2/20/2017 1 The Complex Cases- Rehabilitation of Multi-Ligament Knee Reconstruction Tyler Opitz, DPT, SCS March 4 th , 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 • Classification of knee dislocation is primarily based on the direction the tibia dislocates relative to the femur.9,10 This results in 5 different categories: anterior, posterior, lateral, medial, or rotatory. The anterior- medial and lateral, posterior-medial, and lateral dislocations are classified as “rotatory” dislocation. Other factors to be considered include whether (1) the injury is open or closed, (2) the injury was caused by “high-energy” or “low-energy” trauma, (3) the knee is completely dislocated or subluxated, and (4) there is neurovascular involvement. Furthermore, one should be acutely conscious of the fact that a complete dislocation may spontaneously reduce, and any tripleligamentknee injury constitutes a frank dislocation. • Fanelli et al., 2005 • 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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Multi Lig Knee Presentation - Orthopaedic Research …andrewsref.org/docs/Multi_Lig_Knee_Presentation_Opitz.pdfMulti-Ligament Knee Injury • Defined as injury to 2 or more of the
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2/20/2017
1
The Complex Cases- Rehabilitation
of Multi-Ligament Knee
Reconstruction
Tyler Opitz, DPT, SCS
March 4th, 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 (Fanelliet al., 2005)
• 11% of all ligamentous injuries (Bispo et al., 2008)
• 98.2% males (Bispo et al., 2008)
Knee Dislocation classification
• Classification of knee dislocation is primarily based on the direction the tibia dislocates relative to the femur.9,10 This results in 5 different categories: anterior, posterior, lateral, medial, or rotatory. The anterior-medial and lateral, posterior-medial, and lateral dislocations are classified as “rotatory” dislocation. Other factors to be considered include whether (1) the injury is open or closed, (2) the injury was caused by “high-energy” or “low-energy” trauma, (3) the knee is completely dislocated or subluxated, and (4) there is neurovascular involvement. Furthermore, one should be acutely conscious of the fact that a complete dislocation may spontaneously reduce, and any tripleligament knee injury constitutes a frank dislocation.
• Fanelli et al., 2005
• 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)
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)
Full and adjacent body segment
assessment
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Rehabilitation Considerations
1. Diagnosis/pathology/surgical procedure
2. Severity of tissue damage/invasiveness1. Involved structures- nerve, vascular supply
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 (CBR)
• Progression NOT based on time out from surgery but ability to perform progressive functional tasks
– 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
• No sense in allowing patient to develop bad movement patterns and habits because they are not ready
• Functional tasks are a byproduct of doing basic movement patterns properly, NOT a product of TIME!!!
• 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
Rehabilitation pyramid
Performance
Functional Movement &
Strength
Foundational Movement & Strength
ROM
• PROM
• AROM
Basic Strength
• Against gravity strength
• 5/5 MMT
Function
• Normal Reciprocal Gait
• Step pattern- lumbopelvic dissociation
• Positional activity Tolerance- Quadruped, SL stance, hip hinge
• 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
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)
Y-Balance
• Left to right: anterior Posteriormedial, posterior lateral
• Within 4 cm anteriorly, 6 cm posteriorly
• Composite >85-95% depending on sport
Selective Functional Movement
Assessment (SFMA)• Head-toe movement
assessment
• 4 Categories• FN- Functional Non-painful
• DN- Dysfunctional Non-painful
• FP-Functional Painful
• DP- Dysfunctional Painful
• Assess motor control vs
restriction limitation
Functional Movement Screen
• 7 movements
• Scored 0-3
• Return to Sport
• No 0’s or 1’s
• No dysfunctional
asymmetries
• 14< total score
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Hop Testing
• Single leg hip
• Triple hop
• Cross-over hop
• >95% side<->side distance (Reid
et al., 2007)
• Greater distance -> increased
risk for injury (Brumitt et al., 2013)
Rehab at Andrews Institute… With
Andrews
• ALL YOU NEED TO KNOW…
• ALL YOU NEED TO DO…
Dynamic Movement Assessment Dynamic Movement Assessment
Outcomes
• Not as consistent as single ligament injuries (aaos.org, 2016)
• Restoration of ligamentous stability in 44% of patients; 20% had 5-10 mm residual laxity
• 44% had degenerative changes a time of surgery (Wang et al., 2002).
• 100% negative Lachman test, 66% negative posterior drawer, 44% had grade I posterior drawer. (Ohkoshiet 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. (Ohkoshiet al., 2002)
Outcomes
• 23-25% of subjects (mean age 16) sustained 2nd ACL injury within 12 months upon RTS following ACLR. (Paterno et al., 2014– 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)
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Outcomes
• 90% objective stability
success rate (Moulton
et al, 2016)
Rehab Principles
• Restore functional ROM, mobility, and strength
• Don’t forget the THORACIC SPINE
• Progressively overload tissues
• Static -> Dynamic
• Ensure dynamic movements are performed with
proper joint alignment prior to progressing exercise.