify functional lower extremity

strength and identify movement strategies that a patient utilizes for transitional movements, as

well as assess balance and fall risk.29 Testing protocols and instructions by the University of

Delaware30 were followed, with the adjustment of having the patient use his upper extremities for

assistance due to the NWB protocol. This test involved having the patient sit with their back

against the chair and performing five sit-to-stands with a FWW placed in front of the patient to

decrease the chances of a fall. The FTSTS test has excellent intrarater reliability (ICC = 0.914-

0.933) and excellent test-retest reliability (ICC = 0.988-0.995) in healthy older adults that did not

utilize an assistive device.29 When comparing the FTSTS test to the Timed Up and Go test (r =

0.64, p < 0.001),29 it has been shown as a valid measure of dynamic balance and functional

mobility. The minimal detectable change (MDC) for the test is within 3.6-4.2 seconds, with the

MCID being 2.3 seconds.29 Lower timed scores indicate a decreased fall risk on this outcome

measure, with age-related norms for the 70-79-year-old population being 12.6 seconds. Scores

13
above 12.6 seconds indicate an increased risk of falling, while scores below this integer indicate

a decreased fall risk. For the geriatric population, scores greater than 15 seconds indicate an

incidence of recurrent falls.31 With increased fatigue and the inability to bear weight through the

RLE, the patient was scored at a high fall risk at the initial examination. See Figure 1 for

additional details on the patient’s outcome measure of the FTSTS.

Clinical Impression #2

The patient presented with deficiencies in strength in bilateral lower extremities,

functional independence with transfers and ambulation, and ability to participate in ADLs while

maintaining weight-bearing precautions. The initial examination was limited by a lack of

communication between the surgeon and the rehabilitation team regarding their protocol, the

patient’s level of pain, and the patient’s level of endurance requiring frequent rest breaks.

Frequent rest breaks taken by the patient during the initial examination may have altered

outcome measurements taken during this physical therapy session. Stair climbing and car

transfers were not assessed during the initial examination due to a lack of communication from

the surgeon regarding what protocol would be in place. A FWW was utilized for ambulation to

increase patient stability and decrease subsequent chances of a fall due to the patient being

categorized as a high fall risk. Despite the list of patient impairments and their past medical

history, the patient had good rehabilitation potential. Positive factors such as family and

community support, as well as increased patient motivation, were potential indicators that the

patient was a good candidate for improved outcomes observed. The patient's initial barriers to

recovery and discharge to their home environment were the inability to put weight through the

RLE, RLE ROM restrictions, and the patient's level of perceived pain limiting their ability to

participate in ADLs. In addition to these factors, the patient’s insurance coverage had been

14
diminished due to the previous stay in subacute rehabilitation while the external fixator was in

place, limiting the amount of days he would be able to participate in subacute rehabilitation

services after the ORIF procedure.

Given these deficits and the patient's goals, a plan of care was developed. The first

physical therapy goal was to have the patient complete safe transfers and ambulation for

household distances prior to discharge to their home environment. The second goal was to

decrease the patient’s fall risk score to diminish the subsequent chances of obtaining a secondary

injury. The third goal was to increase the patient’s endurance by ambulating with the appropriate

assistive device, all while maintaining weight-bearing restrictions. The fourth goal was to

increase RLE AROM with decreased levels of patient-perceived level of pain. The patient’s

stated goals were to return to their home environment safely, improve their independence with

transfers, decrease pain in the RLE, and return to modified independent ambulation. To meet the

patient’s goals and address their deficits, the patient would participate in subacute rehabilitation

physical therapy services 5 times per week for an anticipated length of stay of 2 weeks.

The range and extent of the patient’s deficiencies in pain, endurance, independence,

strength, and functional mobility make them an interesting case report subject. These

deficiencies, combined with the aging process affecting healing rates, also make this patient an

interesting case report subject. Bicondylar tibial plateau fractures are not typical, with no clinical

practice guidelines analyzing the most important interventions or outcome measures to use with

this population, and varying rehabilitation guidelines based on tissue healing factors that impact

the plan of care.

Interventions

15
 The patient participated in inpatient rehabilitation with physical therapy 1 time a day, 5

times per week, with each session lasting 45 minutes to 1 hour. The interventions implemented

to address impairments and work towards functional independence included gait training,

neuromuscular re-education, therapeutic activities, and therapeutic exercise. Given the patient’s

recent surgery, pain rating was assessed at the beginning of each therapy session and monitored

throughout the plan of care. The interventions performed were within the patient’s lower

extremity precautions: RLE ROM restrictions within 0-90° and an NWB protocol that

progressed to TTWB after the fifth session.

It was important to note that the patient was also participating in occupational therapy

sessions to strengthen his upper extremities and improve his participation in ADLs prior to

discharge. Physical therapy sessions were scheduled to occur before occupational therapy

sessions due to limiting patient fatigue. The patient was able to participate in each physical

therapy session without limitations from occupational therapy sessions.

Gait training. In a study conducted by Graham JE et al,32 discharge functional status utilizing the

FIM instrument was used to assess inpatient rehabilitation after a lower extremity fracture. The

study concluded that FIM scores at discharge compared to the initial evaluation had increased in

this patient population. Given the research and post-operative weight-bearing restrictions

provided by the surgeon, a FWW was used during ambulation training. In the first six sessions

while the NWB protocol was being adhered to, the patient performed ambulation with a FWW

and a 3-point gait pattern. The patient was able to ambulate with a FWW utilizing a 3-point gait

pattern and minimal assistance provided by the therapist for 16 feet (FIM score of 1) before

fatigue and pain prevented further participation. The patient required frequent static standing rest

breaks during the 16 feet of ambulation and moderate verbal cueing to adhere to the instructed

16
gait pattern. The patient was able to progress to TTWB after the fifth session as approved by the

surgeon. The patient progressed to include ambulation in the parallel bars to teach the patient the

3-1-point gait pattern for TTWB. The parallel bars were introduced as a progression of gait once

the patient’s weight bearing restriction was lifted due to requiring more LE coordination for the

newly introduced gait pattern technique. The parallel bars allowed the patient to use their upper

extremities during the LLE swing phase in gait while adhering to the RLE TTWB restriction,

requiring less upper extremity muscle activation compared to utilizing a FWW, further

challenging the patient’s endurance. The progression of gait training through assistive device

equipment and weight bearing through the affected lower extremity may have indirectly led to an

increase in FIM scores, as well as an increase in endurance. By the eighth session, the patient

was able to ambulate 40 feet in the parallel bars with modified independence (FIM score of 1)

while requiring zero verbal cueing for adhering to the 3-1-point gait pattern before lower

extremity fatigue prevented further participation.

During the last physical therapy session, it was noted that the patient would be discharged

to their home environment the following day due to insurance coverage purposes. Due to the

time frame of discharging to their home environment so quickly, stair training was introduced to

increase patient safety upon arrival at their home. The patient's home required 3 steps to enter

with a railing on the left, and this environment was replicated in the rehabilitation gym for task-

specific training purposes. The patient was able to tolerate four step-ups/downs utilizing a step-

to-pattern during the last session, requiring moderate assistance (FIM score of 3) from the

therapist. At discharge, the patient was met at their home to assist with stair climbing and home

environment modification. The patient required moderate assistance to ascend four steps safely

to enter their home. Moderate assistance was applied by the therapist with a gait belt around the

17
patient’s lower abdominal area. No losses of balance were observed during stair training, with

the patient being able to maintain their center of mass within their base of support while adhering

to the TTWB protocol.

Neuromuscular reeducation. Wu Y et al33 conducted a study aimed to investigate the effects of

transcutaneous electrical acupoint stimulation (TEAS) combined with proprioceptive

neuromuscular facilitation (PNF) on postural stability, muscle strength, and pain in patients with

tibial plateau fractures. The study concluded that PNF training could improve dynamic postural

stability and relieve pain at 3 weeks; however, TEAS combined with PNF training led to more

effective results in muscle strengthening at 6 weeks post-intervention. Given the research and

MMT strength grades of the contralateral lower extremity, neuromuscular reeducation

interventions were performed to improve the strength of the LLE. The application of TEAS was

not utilized for this patient due to this rehab setting not having the proper equipment for proper

application. Incorporating PNF techniques helps to increase coordination, irradiation, or

overflow to the contralateral lower extremity musculature, as well as strength.34 For the first

session, a PNF technique called rhythmic initiation was introduced to the patient’s LLE.

Rhythmic initiation is a PNF technique used to move the patient's extremity through the desired

movement using PROM, active assisted range of motion (AAROM), and AROM.34 Rhythmic

initiation was performed passively by the examiner into the LLE flexion pattern (hip flexion, hip

adduction, hip external rotation) to give the patient an understanding of this desired movement.

The patient was able to tolerate one set of 20 repetitions before fatigue prevented further

participation. This exercise progressed after two sessions, changing PNF techniques from

rhythmic initiation to dynamic reversals. The dynamic, or slow, reversal technique is a PNF

pattern used to build endurance and strengthen the weaker musculature of the targeted extremity.

18
The dynamic reversal technique is based on Sherrington’s principle of successive induction,

stating that “immediately after the flexor reflex is elicited, the excitability of the extensor reflex

is increased.”35(p26) It involves applying manual resistance throughout the entire flexion and

extension PNF patterns, a progression from the passive rhythmic initiation technique used in

previous sessions. By the eighth session, the patient was able to tolerate three sets of 20

repetitions of LLE flexion and extension dynamic reversal exercises before endurance limited

further participation.

Therapeutic activities. The use of neuroplastic principles in therapeutic interventions was

examined in an article by Marsh E36 This article explained how important neuroplasticity is for

the rehabilitation process in all populations. Neuroplasticity describes the “ability of the human

brain to adapt to environmental pressure, experiences, and challenges of daily life.”36(p1) A few

neuroplastic principles include use it or lose it, specificity, and saliency.36 The concept of use it

or lose it refers to the failure to drive specific brain functions which can lead to functional

degradation.37 Specificity states that “the nature of the training experience dictates the nature of

plasticity.”37(p227) Saliency means that the intervention must be engaging, relevant, and

meaningful to the patient for true neuroplasticity to occur.37 Saliency was the primary

neuroplastic principle used when developing the plan of care. Sit-to-stands were an important

aspect of each therapy session to improve patient independence prior to discharge from subacute

rehabilitation. Moving from sitting to standing is an important aspect of everyone’s life and is

required for many functional activities such as getting into and out of a chair/car. Assessing and

performing a sit-to-stand exercise also contributes to increasing lower extremity knee and hip

ROM, lower extremity quadriceps and hamstrings strength, as well as promoting the proper

posture for biomechanical purposes.48 The FTSTS outcome measure was utilized to assess fall

19
risk due to its excellent reliability, with sit-to-stands being incorporated into the plan of care to

decrease the chances of the subject obtaining a subsequent fall.29 Each session included sit-to-

stands to improve the overall FTSTS score and decrease their fall risk. In the first three therapy

sessions, the patient was able to tolerate two sets of five sit-to-stands before pain and fatigue

limited further participation. In the following four sessions, the patient progressed to completing

three sets of five sit-to-stands with rest breaks taken between sets.

The patient emphasized that one of their goals was to increase their independence with

bed mobility transfers in their home environment. The transfers that were assessed were supine

to sitting at the edge of the bed (EOB) and sitting EOB to lying supine. FIM scores were

assessed at initial examination, after week 1, and at discharge. The patient required moderate

assistance (FIM score of 3) with these transfers, exhibiting symptoms of increased pain during

the performance. Incorporated into the plan of care was transfer training utilizing actions of log

rolling and momentum from weight shifting and gravity for increased independence. Before each

session, the patient was met in their hospital bed where they performed 10 repetitions of rolling

to their right and utilizing momentum from their upper torso and gravity for salient purposes. At

first, the patient required moderate assistance from the therapist to protect the affected RLE from

adhering to their ROM restrictions. As the plan of care progressed and the patient experienced

less pain, this activity was progressed after the fifth session to promote rolling coupled with

transferring to sitting at the EOB. Combining these transfers of bed mobility allowed for the

patient to utilize more of his momentum prior to participating in the therapy session.

At the end of week 1, the patient was being transported by his stepson to his referring

physician for a post-surgical assessment. Due to the patient still experiencing pain with

ambulation, the examiners wanted to replicate this environment that they would be participating

20
in. The same vehicle would be used for the physician referral and discharge to their home

environment. The car was brought to the rehabilitation unit front entrance where the examiner

would assist the patient into the vehicle. The patient was transported to the vehicle in a standard

wheelchair to prevent lower extremity fatigue prior to the transfer. Upon arrival, the patient

performed a sit-to-stand independently to a FWW and a stand pivot transfer with supervision

from the examiner. The patient was educated to perform a swing pivot transfer while the

examiner provided moderate assistance (FIM score of 3) to the RLE to adhere to ROM

restrictions dictated by the surgeon. Upon return, the patient was able to transfer out of the car

with the same level of assistance provided by the examiner before.

Therapeutic exercise. Iliopoulos E et al38 conducted a systematic review of literature focused on

post-operative rehabilitation of patients that sustained a tibial plateau fracture. It was concluded

that early ROM exercises and early weight bearing should be encouraged to improve patient

outcomes and that immobilization does not seem to provide any benefit in the recovery timeline.

Given the patient’s debilitated status, research, and extended subacute rehabilitation stay,

therapeutic exercises were included in the plan of care. A few of the primary focuses for this

patient in subacute rehabilitation was to improve lower extremity strength, endurance, and

independence prior to discharge to their home environment. To address these deficits, PROM

exercises of the RLE were an important aspect of every treatment session. During the initial

evaluation, no exercises were completed due to a lack of communication from the surgeon and

their protocol. For the first five sessions after the initial evaluation, the patient was fitted with the

knee brace and PROM exercises into right knee flexion and extension were provided by the

therapist. The patient was encouraged to verbalize feedback regarding pain levels during passive

motion of the right knee. Rest breaks were taken in supine between sets due to the patient's level

21
of perceived pain. These PROM exercises were performed within a ROM that did not exceed an

8/10 on the NPRS, as well as within the ROM where the knee brace was set. During the second

session, the therapist was able to passively flex and extend the right knee within a minimal

PROM for 30 seconds before the patient required a rest break due to pain and fatigue. After five

sessions with the knee brace still applied, the therapist was able to passively flex and extend the

right knee within a greater PROM for a total of 3 minutes before the patient required a rest break

due to fatigue and pain.

Lower extremity exercises were performed in standing within a set of parallel bars to

increase patient stability as well as decrease the weight-bearing of the affected RLE. This

included hip flexion, hip abduction, and hip extension AROM exercises of the RLE with no

resistance other than gravity. Exercises incorporating the hip were introduced to increase the

strength of bilateral lower extremities while decreasing stress on the surgical site. AROM

exercises of the RLE were completed in standing due to not allowing AROM of the LLE in

standing, which would require full weight bearing through the affected RLE. The patient was

able to perform 10 repetitions in each osteokinematic direction during the second session,

progressing to be able to complete three sets of 15 repetitions without a rest break by discharge.

While the patient was in the supine position, ankle dorsiflexion and plantarflexion AROM

exercises were performed to increase circulation in both lower extremities. Increasing circulation

was an important aspect during interventions due to the patient's debilitated status and post-

surgical precautions of obtaining deep vein thrombosis (DVT). The patient completed 40

repetitions of ankle dorsiflexion and plantarflexion before each session, helping promote an

increase in AROM while decreasing susceptibility to obtaining a DVT.

22
 For the final two sessions, the knee brace was withheld during exercise due to the

surgeon allowing AROM of the knee into flexion and extension with gravity resistance applied,

as well as progressing the weight-bearing restriction of NWB to TTWB of the affected RLE.

Long arc quadricep (LAQ) exercises were completed with the patient sitting at the edge of the

table within a pain-free AROM. LAQ exercises include having the patient flex and extend their

right knee against gravity. The patient was encouraged to perform this exercise at a slower rate to

increase the eccentric strength of the quadriceps muscles, an important aspect of ambulation.

Eccentric control and strength of LE musculature is necessary during gait to allow for shock

absorption and support of body weight against gravity.49 The therapist was closely guarding the

affected lower extremity due to the patient experiencing AROM without the knee brace for the

first time. The patient was hesitant during the first session of applying this exercise, only

completing three repetitions before fatigue and pain prevented further continuation. By the last

session and with reassurance from the examiner, the patient was able to complete 20 repetitions

of LAQs with the affected RLE before fatigue and pain prevented further participation. Allowing

the patient to actively move their affected lower extremity against gravity helped promote an

increase in strength while also increasing ROM. As the patient became comfortable without the

knee brace being applied, they were able to complete more repetitions and move through a wider

range of motion compared to when the knee brace was applied.

After the third session with physical therapy, the patient verbalized soreness in the left

hip after ambulation and weight-bearing. While in supine, the examiner passively flexed and

adducted the patient’s left hip, noting a limitation in the amount of range that was available in

this osteokinematic direction. The patient was taught a static stretch of the piriformis muscle, an

important lateral rotator and abductor of the lower extremity, to try and improve the symptoms

23
associated with soreness. This involved the patient lying supine, flexing the left hip towards their

chest, and adducting the lower extremity towards the contralateral shoulder. This was performed

by the patient for 3 sets of 30-second holds for a total end range time (TERT) of 90 seconds. The

patient was educated to stretch for a total of 90 seconds when stretching a muscle, with literature

supporting increased muscle length associated with this time spent at the muscle’s total end

range.39 The patient completed this stretch after returning to their hospital bed after each session

to decrease symptoms of soreness in the weight-bearing lower extremity.

Outcomes

The patient was able to meet all physical therapy and personal goals upon discharge from

subacute rehabilitation. The patient stated that they were participating in-home therapy sessions

starting in 2 days to improve his strength, independence, ambulation of household and

community distances, and participation in ADLs/IADLs of cooking and cleaning. The patient

participated in a total of 8 physical therapy sessions over 13 days of subacute rehabilitation stay.

Active range of motion

Overall, the patient exhibited increases in AROM of the RLE into knee flexion and extension

while having decreased levels of perceived pain. By discharge, the patient was able to actively

flex their right knee in a range of 12°-79°, and actively extend their right knee to 12° of flexion.

See Table 2 for further AROM measurements of the right lower extremity. The difference

between utilizing the parallel lines method versus the standard goniometry procedure is that

anatomical landmarks are not used as heavily. The parallel lines method utilizes body segments,

aligning the indicator and reference arms in a parallel fashion compared to the body segments

that are being measured, and the fulcrum is placed at the axis of rotation. The MDC for knee

goniometric measurements utilizing a goniometer and the standard protocol for measurement

24
was found to be 10°.50 Due to not having MDC or MCID statistics for the parallel lines method

of measuring ROM, it is unclear if this patient had a truly significant difference in measurements

at discharge compared to initial examination. However, an increase was observed in both knee

flexion and knee extension AROM throughout the plan of care with this patient. These findings

suggest that therapeutic exercise may be beneficial to incorporate into a plan of care when

attempting to increase the AROM of a joint. The improvements in AROM of the knee has been

shown to increase functional mobility in regards to standing, walking, ascending/descending

stairs, and improved participation in more ADL’s.51

Strength

The strength of the LLE demonstrated improvements from the initial examination compared to

discharge. See Table 4 for LLE strength measurements throughout the plan of care. At discharge,

improvements were made in left hip flexion and hip abduction to 4/5, with all other MMT scores

being unchanged. MDC and MCID data has not been established for this patient population to

date utilizing manual muscle testing; however, an increase in strength of the LLE was observed

throughout his plan of care. A systematic review concluded that in order to see a true change in

MMT, the score must change by at least a full grade.52 These findings suggest neuromuscular re-

education PNF techniques, combined with therapeutic exercise, may be beneficial to incorporate

into a plan of care to increase the strength of the unaffected lower extremity with ROM and

weight-bearing restrictions of the affected lower extremity. Improving strength of the

contralateral LE helped improve patient mobility and endurance, further increasing the patient’s

ability to participate in functional ADLs.

Pain.

25
This measurement was assessed at the start of each session over the 8 total visits in subacute

rehabilitation during physical therapy. Throughout the patient’s stay in subacute rehabilitation,

NPRS scores decreased at discharge (5/10) when compared to the initial evaluation (7/10). The

MCID for the NPRS is 1.3 points,26 with the patient scoring 2 points lower when comparing

sessions. These findings suggest that physical therapy interventions including therapeutic

activities and therapeutic exercise focused on improving PROM/AROM of a joint may help

decrease levels of perceived pain for patients that have suffered a fracture of the lower extremity.

Transfers

The patient demonstrated improvements in FIM scores through the following transfers: the

supine to sitting EOB transfer, the sitting EOB to supine transfer, the stand pivot transfer, and the

car transfer when tracked over the plan of care. At the initial examination, the patient scored at

moderate assistance in the supine to sitting EOB transfer, the sitting EOB to supine transfer, and

the stand pivot transfer. These transfers exacerbated symptoms of pain in the RLE during the

initial examination. The car transfer was assessed at the end of week 1, while the patient required

moderate assistance from the therapist and had increased pain levels during the activity. By

discharge, the patient was categorized as independent with the supine to sitting EOB and the

sitting EOB to supine transfer, modified independence with the stand pivot transfer, and minimal

assistance with the car transfer. No increase in pain was verbalized by the patient at discharge for

these transfers.

The FIM was used in a study conducted by Graham JE. et al,32 with the examiners

concluding a 3.6-point difference observed in FIM scores from initial examination compared to

discharge. This case subject observed a 3.67-point difference in FIM scores from the initial

examination compared to discharge with transfers that were completed at both sessions

26
excluding ambulation, results similar to this study. At the initial examination, the patient was

able to ambulate 16 feet (FIM score of 1) with a FWW and minimal assistance provided by the

examiner to adhere to NWB restrictions with frequent static standing rest breaks. By discharge,

the patient was able to ambulate 40 feet within the parallel bars (FIM score of 1) and a TTWB

restriction with no rest breaks due to fatigue. Although the patient did not meet the MDC for

FIM scores of locomotion, the patient was able to ambulate for increased distance, as well as

able to bear weight through his RLE. These findings suggest that therapeutic activities combined

with therapeutic exercise may be beneficial for improving functional independence with the

supine to sitting EOB transfer, a sitting EOB to supine transfer, a stand pivot transfer, a car

transfer, and with ambulation. See Table 1 for additional details on the patient’s FIM score for

transfers and mobility, as well as operational definitions related to the level of assistance

required.

Fall risk.

The patient’s initial examination score of the FTSTS was recorded at 93.3 seconds, indicating a

high fall risk. In the 8th physical therapy session, the patient was recorded at 26.8 seconds,

indicating a high fall risk when compared to the healthy geriatric population. The MDC for the

FTSTS is 3.6-4.2 seconds,29 indicating a significant difference was shown. These findings

suggest task specificity through therapeutic activities may be beneficial for improving scores

through the FTSTS outcome measure. The patient was still categorized as a high fall risk at

discharge, but the combination of task-specificity with therapeutic activity helped move the

patient towards a lower fall risk compared to at initial examination.

Discussion

27
 The purpose of this case report was to describe the impact of physical therapy

interventions on improving independence for a geriatric patient status-post ORIF of a bicondylar

tibial plateau fracture prior to discharge home from subacute rehabilitation. During occupational

therapy sessions, the patient focused on ADL/IADL training, self-grooming, and upper extremity

strengthening through therapeutic exercise. Physical therapy interventions included gait training,

neuromuscular reeducation, therapeutic activities, and therapeutic exercise.

The patient’s improvement in the FTSTS test is consistent with many research studies

that have been conducted with the geriatric population. In a randomized control trial conducted

by Ghahramani M et al,40 the examiners compared the older population to the younger population

in terms of variability with the FTSTS test. The results of this study “yielded a sensitivity of

85.4% and a specificity of 83.3% in recognizing older fallers from older non-fallers and a

sensitivity and specificity of 86.7% and 85.7% respectively in recognizing older multiple-fallers

from other older participants.”40(p194) The authors concluded that variability analysis of the FTSTS

transition has the potential to be used for fall risk analysis in older adults. These results help

improve the efficacy of the FTSTS and its use within the geriatric population for determining fall

risk potential. Sit-to-stands were incorporated into the plan of care not only to decrease the

patient’s fall risk, but to increase the patient’s confidence with this functional skill. This exercise

allowed for improvements in the FTSTS outcome measure and increased the patient’s confidence

level in returning to his home environment safely.

Improvements in the FIM and level of assistance needed to complete these activities is

consistent with current research. Graham JE et al32 observed large differences in FIM scores at

discharge compared to the initial evaluation in the inpatient rehabilitation setting for patients that

sustained a lower extremity fracture. Although this study included lower extremity fractures that

28
differed from the case subject’s, it can be inferred that similar outcomes may be observed due to

weight bearing being affected. In this study among fracture patients, a 3.6-point difference in

FIM score was observed throughout their stay in inpatient rehabilitation. Using only the FIM

subjects that were tested at both initial examination and at discharge excluding ambulation, this

case report patient scored at a 3.67-point difference from initial examination until discharge. The

patient was able to complete these transfers with less pain compared to initial examination, with

pain levels not being assessed in this study. The patient was unable to improve his FIM score

during ambulation due to the distance requirements necessary for this change to be seen.

Although the patient was not able to improve his FIM score for locomotion, the patient was able

to ambulate with less pain at an increased distance compared to the initial examination. This

subsection of the FIM has limitations for certain populations, not taking into account pain, gait

technique, or tissue healing properties.

The patient’s improvements in the NPRS score for levels of perceived pain are consistent

with the findings of Aghamiri SM et al.41 The authors examined differences in pain levels

between the geriatric and pediatric population suffering a tibial plateau fracture. They concluded

that visual analogue scale (VAS) scores for pain were not significantly different between both

groups (P>0.05).41 With these results, as well as other measures looking at ROM and quality of

life, they concluded that increasing age did not affect the surgical outcomes after sustaining a

tibial plateau fracture. This case report subject is slightly different than the population examined

by Aghamiri SM et al,41 but one can infer that similar outcomes may have been observed. The

VAS is different from the NPRS, using the patient’s facial expressions to grade pain subjectively

instead of asking the patient to provide an objective number. The case report subject was able to

meet the MCID of 1.3 points,26 scoring 2 points lower at discharge compared to initial

29
examination. The patient was taking oxycodone and acetaminophen to help decrease symptoms

of pain, a potential limitation to comparing it to the study conducted by Aghamiri SM et al;41

however, this study did not provide details on this population's medication records or dosages

associated with them.

The patient’s motivation to return to their home environment and become more

independent with their daily life was a factor that contributed to the patient’s progress in physical

therapy through subacute rehabilitation. Other positive factors that contributed to the patient’s

success in therapy were his family support, support from the interdisciplinary team, and having

an independent lifestyle prior to the injury sustained. The patient’s stepson had previously

participated in physical therapy services due to a vertebral injury and understood the importance

of rehabilitative services and their impact on the return to an independent lifestyle. The patient

had other family members that lived close to the area as well that would be helping with

ADLs/IADLs of grocery shopping, transportation to and from their primary care provider

appointments, as well as with cooking and cleaning. The interdisciplinary team composed of

nursing, pharmacy, case managing, and rehabilitation was also a contributor to increasing

independence prior to discharge to their home environment. The interdisciplinary team and

community allowed rehabilitation therapists to complete a home environment evaluation. This

evaluation included moving furniture to decrease fall risk, recommendations on how to transfer

between rooms and surfaces, as well as removal of objects that may inhibit the patient’s

functional mobility. Communication between physical therapy and occupational therapy was

conducted before each session to establish if the plan of care was effectively translating to a

positive increase towards their goals through both disciplines. In a study conducted by Jennifer

Barnes42 examining how interdisciplinary communication affects patient outcomes, it was shown

30
that 80% of respondents reported that utilizing the patient’s whiteboards would significantly

improve communication, assist in prioritizing their day, and allow for better time management.

Lastly, the patient’s level of independence prior to sustaining the bicondylar tibial plateau

fracture played a role in the positive outcomes observed. The patient did not have a prior history

of osteoporosis which can play a role in bone tissue healing and formation due to his active

lifestyle. Piat M et al43 stated how family members and friends are primary support networks for

an individual and the impact they play on someone’s mental and physical health. The authors

concluded that having positive support networks led to overall greater improvements in mental

and physical health compared to individuals that did not.43

This case report subject is different from populations studied by previous research due to

multiple factors. The patient was not able to bear weight through the RLE for a large part of his

stay in subacute rehab. Wolff’s law states that bone reacts to the stresses placed upon it, meaning

that if a bone is subjected to a heavier load, it will reconstruct itself to accommodate for the

change in weight.44 The patient was not able to bear weight through the RLE, which according to

Wolff’s law, may have affected his body's ability to produce osteoblast formation. In addition to

this, the patient had developed cellulitis around the superior aspect of his external fixator prior to

the surgery, suppressing his immune system's ability to fight off infection. The patient suffered

an injury that affects less than 1% of the population,1 making this subject difficult to compare to

other populations. This injury affected the patient’s ability to bear weight through the RLE

without a drastic increase in pain, as well as perform AROM exercises without this increase in

pain level. In a study conducted by Williamson et al45 examining weight bearing after tibial

plateau fractures, the authors concluded that immediate postoperative full weight bearing does

not affect the fixation or cause articular collapse up to three months after surgery. Thus, they

31
recommended that patients may fully bear weight immediately after surgical stabilization of the

tibial plateau.45 Pain was a possible barrier to observing improved patient outcomes as well,

contributing to overall fatigue and participation in therapy sessions. Pain has been investigated as

one of the primary barriers to incorporating physical activity in the patient population,46 which

has the potential to lead to other complicating factors affecting an individuals daily life. Lastly,

the patient’s insurance coverage did not allow the patient to have increased visits through

subacute rehabilitation services to continue working on improving functional independence.

These factors, as well as ones stated previously, may have been potential barriers to achieving

more improved patient outcomes.

Future research should look at patient status-post lower extremity fracture ORIF with

weight bearing protocol variabilities. Many surgeons use different weight-bearing protocols after

a procedure like an ORIF,10,11 with variability based on the surgeon's clinical reasoning behind

what protocol to put in place. Having an established protocol to follow the day of the

examination after a bicondylar tibial plateau fracture may help rehabilitation services in their

ability to implement research-supported interventions for this population. Based on results shown

with this case report subject and research studies examining this patient population, it is

recommended that a TTWB restriction may be implemented immediately after an ORIF

procedure of the tibial plateau. The effects of bracing versus not bracing the lower extremity

after an ORIF have not been studied vastly in current research, which should be considered in

future research. If patients have improved outcomes through physical therapy interventions with

a ROM restriction, or vice versa if they have detrimental outcomes with a ROM restriction, it

would be important to include it in a protocol for rehabilitation services. Finally, future studies

should look at the frequency and duration of physical therapy interventions for the population of

32
patients suffering from a bicondylar tibial plateau fracture. Currently, there are no research

articles or clinical practice guidelines examining the effects of these dosages through physical

therapy services. Frequency of physical therapy sessions may have impacted the patient’s ability

to improve his final outcomes of ROM and endurance, and should be studied to include how

more or less physical activity affects the overall function of the knee joint after a bicondylar

tibial plateau fracture. It is important for each clinician to design a plan of care that is specific to

the individual and their impairments, but with no clear clinical practice guidelines for this

population, it is difficult to provide research-supported interventions that lead to the best-

reported patient outcomes for maximizing functional independence.

33
References

1. Mthethwa J, Chikate A. A review of the management of tibial plateau fractures.

Musculoskelet Surg. 2018;102(2):119-127.

2. Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based

Epidemiology of Tibial Plateau Fractures. Orthopedics. 2015;38(9):e780-6.

3. Meling T., Harboe K., Søreide K.: Incidence of traumatic long-bone fractures requiring
in-hospital management: a prospective age- and gender-specific analysis of 4890
fractures. Injury 2009; 40: 1212-1219

4. MacKenzie E.J., Bosse M.J., Kellam J.F., Pollak A.N., Webb L.X., Swiontkowski M.F.,
et. al.: Early predictors of long-term work disability after major limb trauma. J Trauma
2006; 61: 688-694.

5. MacKenzie E.J., Jones A.S., Bosse M.J., Castillo R.C., Pollak A.N., Webb L.X., et. al.:
Health-care costs associated with amputation or reconstruction of a limb-threatening
injury. J Bone Joint Surg Am 2007; 89: 1685-1692.

6. Malik S, Herron T, Mabrouk A, Rosenberg N. Tibial Plateau Fractures. In: StatPearls.

Treasure Island (FL): Publishing; 2022.

7. Rozell JC, Vemulapalli KC, Gary JL, Donegan DJ. Tibial Plateau Fractures in Elderly
Patients. Geriatr Orthop Surg Rehabil. 2016;7(3):126-134.
doi:10.1177/2151458516651310.

8. Verona M, Marongiu G, Cardoni G, Piras N, Frigau L, Capone A. Arthroscopically

assisted reduction and internal fixation (ARIF) versus open reduction and internal
fixation (ORIF) for lateral tibial plateau fractures: a comparative retrospective study. J
Orthop Surg Res. 2019;14(1):155.

9. What is an open reduction/internal fixation surgery? Orthopedic Specialists of SW

Florida. https://www.osswf.com/blog/2020/december/what-is-an-open-reduction-internal-
fixation-surg/. Published 2020.

10. Crall T, White B. Rehabilitation guidelines for tibial plateau fracture - mammoth ortho.
Mammoth Ortho Institute. https://www.mammothortho.com/pdf/tibial-plateau-fracture-
crall.pdf. Published 2016.

11. Rubin A. Standard of care: Tibial Plateau fracture - Brigham and Women's Hospital.
https://www.brighamandwomens.org/assets/bwh/patients-and-families/rehabilitation-
services/pdfs/knee-tibia-plateau-fracture.pdf. Published 2007.
12. Henkelmann R, Schneider S, Müller D, Gahr R, Josten C, Böhme J. Outcome of patients
after lower limb fracture with partial weight bearing postoperatively treated with or
without anti-gravity treadmill (alter G®) during six weeks of rehabilitation - a protocol of
a prospective randomized trial. BMC Musculoskelet Disord. 2017;18(1):104. Published
2017. doi:10.1186/s12891-017-1461-0.

13. AlterG® anti-gravity treadmill™ - redefine what's possible. AlterG, Inc. 48368 Milmont
Dr., Fremont, CA 94538. https://alterg.com/. Published 2022.

14. Thewlis D, Fraysse F, Callary SA, et al. Postoperative weight bearing and patient
reported outcomes at one year following tibial plateau fractures. Injury. 2017;48(7):1650-
1656. doi:10.1016/j.injury.2017.05.024.

15. Chauhan A, Slipak A, Miller MC, Altman DT, Altman GT. No Difference Between
Bracing and No Bracing After Open Reduction and Internal Fixation of Tibial Plateau
Fractures. J Am Acad Orthop Surg. 2018;26(6):e134-e141. doi:10.5435/JAAOS-D-16-
00021.

16. Osteoporosis in aging. National Institutes of Health.

https://newsinhealth.nih.gov/2015/01/osteoporosis-aging. Published 2017.

17. Campion JM, Maricic MJ. Osteoporosis in men. American Family Physician.
https://www.aafp.org/pubs/afp/issues/2003/0401/p1521.html#:~:text=About%204%20to
%206%20percent,meeting%20diagnostic%20criteria%20for%20osteoporosis). Published
2003.

18. Brandi ML, Collin-Osdoby P. Vascular biology and the skeleton. J Bone Miner Res.
2006;21:183–192.

19. Raj M, Gill S, Rajput A, Singh KS, Verma KS. Outcome Analysis of Dual Plating in
Management of Unstable Bicondylar Tibial Plateau Fracture - A Prospective Study.
Malays Orthop J. 2021;15(3):29-35. doi:10.5704/MOJ.2111.005.

20. Rask-Madsen C, King GL. Vascular complications of diabetes: mechanisms of injury and
protective factors. Cell Metab. 2013;17(1):20-33. doi:10.1016/j.cmet.2012.11.012.

21. Loubert PV, Andraka JA, Conine E,Cruzan N, Peltz M. (2017). Clinical Range of Motion
Assessment. 1st ed. Toronto, ON: Top Hat Monacle.
22. Reese NB. Muscle and Sensory Testing. Third ed. St. Louis, MO: Elsevier; 2020.

23. Manual Muscle Test. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-

measures/manual-muscle-test#musculoskeletal-conditions. Published 2020.

24. Mezack R, Torgerson W. Numeric Pain Rating Scale (NPRS).

25. Siemann I. How mcgill invented pain: 1970s pain scale still used today. The McGill
Tribune. https://www.mcgilltribune.com/sci-tech/how-mcgill-invented-pain-1970s-pain-
 scale-still-used-today-012417/#:~:text=Over%2040%20years%20ago%2C
%20McGill,analyze%20the%20condition%20of%20patients. Published 2017.

26. Numeric pain rating scale. Shirley Ryan AbilityLab.

https://www.sralab.org/rehabilitation-measures/numeric-pain-rating-scale. Published
2013.

27. Granger CV, Hamilton BB, Zielezny M, Sherwin FS. Advances in functional assessment
in medical rehabilitation. Topics in Geriatric Rehabilitation. 1986;1(3):59–74.

28. Functional independence measure. Shirley Ryan AbilityLab.

https://www.sralab.org/rehabilitation-measures/functional-independence-measure#older-
adults-and-geriatric-care. Published 2015.

29. Five Times Sit to Stand Test. Physiopedia.

https://www.physio-pedia.com/Five_Times_Sit_to_Stand_Test. Published 2021.

30. 5x sit-to-stand test (5XSST) - thompson health. University of Delaware.

https://www.thompsonhealth.com/Portals/0/_RehabilitationServices/PT%20Mgmt%20of
%20Knee/5XSST_handout.pdf.

31. Buatois, S., Perret-Guillaume, C., et al. (2010). "A simple clinical scale to stratify risk of
recurrent falls in community-dwelling adults aged 65 years and older." Phys Ther 90(4):
550-560.

32. Graham JE, Deutsch A, O'Connell AA, Karmarkar AM, Granger CV, Ottenbacher KJ.
Inpatient rehabilitation volume and functional outcomes in stroke, lower extremity
fracture, and lower extremity joint replacement. Med Care. 2013;51(5):404-412.
doi:10.1097/MLR.0b013e318286e3c8.

33. Wu Y, Zhou J, Zhu F, Zhang M, Chen W. The effects of pain relief on proprioception
and muscle strength for tibial plateau fractures: A randomized controlled trial [published
online ahead of print, 2022]. Musculoskelet Sci Pract. 2022;62:102658.
doi:10.1016/j.msksp.2022.102658.

34. Physiopedia contributors. Neurology treatment techniques. Physiopedia.

https://www.physio-pedia.com/Neurology_Treatment_Techniques#:~:text=Rhythmic
%20Initiation%3A%20Begins%20with%20the,finally%20active%20range%20of
%20motion. Published 2022.

35. GD, Victoria et Al (2013). The PNF (Proprioception Neuromuscular Facilitation)

Stretching Technique – A Brief Review. Science, Movement and Health, Vol. XIII,
ISSUE 2 supplement, 2013, 13 (2), 623-62.

36. Marsh E. Neuroplasticity... why is it important to rehabilitation? . Burt.

https://medical.barrett.com/blog/2020/10/19/neuroplasticity. Published 2021.
37. Kleim, Jeff & Jones, Theresa. (2008). Kleim JA, Jones TAPrinciples of experience-
dependent neural plasticity: implications for rehabilitation after brain damage. J Speech
Lang Hear Res 51:S225-S239. Journal of speech, language, and hearing research :
JSLHR. 51. S225-39. 10.1044/1092-4388(2008/018).

38. Iliopoulos E, Galanis N. Physiotherapy after tibial plateau fracture fixation: A systematic
review of the literature. SAGE Open Med. 2020;8:2050312120965316. Published 2020
Oct 14. doi:10.1177/2050312120965316.

39. Page P. Current concepts in muscle stretching for exercise and rehabilitation. Int J Sports
Phys Ther. 2012;7(1):109-119.

40. Ghahramani M, Stirling D, Naghdy F. The sit to stand to sit postural transition variability
in the five time sit to stand test in older people with different fall histories. Gait Posture.
2020;81:191-196. doi:10.1016/j.gaitpost.2020.07.073.

41. Aghamiri SM, Sarzaeem MM, Shahrezaee M, Omidian M, Amouzadeh Omrani F.

Outcomes of Tibial Plateau Fracture Surgical Fixation: a Comparative Study between
Younger and Older Age Groups. Arch Bone Jt Surg. 2021;9(6):647-652.
doi:10.22038/abjs.2021.52884.2629.

42. Barnes, Jennifer J., "Improving Interdisciplinary Communication to Improve Patient

Satisfaction" (2014). Master's Projects and Capstones. 105.

43. Piat M, Sabetti J, Fleury MJ, Boyer R, Lesage A. "Who believes most in me and in my
recovery": the importance of families for persons with serious mental illness living in
structured community housing. J Soc Work Disabil Rehabil. 2011;10(1):49-65.
doi:10.1080/1536710X.2011.546310.

44. Begum J. Wolff's law: A way of understanding how bones change. WebMD.
https://www.webmd.com/osteoporosis/what-is-wolffs-law#:~:text=Wolff's%20Law
%20Applied%3F-,What%20is%20Wolff's%20Law%3F,themselves%20to
%20accommodate%20that%20weight. Published 2021.

45. Williamson M, Iliopoulos E, Jain A, Ebied W, Trompeter A. Immediate weight bearing

after plate fixation of fractures of the tibial plateau. Injury. 2018;49(10):1886-1890.
doi:10.1016/j.injury.2018.06.039.

46. Boutevillain L, Dupeyron A, Rouch C, Richard E, Coudeyre E. Facilitators and barriers

to physical activity in people with chronic low back pain: A qualitative study. PLoS One.
2017;12(7):e0179826. Published 2017. doi:10.1371/journal.pone.0179826.

47. Ciccone CD. Davis's Drug Guide for Rehabilitation Professionals. F.A. Davis; 2013.
48. Duarte Wisnesky U, Olson J, Paul P, Dahlke S, Slaughter SE, de Figueiredo Lopes V.
Sit-to-stand activity to improve mobility in older people: A scoping review. Int J Older
People Nurs. 2020;15(3):e12319. doi:10.1111/opn.12319

49. Eston RG, Mickleborough J, Baltzopoulos V. Eccentric activation and muscle damage:
biomechanical and physiological considerations during downhill running. Br J Sports
Med. 1995;29(2):89-94. doi:10.1136/bjsm.29.2.89.

50. Hancock, G.E., Hepworth, T. & Wembridge, K. Accuracy and reliability of knee
goniometry methods. J EXP ORTOP 5, 46 (2018). https://doi.org/10.1186/s40634-018-
0161-5.

51. Hyodo K, Masuda T, Aizawa J, Jinno T, Morita S. Hip, knee, and ankle kinematics
during activities of daily living: a cross-sectional study. Braz J Phys Ther.
2017;21(3):159-166. doi:10.1016/j.bjpt.2017.03.012

52. Cuthbert SC, Goodheart GJ, Jr. On the reliability and validity of manual muscle testing: a
literature review. Chiropractic & osteopathy. 2007;15:4.