Professional Documents
Culture Documents
KAI MITHOEFER, MD1 • KAREN HAMBLY, PT, PhD, MCSP2 • DAVID LOGERSTEDT, PT, PhD, MPT, SCS3
MARGHERITA RICCI, MD4 • HOLLY SILVERS, MPT5 • STEFANO DELLA VILLA, MD4
A
cute and chronic injuries of the articular cartilage surfaces of the knee in the athlete frequently occur
of the knee are frequently observed in athletes. A recent in association with other injuries, such as
ligament or meniscal tears, traumatic
systematic review demonstrated an average prevalence of full-
patellar dislocations, and osteochondral
thickness focal chondral defects in 36% of athletes.49 Defects injuries.104 Articular cartilage defects of
were located predominantly in the patellofemoral compartment the femoral condyles have been observed
(37%) and femoral condyles (35%), and less frequently on the tibial in up to 50% of athletes undergoing an-
plateau (25%). Magnetic resonance imaging (MRI) evaluation of terior cruciate ligament reconstruction,
with an increased incidence in female
asymptomatic professional basketball world-class-level soccer players. In addi- athletes.143 Articular cartilage defects
players revealed articular cartilage ab- tion to the rising incidence of such inju- can also develop in the high-impact ath-
normalities in the knee of up to 89% of ries in high-level competitive athletes, the letic population from chronic, pathologic
the players,181 and cartilage injury has increase in recreational participation in joint-loading patterns that result from
been reported to exist in 20% of profes- pivoting sports such as football, basket- joint instability or malalignments.104 Irre-
sional American football players.19 Levy ball, and soccer has been associated with spective of their origin, articular cartilage
et al96 demonstrated an increasing inci- a rising number of sports-related articu- injuries will frequently limit the ability of
dence of chondral injuries over time in lar cartilage injuries in that population.6 the affected athletes to continue partici-
competitive collegiate, professional, and Injuries of the articular cartilage surface pation in their sport and predispose them
to progressive joint degeneration.88
TTSYNOPSIS: Articular cartilage injury is ob-
The limited ability of spontaneous
take into consideration the biology of the cartilage
served with increasing frequency in both elite and repair technique, cartilage defect characteristics, repair following acute or chronic articu-
amateur athletes and results from the significant and each athlete’s sport-specific demands to lar cartilage injury is well documented.77
acute and chronic joint stress associated with optimize functional outcome. Systematic, stepwise The lack of vascularization of articular
impact sports. Left untreated, articular cartilage rehabilitation with criteria-based progression is cartilage prevents the physiologic in-
defects can lead to chronic joint degeneration recommended for an individualized rehabilitation flammatory response to tissue injury and
and athletic and functional disability. Treatment of of each athlete not only to achieve initial return resultant repair. This failure of recruit-
articular cartilage defects in the athletic popula- to sport at the preinjury level but also to continue
tion presents a therapeutic challenge due to the ment of extrinsic, undifferentiated repair
sports participation and reduce risk for reinjury
high mechanical demands of athletic activity. cells combined with the intrinsic inabil-
or joint degeneration under the high mechani-
Several articular cartilage repair techniques have ity for replication and repair by mature
cal demands of athletic activity. J Orthop Sports
been shown to successfully restore articular chondrocytes results in a repair cartilage
Phys Ther 2012;42(3):254-273. doi:10.2519/
cartilage surfaces and allow athletes to return to that is both qualitatively and quantita-
jospt.2012.3665
high-impact sports. Postoperative rehabilitation
TTKEY WORDS: ACI, chondrocytes, microfracture,
tively insufficient. Repetitive loading of
is a critical component of the treatment process
for athletic articular cartilage injury and should OATS the injured articular cartilage, as occurs
in impact and pivoting sports, results in
1
Director, Center for Biologic Joint Restoration, Department of Orthopedics and Sports Medicine, Harvard Vanguard Medical Associates, Boston, MA. 2Lecturer and Director of
Learning and Teaching, Centre for Sports Studies, University of Kent, Medway, UK. 3Postdoctoral Researcher, Department of Physical Therapy, University of Delaware, Newark,
DE. 4Educational and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy. 5Director of Research, Santa Monica Orthopaedic and
Sports Medicine Research Foundation, Santa Monica, CA. Address correspondence to Dr Margherita Ricci, Educational and Research Department, Isokinetic Medical Group, FIFA
Medical Centre of Excellence, Via Casteldebole 8/4, Bologna, Italy 40132. E-mail: m.ricci@isokinetic.com
254 | march 2012 | volume 42 | number 3 | journal of orthopaedic & sports physical therapy
T
and injury of articular cartilage.84 High- reatment of articular carti- technique does not involve regeneration
impact joint loading beyond the capabil- lage injuries in the athletic popu- of a cartilage repair tissue. While im-
ities of the cartilage has been shown to lation has traditionally presented mediate hyaline cartilage restoration is
decrease cartilage proteoglycan content, a significant therapeutic challenge due achieved, bone-to-bone healing of the
increase levels of degradative enzymes, to the limited capacity for spontaneous transferred osteochondral cylinder to
and cause chondrocyte apoptosis.84,100 If repair. However, development of new the surrounding bone is required and
the integrity of the functional weight- surgical techniques has created consid- immediate postoperative rehabilitation is
bearing unit (articular cartilage, menisci, erable clinical and scientific enthusiasm dictated by the biology of the bony heal-
ligaments, muscle) is lost, either through for articular cartilage repair. Based on ing process rather than formation of new
acute injury or chronic microtrauma in the source of the cartilage repair tissue, repair cartilage tissue.
the high-impact athlete, a chondropenic these surgical techniques can generally As an alternative to the use of au-
response is initiated that can include loss be categorized into restorative and re- tologous tissue, osteochondral allografts
of articular cartilage volume and stiff- parative procedures. Restorative proce- are used for treatment of large and deep
ness, elevation of contact pressures, and dures restore articular cartilage without chondral and osteochondral lesions from
journal of orthopaedic & sports physical therapy | volume 42 | number 3 | march 2012 | 255
R
tilage defects of up to 2 to 4 cm2 in size. ehabilitation following carti- thesis.176,184 Similarly, patients with a body
Postsurgical rehabilitation must consider lage repair surgery is a critical mass index (BMI) greater than 30 kg/m2
that cartilage repair after microfracture component of the process of re- may need slower progression during re-
occurs in 3 biologic phases: the clot for- turning the athlete to sports activity. habilitation. Although the relationship
mation phase, repair cartilage formation The focus of the rehabilitation program between BMI and cartilage repair has not
phase, and cartilage maturation phase. for all articular cartilage repair proce- been well established, individuals with
Chondrocyte-Based Cartilage Repair dures is to provide a mechanical envi- BMI greater than 30 kg/m2 have had
Techniques ACI is a 2-step procedure. ronment for the local adaptation and worse outcomes after microfracture.8,125
The first step involves an arthroscopic remodeling of the repair tissue that will Higher BMI is also a risk factor for knee
evaluation and cartilage grafting from an enable the patient to safely return to osteoarthritis98,128 and cartilage degen-
area of the joint that has limited weight the optimal level of function. The cur- eration38,44 and is related to decreased
bearing (usually the intercondylar notch). rent concepts of rehabilitation follow- cartilage volume.17,182 Impact sports can
Chondrocytes are then isolated from the ing cartilage repair in the athlete are result in tremendous biomechanical
harvested cartilage tissue and cultured based on a combination of basic science loads from repetitive joint loading asso-
with a combination of growth factors to data, the surgical techniques currently ciated with impacts, rapid deceleration,
multiply the cells for 3 to 6 weeks. Follow- available, empirical information, and a and frequent cutting and pivoting. These
ing in vitro chondrocyte expansion, the limited number of clinical studies.5,37,39, sports increase the risk of osteoarthri-
chondrocytes are implanted in a second- 45,48,52,62,69,71,72,74,76,92,107,136,147,154,155,190,191
Due tis and can be detrimental to cartilage
ary open procedure. Implantation into to the complex nature of cartilage repair repair.96,153 Kujala et al88 observed that
the defect occurs under a periosteal cover and variable defect characteristics and soccer players and weight lifters had an
that is sutured over the cartilage defect.18 comorbidities, an individualized rehabili- increased risk of developing premature
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gym and in the pool. The last phase of re- the initiation of on-field rehabilitation, recommend that athletes perform the ex-
habilitation takes place on a specialized the patient performs an aerobic fitness ercises at or below their aerobic thresh-
rehabilitation field under the supervision test to identify aerobic and anaerobic old. Athletes are progressed to the next
of rehabilitation specialists. On-field re- thresholds used to personalize the in- phase, when they can perform these drills
habilitation is designed as a sport-specific tensity of each training session based on without pain, swelling, or apprehension.
progression of exercises that allows grad- metabolic training loads. Aerobic and Stage 2. At this stage, circular run-
ual functional recovery of sport-specific anaerobic thresholds are assessed by ning and skipping exercises, advanced
skills, starting with in-line running and an incremental treadmill-running test, proprioception exercises, alternating
jumping and progressing to acceleration starting at 7 km/h, increasing by an in- running and stopping, and lateral slides/
and deceleration drills, pivoting and cut- crement of 2 km/h every 3 minutes until shuffles are introduced (FIGURE 10B). The
ting maneuvers at increasing speeds, and capillary blood lactate concentrations patient also performs light jumps and
incorporation of sport-specific equip- exceed 4 mmol/L.31,152 Aerobic threshold soft landing on sand. Proper technique
ment and movement patterns. is identified by a capillary blood lactate and optimal trunk and lower-limb align-
On-field rehabilitation should consist concentration of 2 mmol/L.50 The heart ment are emphasized through all exer-
of specific exercises and drills, lasting ap- rate that corresponds with the aerobic cises, with particular attention to the
proximately 90 minutes, performed be- threshold is identified as the aerobic use of adequate hip and knee flexion and
tween 3 and 5 times a week (depending threshold training heart rate. Anaerobic controlling for excessive knee abduction.
on the athlete’s activity level) for at least threshold is identified by capillary blood Additionally, the metabolic requirements
8 weeks. A significant aspect of on-field lactate concentration of 4 mmol/L.50 are increased, with athletes performing
rehabilitation is dedicated to aerobic con- The heart rate that corresponds with the tasks between their aerobic and anaero-
ditioning and sport-specific fitness exer- anaerobic threshold is identified as the bic thresholds. Aerobic conditioning is
cises to facilitate the readiness for return anaerobic threshold training heart rate. performed at the aerobic threshold for
to competition at the preinjury level and During each training session, athletes 10 to 15 minutes, and anaerobic condi-
to reduce the risk of reinjury after suc- wear a heart rate monitor to control the tioning is performed for less than 10%
cessful return. Progression is always metabolic intensity of the training. Peri- of the training time. To progress to the
criteria-based, requiring the absence of odic reassessment of metabolic training next phase, the athlete must demonstrate
pain and swelling and the maintenance load is performed to adjust the metabolic proper technique during all drills per-
of full ROM with the increasing activity intensity to improve cardiorespiratory fit- formed at near full speed, without pain,
demands. During this phase, the athlete ness for return to sport. swelling, or apprehension.
should continue strengthening and flex- Stage 1. In the first few sessions, the Stage 3. The aerobic fitness test is re-
ibility exercises in the gym. A recent co- patient walks along a straight line to peated to establish new aerobic and an-
hort study demonstrated that return to gain confidence with the training envi- aerobic thresholds. Additionally, squat
sport after arthroscopic ACI, accelerated ronment, rehabilitation field, and the and countermovement jump tests are
by an on-field rehabilitation program, ground. Initially, a more compliant sur- performed to measure jumping per-
was achieved in 81% of cases with an av- face, such as sand, is used as an effec- formance and lower extremity power.
erage time of return of 10.6 months. 32 tive low-impact method for improving If available, the tests can be performed
On-field Rehabilitation Stages On-field strength and proprioception. Once the on a platform connected to a digital
rehabilitation is divided into 5 stages athlete has become familiar with the timer that records flight and contact
(TABLE 5), each characterized by well- training environment, slow running in a time.109 The athlete performs the squat
defined, progressive, sport-specific exer- straight line is initiated, as well as global jump by jumping from a semisquat po-
cises performed outdoors on a grass field coordination exercises (agility drills) sition without countermovement, and
or indoors on a synthetic field. Prior to (FIGURE 10A). Throughout this phase, we the countermovement jump by allow-
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A
5. Allen MK, Wellen MA, Hart DP, Glasoe WM.
without pain, swelling, or apprehension. rticular cartilage repair in Rehabilitation following autologous chondrocyte
Stage 4. Technical and sport-specific athletes requires effective and du- implantation surgery: case report using an
exercises are initiated, such as kicking rable joint surface restoration that accelerated weight-bearing protocol. Phys-
or hitting a ball, changing direction and can withstand the significant joint stress- iother Can. 2007;59:286-298. http://dx.doi.
org/10.3138/ptc.59.4.286
deceleration, and cutting and pivoting es generated during athletic activity. Sev- 6. Aroen A, Loken S, Heir S, et al. Articular carti-
maneuvers with the ball or other sport- eral surgical techniques can successfully lage lesions in 993 consecutive knee arthrosco-
specific equipment (FIGURE 10D). Athletes restore articular cartilage surfaces and pies. Am J Sports Med. 2004;32:211-215.
also start incorporating rotational com- allow for return to high-impact athlet- 7. Arokoski JP, Jurvelin JS, Vaatainen U, Helminen
HJ. Normal and pathological adaptations of
ponents to the jumping and landing ics after injury. Postoperative rehabilita- articular cartilage to joint loading. Scand J Med
drills. Aerobic threshold conditioning is tion is a quintessential component of the Sci Sports. 2000;10:186-198.
performed for 15 to 20 minutes. Anaero- treatment process for cartilage defects in 8. Asik M, Ciftci F, Sen C, Erdil M, Atalar A. The
bic threshold running is performed less the athlete. To optimize functional out- microfracture technique for the treatment
of full-thickness articular cartilage lesions
than 50% of the training time. Athletes come and the ability to return to sport,
of the knee: midterm results. Arthroscopy.
can progress to the next phase when they cartilage repair rehabilitation in the ath- 2008;24:1214-1220. http://dx.doi.org/10.1016/j.
demonstrate proper technique during all lete has to be adapted to the biology of arthro.2008.06.015
drills performed at full speed, without the surgical repair technique, individual 9. Axe MJ, Snyder-Mackler L. Operative and post-
operative management of the knee. In: Wilmarth
pain, swelling, or apprehension. cartilage defect specifications, and each
MA, ed. Orthopaedic Section Independent Study
Stage 5. During the last stage, the em- athlete’s sport-specific demands. This can Course 15.3: Postoperative Management of
phasis is on improving and intensifying be achieved by a stepwise, phased reha- Orthopaedic Surgeries. La Crosse, WI: APTA Inc;
sport-specific movement patterns, while bilitation approach using criteria-based 2005.
10. Ayotte NW, Stetts DM, Keenan G, Greenway
simulating game-intensive conditions progression of the athlete through the
EH. Electromyographical analysis of selected
(FIGURE 10E). This can be done with con- individual rehabilitation phases, based lower extremity muscles during 5 unilateral
trolled introduction of an opponent for on a thorough understanding of the bio- weight-bearing exercises. J Orthop Sports Phys
one-on-one technical and agility drills. mechanics and biology of cartilage injury Ther. 2007;37:48-55. http://dx.doi.org/10.2519/
jospt.2007.2354
Aerobic conditioning is also conducted and repair. Using these principles and
11. Baker V, Bennell K, Stillman B, Cowan S, Cross-
with more intense and prolonged aerobic close communication between surgical ley K. Abnormal knee joint position sense in
workouts. Aerobic and anaerobic thresh- and rehabilitation teams, return to even individuals with patellofemoral pain syndrome.
old tests and countermovement and demanding high-impact sport and con- J Orthop Res. 2002;20:208-214. http://dx.doi.
org/10.1016/S0736-0266(01)00106-1
squat jump tests are performed to help tinued sports participation can be suc-
cessfully achieved. t
12. Barber SD, Noyes FR, Mangine RE, McCloskey
confirm progress and determine readi- JW, Hartman W. Quantitative assessment of
ness to return to competition. functional limitations in normal and anterior
The progression of exercises during cruciate ligament-deficient knees. Clin Orthop
Relat Res. 1990;255:204-214.
on-field rehabilitation follows the prin-
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@ MORE INFORMATION
Interrater reliability of a clinical scale to assess articular cartilage and volume fraction of
knee joint effusion. J Orthop Sports Phys Ther. subchondral tissue. Osteoarthritis Cartilage.
2009;39:845-849. http://dx.doi.org/10.2519/ 1998;6:400-409. http://dx.doi.org/10.1053/ WWW.JOSPT.ORG
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