3/6/2017 1 The Complex Cases- Rehabilitation of Multi-Ligament Knee Reconstruction & Meniscus Pathology Tyler Opitz, DPT, SCS March 3 rd , 2017 Objectives • Understand basic healing times and to be able to prioritize pathology within rehabilitation continuum. • Gain knowledge of precautions and biomechanics behind specific tissue restrictions and function with rehab tasks. • Utilize rehabilitation principles incorporating criteria based rehabilitation competently and appropriately. • Discuss patient outcomes, expectations, and determine return to play/sport criteria Multi-Ligament Knee Injury • Defined as injury to 2 or more of the 4 major ligaments in the knee (Dywer et al., 2012) • Multi-ligament knee injuries are often associated with knee dislocations – Knee dislocation 0.02% of all orthopaedic injuries (Skendzel et al., 2012) – Invariably results in 3 of 4 knee ligament injury (Fanelli et al., 2005) • 11% of all ligamentous injuries (Bispo et al., 2008) • 98.2% males (Bispo et al., 2008) Knee Dislocation classification Factors • 5 Categroies of dislocation-Direction oriented: – Anterior – Posterior – Lateral – Medial – Rotatory- Anterior-medial & -Lateral, Posterior-medial & lateral • Open vs closed • High energy vs low energy • Dislocated vs subluxed – Complete dislocation may spontaneously reduce – Any triligamentous injury constitutes dislocation • Neurovascular involvement – Fanelli et al., 2005 Classifications • KD-I- Single cruciate torn (ACL or PCL) • KD-II- Bicruciate disruption, MCL/LCL intact • KD-III- Bicruciate disruption, torn MCL or LCL/PLC • KD-IV- ACL, PCL, MCL, LCL torn • KD-V- All ligaments torn with fracture Knee Anatomy
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3/6/2017
1
The Complex Cases- Rehabilitation
of Multi-Ligament Knee
Reconstruction & Meniscus
Pathology
Tyler Opitz, DPT, SCS
March 3rd, 2017
Objectives
• Understand basic healing times and to be able to prioritize pathology within rehabilitation continuum.
• Gain knowledge of precautions and biomechanics behind specific tissue restrictions and function with rehab tasks.
• Utilize rehabilitation principles incorporating criteria based rehabilitation competently and appropriately.
• Discuss patient outcomes, expectations, and determine return to play/sport criteria
Multi-Ligament Knee Injury
• Defined as injury to 2 or more of the 4 major ligaments in the knee (Dywer et al., 2012)
• Multi-ligament knee injuries are often associated with knee dislocations
– Knee dislocation 0.02% of all orthopaedic injuries (Skendzel et al., 2012)
– Invariably results in 3 of 4 knee ligament injury (Fanelli et al., 2005)
• 11% of all ligamentous injuries (Bispo et al., 2008)
• Dislocated vs subluxed– Complete dislocation may spontaneously
reduce
– Any triligamentous injury constitutes dislocation
• Neurovascular involvement– Fanelli et al., 2005
Classifications
• KD-I- Single cruciate torn (ACL or PCL)
• KD-II- Bicruciate disruption, MCL/LCL intact
• KD-III- Bicruciate disruption, torn MCL or LCL/PLC
• KD-IV- ACL, PCL, MCL, LCL torn
• KD-V- All ligaments torn with fracture
Knee Anatomy
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Knee AnatomyMOI
MOI Complications
• Injuries to Popliteal
artery, common fibular
nerve. (Mills et al.,
2004)
– Popliteal injury 4.8%-
65% of time
• High energy injuries
increased incidence
– Fibular nerve injury 20%
of time (Robertson et al.,
2006)
Complications
• DVT
• Compartment syndrome
Regional Interdependence
• Concept of Regional Interdependence is the relationship of adjacent and distant segments have on motion and stability of body parts of seemingly unrelated sections that can contribute to pathology or have an effect on one another. (Wannier et al., 2007)
• New definition:
• Does not limit to musculoskeletal system– “the concept that a
patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s).” (Sueki et al., 2013)
2. Comorbidities with injury (compartment syndrome)
3. Pain level
4. Duration since injury
5. Tissue healing & quality
6. Patient stage of rehab
7. Current level of function and movement quality
8. Patient Goals
9. Outcomes expectations
10. Psychosocial factors
Criteria Based Rehab Principles• *PRECAUTIONS GUIDE PROGRESSIONS*
• Once tissue is at appropriate healing level for activity…• Ability to perform PROGRESSIVE FUNCTIONAL rehab tasks in
sequence determines progression NOT given amount of weeks from surgery
• Example): Just because they are 12 weeks out DOES NOTmean they should advance to plyometrics if they can’t perform a basic squat– Walking without crutches not based on being 4 weeks post op:
• Full quad and hip muscle activation
• Walk without deviations with 2 crutches -> 1 crutch with and without brace.
• Then can walk without brace and crutches
• Functional tasks are a byproduct of doing basic movement patterns properly, NOT a product of TIME!!!
Grzybowski et al., 2015, Wahoff et al., 2014
Car Analogy
• If you have a flat tire, is
it because the tire is
bad or is it because the
alignment was off
and/or the shocks bad
causing the tired to
have abnormal wear.
• Does fixing the tire
solve the problem?
• Be sure to fix the
alignment and treat the
shocks.
Knee Symmetry Model
• Goal is to restore limb symmetry between limbs
• Utilizes subjective and objective measures to
determine when successful rehab has concluded. (Biggs et al., 2009, Kinzer et al., 2010)
– Measures Include:
• ROM
• Strength
• Stability
• Girth
• Subjective questionnaire scores
Rehab Concepts
• Increasing depth of squat increases SHEAR forces on knee joint
• Increased knee extension in closed chain increases COMPRESSIVE loads on knee joint.
• Protect lateral meniscus as has increased translation with knee motion than medial meniscus
• Bone tunneling has increased risk for stress fractures compared to healing of traditional fractures
• Avoid loading maturing reconstructed ligaments even though patient function is improving.
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Joint Reaction Forces
• Knee deviation increases joint reaction forces and shear on cartilage, meniscus and ligamentous lading
• Decreased knee flexion– Decreased
patellofemoral force
– Increased force to hips(J Biomech. 2007; 40(16): 3725-3721)
• Successful completion of functional sport movement assessment(s)– Drop jump catches, single leg lands, change of direction
assessment
• Completion of interval running program– Linear and multi-direction
– Agility drills- Shuttle, T-drill, 3 cone, etc.
• Pain free participation in interval practice and full practice programs
• Participate in simulated game without setbacks
Dynamic Movement Assessment
• Drop jump catches
• Deceleration from run
• Change of direction
running
• Tuck jumps
• SL jumps
• Can utilize:
– Slow motion video
analysis
• Iphone
• Hudl
• Myjump
– Force plate
– Agility test run times
• shuttle run times
• T-test time
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Return to Play Criteria
• Criteria:
– Wait >9 Months
– Within 10% side to side of uninjured limb strength
and hop test scores
– Agility T-test in under 11 seconds
– Performing sports specific conditioning/training
• = significantly reduced risk of re-injury upon RTS
(Grindem et al., 2016, Krytsis et al., 2016)
Rehab at Andrews Institute… With
Andrews
• ALL YOU NEED TO KNOW…
• ALL YOU NEED TO DO…
Outcomes
• Not as consistent as single ligament injuries (aaos.org, 2016)
• 44% had degenerative changes at time of surgery (Wang et al., 2002).
• ACL and PCL reconstruction:
– 100% negative Lachman test, 66% negative posterior drawer, 44% had grade I posterior drawer. (Ohkoshi et al., 2002)
– Fanelli et al., 2005 found 94% negative Lachman, 46% negative posterior drawer.
• 0-139° PROM 100% of knees with 2 stage reconstruction (3 months apart PCL then ACL) for PCL, ACL/MCL or PLC. (Ohkoshi et al., 2002)
• Knee dislocation with lateral side injury: (Kinzer et al., 2010)– 91.3% IKDC score
– 16/17 achieved full knee ROM
– 15/17 achieved >90% knee strength with isokinetic testing
– 13/16 return to sport at same level after surgery
Outcomes
• 23-25% of subjects (mean age 16) sustained 2nd
ACL injury within 12 months upon RTS following ACLR. (Paterno et al., 2014, Grindem et al., 2016, Krytsis et al., 2016)– 29% of patients under age of 20 sustained 2nd ACL
injury within 3 years (Webster et al., 2014)
– 87% female (Paterno et al., 2014)
– 75% sustained 2nd on contralateral knee.
– Young athletes that RTS are 15x more likely to have 2nd ACL injury (Paterno et al., 2012)
• 90% objective stability success rate with PLC surgery (Moulton et al, 2016)
Outcomes
• Return to outcomes vary, are surgery dependent, and are inconsistent due to case by case basis of injury
• ACL, PCL, PLC Outcomes: (Strobel et al., 2006)
– 29.4% “nearly normal stability”
– 58.8% “abnormal stability”
– 11.8% “grossly abnormal”
– Most patients able to recover a functionally stable knee and improved knee function compared to pre-operative measures
– Limitations: Unable to restore normal tibiofemoral kinematics
Rehab Principles
• Restore functional ROM, mobility, and strength
• Don’t forget the THORACIC SPINE
• Progressively overload tissues
• Static -> Dynamic
• Ensure movements are performed with proper joint