[
clinical commentary
]
Jason B. Lunden, PT, DPT, SCS1 • Peter J. Bzdusek, PT, ATR2 • Jill K. Monson, PT, CSCS3
Kent W. Malcomson, PT4 • Robert F. LaPrade, MD, PhD5
Current Concepts in the Recognition
and Treatment of Posterolateral
Corner Injuries of the Knee
I
njuries to the posterolateral corner (PLC) of the knee are most
commonly associated with athletic traumas, motor vehicle accidents,
and falls.10 PLC injuries account for 16% of knee ligament injuries47
and often occur in combination with other ligament injuries.11,16
Overlooking this injury can lead to residual instability, which may lead
to chronic pain or surgical failure in the presence of cruciate ligament
reconstruction.18,25,26,42,43,56,57,60,62 The most common mechanisms
leading to PLC injuries include a blow to
the anteromedial aspect of the knee
with the knee at or near full extension, contact and noncontact
knee hyperextension injuries, and
valgus contact force applied to a
flexed knee.44 Another mechanism
of injury consists of a severe tibial ext SYNOPSIS: Injuries to the posterolateral corner
of the knee pose a significant challenge to sports
medicine team members due to their complex
nature. Identifying posterolateral corner injuries
is paramount to determining proper surgical
management of the injured athlete, with the goal of
preventing chronic pain, instability, and/or surgical
failure. Postoperative rehabilitation is based on the
specific structural involvement and surgical procedures. A firm understanding of the anatomy and
biomechanics of the structures of the posterolateral corner is essential for successful rehabilitation
outcomes. Emphasis is placed on protection of
the healing surgical repair/reconstruction, with
gradual restoration of range of motion, strength,
ternal rotation torque applied with the
knee in flexion11 or in hyperextension. The PLC is comprised of
various muscles and ligaments,
with the exact structures varying,
depending on the source of the
description. Given the multitude
of structures involved and the inherproprioception, and dynamic function of the knee.
The purpose of this paper is to provide an overview
of the anatomy, biomechanics, and mechanism
of injury for posterolateral corner injuries, with
a review of clinical examination techniques for
identifying these injuries. Furthermore, a review of
current surgical management and postoperative
guidelines is provided.
t LEVEL OF EVIDENCE: Diagnosis/therapy, level
5. J Orthop Sports Phys Ther 2010;40(8):502-516.
doi:10.2519/jospt.2010.3269
t KEY WORDS: fibular collateral ligament, multiligamentous knee injuries, rehabilitation
ent and distinct biomechanics of each
structure, the PLC is inherently complex
both anatomically and functionally. A
thorough understanding of the anatomy,
biomechanics, and healing physiology is
essential for the successful treatment and
rehabilitation of PLC injuries for patients
to return to the highest level of function.
The aim of this manuscript is the anatomy and biomechanics of the PLC, and to
review the evaluation, surgical treatment,
and rehabilitation of PLC injuries.
Anatomy and
Biomechanics
T
he description of the anatomy
of the PLC varies depending on the
source and nomenclature that is
used. The PLC provides both static and
dynamic stability to the knee to prevent
excessive hyperextension, varus angulation, and tibial external rotation. The
PLC is especially important for providing
stability at lower angles of knee flexion
(45°) in weight-bearing activities. Furthermore, the PLC has been shown to
augment the contribution of the posterior
cruciate ligament (PCL) to tibiofemoral
posterior stability, especially at 30° of
knee flexion.11,23,24,75 There are numerous
structures that compose the PLC. The
1
Faculty, Fairview Sport Physical Therapy Residency Program, Minneapolis, MN; Physical Therapist, University Orthopaedic Therapy Center, Minneapolis, MN. 2 Physical Therapist,
University Orthopaedic Therapy Center, Minneapolis, MN. 3 Physical Therapist, University Orthopaedic Therapy Center, Minneapolis, MN. 4 Adjunct Faculty, Program in Physical
Therapy, University of Minnesota, Minneapolis, MN; Physical Therapist, University Orthopaedic Therapy Center, Minneapolis, MN. 5 Director, Biomechanics Research Department,
Steadman Philippon Research Institute, Vail, CO. Address correspondence to Dr Jason B. Lunden, University Orthopaedic Therapy Center, R102, 2450 Riverside Ave, Minneapolis,
MN 55454. E-mail: [email protected]
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provides an important secondary stabilizer role to varus stability.65 The coronary ligament of the lateral meniscus
extends from the popliteal hiatus to the
popliteomeniscal fascicle. This is also
referred to as the meniscotibial portion
of the posterolateral capsule. This structure is important to provide resistance to
hyperextension and tibial posterolateral
rotation.74 It also secures the posterior
horn of the meniscus to the tibia.65 The
oblique popliteal ligament is formed from
a combination of an expansion of the
semimembranosus complex and a portion of the posterior oblique ligament.65
Muscular contraction of the semimembranosus muscle assists in the tightening
of this ligament. Anatomically, it forms
part of the floor of the popliteal fossa and
attaches to the posterolateral capsule at
the fabella region. The fabellofibular ligament spans from the lateral aspect of the
fabella and attaches to the fibular head.65
If there is no fabella, it originates from
the tendon of the lateral gastrocnemius.65
Clinically, it is thought to be an important
lateral knee stabilizer in extension.65
following anatomic structures and their
contribution to stability of the knee will
be reviewed: iliotibial band (ITB), biceps
femoris muscle, fibular collateral ligament (FCL), popliteus muscle, popliteofibular ligament, lateral gastrocnemius
muscle, lateral joint capsule, coronary
ligament, oblique popliteal ligament, and
the fabellofibular ligament.
Static Structures
The 3 most important stabilizing structures providing static (passive) and
dynamic (active) posterolateral knee
stability are the popliteus tendon, popliteofibular ligament, and FCL ligament
(FIGURE 1).9
The FCL serves as the primary static
stabilizer to varus opening at the knee
from 0° to 30° of knee flexion,65 and it
also provides a checkrein to external rotation of the tibia.45 This extracapsular
structure originates just proximal and
posterior to the lateral femoral epicondyle
and spans roughly 7 cm to its insertion on
the fibular head.29,65 The popliteus muscle
originates from the posteromedial aspect
of the proximal tibia,7,41 and its proximal
tendon has multiple points of insertion
collectively called the popliteus complex.
One such attachment to the posteromedial aspect of the fibula is known as the
popliteofibular ligament. This ligament is
a static stabilizer resisting varus, external
rotation, and posterolateral tibial rotation.46,54 Along with the popliteus muscle,
this ligament is considered a crucial stabilizer to the posterolateral knee and, therefore, typically is surgically reconstructed
when torn. The popliteus complex also
has a tibial attachment and 3 connections,
or popliteomeniscal fascicles, to the lateral meniscus. Together, these structures
stabilize the lateral meniscus and prevent
medial entrapment of the meniscus when
varus forces are applied at the knee.69 The
main tendinous attachment of the popliteus tendon is to the femur at the anterior
aspect of the popliteus sulcus, just posterior to the lateral femoral condyle articular cartilage surface.41 The popliteus
provides dynamic internal tibial rotation
FIGURE 1. Illustration demonstrating the isolated
fibular collateral ligament, popliteus tendon,
popliteofibular ligament, and lateral gastrocnemius
tendon (lateral view, right knee). Reprinted with
permission from the American Journal of Sports
Medicine.46
and serves as both a dynamic and static
stabilizer to the knee against external
tibial rotation.65
Other static contributors to posterolateral knee stability include the posterolateral joint capsule, the coronary
ligament, oblique popliteal ligament,
and fabellofibular ligament. The posterolateral joint capsule includes portions of
the posterior and the lateral joint capsule,
and spans from the anterior border of the
popliteus tendon’s insertion on the femur to the lateral gastrocnemius attachment.65 The posterior capsule attaches
to around the lateral femoral condyle.
The mid-third lateral capsular ligament
is a thickening of the lateral capsule and
Dynamic Structures
The dynamic structures of the knee that
assist with posterolateral stability include
the popliteus muscle, the ITB, biceps
femoris, and the lateral gastrocnemius
tendon. The contribution of the popliteus
complex to posterolateral knee stability is
described above, as it provides static and
dynamic contributions to knee stability.
The ITB is a dense fibrous extension of
the fascia covering the gluteus maximus
and tensor fascia latae muscle. The ITB
originates from the anterior superior iliac
spine, anterior border of the ilium, and
the external lip of the iliac crest.65 The insertion is located on the lateral intermuscular septum, lateral aspect of the patella,
and the anterolateral aspect of the lateral
tibial plateau at Gerdy’s tubercle.65 During knee motion, the ITB moves anterior
in extension and posterior in flexion.
Along with the lateral ligaments and lateral capsular structures, the ITB aids in
lateral knee stability to prevent excessive
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[
clinical commentary
varus in positions of knee extension.
The biceps femoris muscle is composed of a long and short head. The long
head originates from the ischial tuberosity.65 The short head originates from the
middle third of the linea aspera and the
lateral supracondylar ridge of the femur.
The long head has 5 major insertions at
the knee,65 divided into 2 tendinous and 3
fascial components. The tendinous components insert on the lateral and anterior
aspects of the fibular styloid. The fascial
component connects the long and short
heads of the biceps femoris to the posterolateral aspect of the FCL. The short head
of the biceps femoris has multiple insertions including a muscular attachment
onto the long head tendon, FCL, and the
ITB.65 Both heads assist the knee with
flexion and lateral rotation and aid in
dynamic stability in preventing varus angulation, controlling tibial internal rotation, and working synergistically with the
medial hamstrings to prevent excessive
tibiofemoral anterior translation. Surgical repair of the biceps femoris is needed
with avulsions from the fibula. If intact, a
portion of the biceps femoris tendon can
be used as a tenodesis to the lateral femoral epicondyle to reconstruct the FCL. It
is worth noting that the common peroneal nerve lies deep to the biceps femoris
tendon and can be involved with PLC injuries. The lateral gastrocnemius tendon
originates around the supracondylar process of the distal femur.41,65 At the knee,
this structure blends with the posterior
capsule and popliteofibular ligament to
assist with posterolateral stability.46
Evaluation
I
t is important for clinicians to accurately evaluate and assess posterolateral knee injuries. Failure to diagnose
and treat a PLC injury in a patient who
has a PCL or anterior cruciate ligament
(ACL) tear requiring reconstruction can
result in failure of the cruciate ligament
graft.10,18,25,42,43,56,57,60,62 Examination of injuries to the PLC may reveal diffuse tenderness over the posterolateral region of
the knee and localized pain at the fibular
head or joint line upon palpation.
Mechanism of Injury
Mechanisms resulting in PLC injuries
include a posterolateral-directed force to
the anteromedial tibia, knee hyperextension,20 and/or severe tibial external rotation while the knee is partially flexed. The
forces involved during the injury and the
patient’s anatomic makeup will dictate
which specific structures are injured. In
knee hyperextension injuries the posterior capsule is often strained or torn,
followed by injury to the PLC and finally
the PCL.3 In a cadaveric biomechanical
model, Csintalan et al11 demonstrated
that external rotation injuries with the
knee partially flexed may result in tears
to the popliteus tendon, popliteofibular
ligament, FCL, and the ACL. Following
PLC injury, pain may be reported at the
medial and/or lateral joint line, or the
posterolateral aspect of the knee. Often
described is functional instability which
may include a feeling of the knee giving
way into hyperextension with stairs or
graded ambulation.29 Perception of instability can also result with cutting or
pivoting movements.
Gait
Due to the knee instability resulting from
an injury to the PLC, the gait pattern is
often altered to an extent that the patient
cannot employ a muscular compensation
strategy to effectively stabilize the knee.
A varus thrust of the knee is often seen
during the loading-response phase of gait
in individuals with a chronic posterolateral knee injury, especially those with
underlying varus osseous alignment. The
varus thrust gait pattern is likely associated with a lift-off of the lateral compartment of the knee, which has been shown
to significantly increase medial compartment joint stresses and ultimately hasten
medial compartment cartilage wear if
left untreated.68,78 Currently, there are no
studies specifically addressing the effects
of acutely induced high adduction moments, as seen in patients with traumatic
]
acute PLC injuries. However, studies
looking at varus knee alignment66,78 establish a good foundation for the importance
of critically observing and correcting abnormal gait patterns as a means to protect
the long-term health of the medial compartment cartilage of the knee.
In addition to the increased adduction moment found in the gait pattern of
patients with PLC injuries, patients also
often demonstrate a knee hyperextension
thrust during the loading response into
the early stance phase of gait. This hyperextension thrust gait pattern observed in
individuals with an ACL-deficient knee
or those who are post-ACL reconstructive
surgery is often referred to as a “quadriceps avoidance pattern.”2 With this abnormal gait pattern, a decrease in knee
flexion moment and increase in hip flexion moment have been observed during
loading response.2 It has been postulated
that the hyperextension thrust is used as
a strategy to stabilize the ACL-deficient
knee2,77; however, the lack of a proper
deceleration moment achieved through
knee flexion and eccentric quadriceps
activation during loading response may
result in increased compressive forces at
the tibiofemoral joint.66
In the individual with a PLC injury,
the hyperextension thrust gait pattern
may be the result of significant genu recurvatum instability rather than quadriceps weakness, due to injury to multiple
static and dynamic posterior lateral stabilizing structures. Further complicating
the gait pattern of a patient with a PLC
injury is the fact that these patients may
also present with a footdrop gait pattern
due to an injury to the common peroneal
nerve. With the known deleterious effects
of faulty gait mechanics on the health of
the knee’s articular cartilage, it is critical
to address the muscular control and recruitment deficits to normalize lower extremity kinematics and minimize medial
compartment knee joint stresses.
Associated Injuries
Because of the risk for vascular injuries
with knee trauma, it is important to
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screen for vascular compromise. Therefore, it is critical to palpate for pedal
and posterior tibial pulses at the foot
and ankle and/or to perform an anklebrachial index (ABI) of pulse pressures.
If a diminished foot pulse is detected in
comparison to the contralateral limb or
the ABI is less than 0.9, an arteriogram
or vascular ultrasound study may be
warranted.
Patients may report neural symptoms,
paresthesia, or weakness due to injury to
the common peroneal nerve. Numbness
is often along the patient’s first dorsal
web space and the dorsum of the foot.
Weakness is often seen in ankle dorsiflexion, foot eversion, and great toe extension, presenting with a resultant drop
foot and steppage gait. The prevalence of
peroneal nerve injuries in patients with
PLC injuries has been reported to be 13%
and should not be overlooked.44 Depending on the amount of motor deficit, peroneal nerve injuries may be treated with
an ankle foot orthosis initially, and a
tibialis anterior or extensor hallucis longus tendon transfer may be performed
in patients who have no return of motor
function following completion of PLC
rehabilitation.
Special Tests
There are several special tests for PLC
injuries that can and should be used to
help confirm a diagnosis. We will review
the posterolateral drawer, Dial, external
rotation recurvatum, varus stress, reverse
pivot-shift, and standing apprehension
tests.
The posterolateral drawer test is performed with the patient in supine, with
the knee flexed to 80° to 90° and the foot
externally rotated 15°. While the clinician
stabilizes the patient’s foot, a posterolateral drawer force is applied (FIGURE 2).30 A
positive posterolateral drawer test, indicated by increased posterolateral rotation
compared to the contralateral knee, may
implicate injury to the popliteus tendon,
popliteofibular ligament, and FCL. This
should not be confused with testing the
knee in neutral rotation or internal ro-
FIGURE 2. Posterolateral drawer test. The patient is
positioned supine, with the knee flexed 80° to 90°
and the foot externally rotated 15°. While the clinician
stabilizes the patient’s foot, a posterolateral drawer
force is applied.
tation at 90°, which would be utilized
to assess a PCL injury.30 Sensitivity and
specificity values have not been reported
for the posterolateral drawer test in diagnosing PLC injuries.
The Dial test may be performed with
the patient positioned either supine or
prone7,73 and has been shown to have
substantial agreement within and between testers.32 If a PCL-PLC combined
injury is suspected, performing the Dial
test with the patient in prone or adding
an anteriorly directed force to the tibia
while testing in the supine position can
increase the amount of tibial external rotation observed and would presumably
increase the sensitivity of the test.32,73
However, sensitivity and specificity values have not been reported for the Dial
test. With the patient supine, the knee is
flexed off the edge of the examining table
to 30° and then 90° with the thigh stabilized against the table.55 The foot is externally rotated, while the examiner records
the amount of external rotation of the tibial tubercle compared to the uninvolved
limb (FIGURE 3). An increase of greater
than or equal to 15°, as compared to the
contralateral side, is considered positive.1
A Dial test that is positive at 30° of knee
flexion but normal at 90° of knee flexion
FIGURE 3. The prone dial test. With the patient
prone, the examiner rotates the tibia through the foot
and observes the amount of tibial external rotation
present at 30° of knee flexion (pictured) and 90° of
knee flexion.
FIGURE 4. The external rotation recurvatum test.
With the patient supine, the examiner stabilizes
the patient’s distal femur with 1 hand and lifts the
patient’s great toe with the other hand, to observe the
amount of genu recurvatum.
is indicative of a potential injury to the
PLC, or more specifically, the popliteus
complex.1 A positive test at both 30° and
90° of knee flexion indicates both a PCL
and PLC injury.1,73
The external rotation recurvatum test
may be used to detect a concomitant PLCACL injury.30,40 The external rotation recurvatum test is performed by lifting a
supine patient’s great toe, while gently
stabilizing the distal thigh and observing the relative amount of genu recurvatum present.30,43,48 The test is considered
positive if the amount of genu recurvatum
measured by either a goniometer or heel
height off the examination table is greater
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FIGURE 5. The varus stress test. With the patient
supine, the distal thigh is stabilized against the exam
table, while the examiner palpates the lateral joint
line. The knee is flexed to 30° (pictured) off the edge
of the exam table and a varus stress is applied to the
knee through the foot/ankle. The test is repeated at
0° of knee flexion (not pictured).
than the contralateral knee. The posterolateral structures potentially involved
with a positive test include the coronary
ligament to the lateral meniscus, popliteus
tendon, and the structures which attach to
the fibular head: fabellofibular ligament,
biceps femoris, popliteofibular ligament,
and FCL. Caution is warranted in interpreting the external rotational recurvatum test, as it has been shown to have a
high incidence of false negative results for
ACL-PLC injuries,40 and it is rarely positive in patients with PCL-PLC or isolated
PLC injuries.72 Specifically, the sensitivity
of the external rotation recurvatum test
for ACL-PLC injuries has been reported
as 30%, while the specificity was 100%.40
The varus stress test is performed
with the patient supine, with the proximal femur stabilized on the examination
table. The examiner stabilizes the tibia
from unwanted rotation and applies a
varus stress to the knee through the foot/
ankle, first with the knee at 30° of flexion
and repeated with the knee extended to
0°. The test is considered positive if the
FIGURE 6. The reverse pivot shift test. With the
patient supine, the examiner flexes the knee to 45°
and a valgus plus external rotation force is applied
to the knee (A). The patient’s knee is then extended
(B). If the tibia posterolaterally subluxes, the iliotibial
band will reduce it as it goes from a flexor to an
extensor of the knee.
examiner feels an increased amount of
translation as compared to the contralateral knee. The injury is graded according
to the amount of subjective translation
(or joint opening) and the perceived quality of resistance at the endpoint. A grade
I FCL sprain shows mild gapping with a
firm endpoint, grade II shows moderate
gapping with an endpoint, and a grade
III shows gapping without an endpoint.
A positive varus stress test at 30° is indicative of a complete tear of the FCL
(FIGURE 5). A positive varus stress test at 0°
of knee extension indicates a more severe
injury, which may include the PCL,23,24
FCL, meniscotibial ligament, popliteus
tendon, and the superficial layer of the
ITB.44 However, data on the sensitivity and specificity of the varus stress test
have not been reported.
A positive reverse pivot shift may indicate an injury to the PLC. Specifically,
the reverse pivot shift test is positive with
injuries to the following anatomic structures of the PLC: FCL, popliteus complex,
]
and the mid-third lateral capsular ligament.44 In this test, the knee is flexed to
45° and the foot is externally rotated with
a valgus stress applied (FIGURE 6).44,54,72 A
positive test is indicated by a subluxation
felt with extension at around 25° flexion.
It is important to compare with the contralateral normal knee because this test
has been reported to have a false positive
rate of up to 35%.8
A standing apprehension test has also
been reported to assess injury to the PLC.
The patient stands with his/her weight
on the injured (tested) knee and slightly
flexes it, while the clinician applies a medially directed force on the anterolateral
portion of the lateral femoral condyle.18
Rotation of the condyle relative to the
tibia, in addition to the patient feeling a
giving-way sensation, indicates a positive
test.10 The standing apprehension test
was reported to have 100% sensitivity
for reproducing posterolateral instability
in patients with a history of an ACL reconstruction or other arthroscopic knee
surgery.18 Specificity for the standing apprehension test has not been reported. It
should be noted that injury to the anatomical structures of the PLC was not
confirmed either by imaging studies or
operative examination, thus the standing
apprehension test should only be considered useful to reproduce a patient’s symptoms of knee instability.
Imaging
In cases where there is significant edema
present, a clinical exam may be equivocal and diagnostic imaging will assist in
making a diagnosis. Furthermore, diagnostic imaging is a useful tool to assist
with identification of specific anatomical
structures involved. Plain radiographs
may reveal a fibular head fracture, lateral joint space widening, or avulsions of
the lateral capsule. Magnetic resonance
imaging that includes a coronal oblique
image plane in all sequences of the entire
fibular head and styloid process can be a
helpful diagnostic tool in assessing structural integrity of the PLC, as it has been
found to accurately assess the integrity
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A
B
FIGURE 8. Varus stress radiographs. Bilateral varus stress radiographs demonstrating 4.7 mm increased opening
at the lateral joint line on the injured knee (B). This represents a complete tear of the posterolateral corner
structures and fibular collateral ligament.36
FIGURE 7. Coronal MRI of a posterolateral corner
injury to a left knee. White arrow points to a
disruption of the fibular collateral ligament. Orange
arrow points to an avulsion of the popliteus off of its
insertion on the lateral femoral condyle. Black arrow
points to a complete tear of the lateral capsule with
unrooting of the lateral meniscus.
of most of its components (FIGURE 7).
Imaging can also be very useful in determining avulsion versus midsubstance
injuries. Stress radiographs are very helpful to assess for chronic PLC injuries.
LaPrade et al36 evaluated the use of varus
stress radiographs with the knee at 20°
of flexion to provide objective and reproducible measures of lateral compartment
gapping, and reported a grade III PLC injury should be suspected if an increased
opening of approximately 4 mm is found
(FIGURE 8).
34,79
Classification
Injuries to the PLC can be graded using
2 different classifications proposed by
Hughston28 and Fanelli17 that are based
on the amount of excessive laxity or structures involved (TABLE).
Hughston28 reported 3 grades to classify collateral ligament injuries of the
knee. Grade 1+ instability is indicated
by opening of the affected joint by an
amount of 0 to 5 mm with varus stress;
grade 2+ is indicated by opening of 6 to
10 mm; and grade 3+ with an opening of
greater than 10 mm. Our own sectioning studies have revealed a fault in the
old subjective grading scales that were
not based on actual science (TABLE).36 It
is important to point out that the Hught-
TABLE
Grading Scales for PLC
Injuries of the Knee
Fanelli Scale for PLC Injury (location based)
A: injury to popliteofibular ligament, popliteus tendon
B: injury to popliteofibular ligament, popliteus tendon, and FCL
C: injury to popliteofibular ligament, popliteus tendon, and FCL, lateral capsular avulsion, and cruciate
ligament disruption
Hughston Scale for Collateral Ligament Injury (instability based)
1+: varus opening, 0-5 mm*
2+: varus opening, 5-10 mm*
3+: varus opening, 10 mm*
Varus stress radiographs (sectioning based)
FCL: varus opening, 2.7 mm*
FCL, popliteus tendon: varus opening, 3.5 mm*
FCL, popliteus tendon, popliteofibular ligament: varus opening, 4 mm*
Abbreviations: FCL, fibular collateral ligament; PLC, posterolateral corner.
* Increased opening compared to contralateral knee.
son classification (old American Medical
Association) is a subjective clinical-based
test and that the actual numbers quoted
for the amount of instability are inaccurate. While we recognize that this grading
scale is very important for making clinical decisions, it is also important that the
amount of instability is much less than
that which was subjectively proposed by
both the American Medical Association
and Dr Hughston in their grading scales.
If one reads an article on a surgical procedure that does not return the knee stability back to less than 2 mm, the procedure
would be regarded as a failure under
stress radiograph grading, while subjectively it may be felt to be acceptable.
The Fanelli17 scale classifies injuries
into type A, B, or C. Type A injuries in-
clude the popliteofibular ligament and
popliteus tendon, and only an increase in
knee (tibial) external rotation is observed
upon clinical testing. Type B injuries include the popliteofibular ligament, popliteus tendon, and FCL, and, clinically,
an increase in tibial external rotation is
present along with mild varus opening to
varus stress testing at 30° of flexion. Type
C injuries involve the popliteofibular
ligament, popliteus tendon, FCL, lateral
capsular avulsion, and cruciate ligament
(ACL and/or PCL) disruption. With type
C PLC injuries, the clinical exam reveals
increased tibial external rotation and
marked varus instability at 30° of knee
flexion. Once the grade of injury is established, the clinician can determine
the course of management. Grade 1+ and
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2+ PLC injuries may respond to conservative management; however, grade 3+
PLC injuries are best treated with surgical reconstruction.
Nonsurgical Management
C
onservative management of
PLC injuries is not well documented in the literature. This is most
likely due to the fact that PLC injuries are
typically combined with an injury to one
of the cruciate ligaments, for which surgical management is indicated. In addition, patients with isolated grade 1+ and
2+ PLC injuries, for which conservative
treatment may also be appropriate, often
may not present for treatment. Deleo et
al12 presented a case study of an 18-yearold female who sustained a noncontact
grade II FCL sprain with concomitant
posterolateral instability. The patient
was able to return to her previous level
of activity, which included reserve officer
training, 23 weeks following her injury,
with 9 weeks of intensive physical therapy (23 visits) that included fibular head
mobilization followed by taping of the
fibular head and perturbation training,
in addition to transcutaneous electrical
nerve stimulation and range-of-motion
and strengthening exercises.
Our approach to conservative management of PLC injuries is to initiate an
accelerated form of the postsurgical rehabilitation outlined in detail below. The
program is accelerated compared to the
postsurgical PLC program, as progression for the conservative management of
PLC injuries is not dependent on allograft
healing timelines but is based on anthropometric measures, functional progression, and symptom and impairment
resolution. Briefly, the rehabilitation of
the isolated PLC is based on the patient’s
presentation. For patients who have increased gapping on stress radiographs
but who don’t have a complete FCL tear,
the use of a medial compartment unloader brace for high-level athletic activities
may be indicated. As with all knee injuries, the goals for phase 1 are edema man-
agement, restoration of range of motion,
and quadriceps muscle activation. Patients are progressed to the second phase
of rehabilitation once knee extension is
restored to within normal limits of the
contralateral knee, knee flexion is greater
than 120°, and they are able to perform a
supine straight leg raise (SLR) without a
knee extension lag. The second phase of
rehabilitation is devoted to normalization
of gait mechanics and increasing muscle
strength. Lower extremity strengthening
exercises are particularly focused on the
quadriceps, hamstrings, gastrocnemius,
and popliteus. During later phases of
rehabilitation, emphasis is placed on the
lateral hamstrings and lateral gastrocnemius to control varus moments at the
knee. Emphasis is also placed on control
of tibial external rotation with the medial
hamstrings by having the patient perform
traditional strengthening exercises modified with the tibia positioned in internal
rotation.50 Furthermore, a program of hip
and lumbopelvic stabilization exercises is
included. Patients are typically advanced
from the second phase, when normal
gait pattern has been restored. Phase 3
of PLC rehabilitation is devoted to neuromuscular control and strengthening
with functional movement patterns. Particular emphasis is placed on control of
knee varus and tibial external rotation
at lower angles (45°) of knee flexion
in weight bearing. Verbal, manual, and
visual cueing with the use of a mirror
or video feedback are all utilized to increase the patient’s control with weightbearing activities. Functional testing and
training, including timed balance and
single-limb squat for depth, and hop
testing (single- and triple-crossover hops
for distance and timed hop for speed),
are performed.64 Once patients achieve
a limb symmetry index of greater than
85% on functional testing, they are progressed to phase 4 rehabilitation. Finally,
phase 4 of PLC rehabilitation is devoted
to sport-specific drills, with a gradual return-to-play program. Due to the rarity
of reported treatment of isolated grade 1+
and 2+ PLC injuries and superior surgical
]
outcomes for acute versus chronic PLC
injuries, we treat patients with grade 3+
PLC injuries surgically.
Surgical Treatment
S
urgical treatment of the PLC
can vary, depending on the structural involvement and the time
frame of the procedure from the date of
injury. However, the goals of the reconstruction are the same for all the procedures: to have a stable, well-aligned knee
and to restore the preinjury kinematics
of the knee joint.9 Surgical management
of isolated acute PLC injuries has been
reported to result in more successful outcomes than chronic injuries.6,10,39,75 Acute
injuries include grade 3+ PLC injuries reconstructed within 3 weeks of the injury.
All major structures of the PLC should
be evaluated, including the ITB, biceps
tendon, popliteus, FCL, popliteofibular
ligament, and the peroneal nerve.9 Surgical approaches can vary, and an extensive
report is beyond the scope of this paper.
In general, it is recommended that anatomic repairs or reconstructions of the
PLC structures be performed. Similar to
the outcomes following reconstructions
of the cruciate ligaments, it has been
found that the outcomes of delayed primary repairs and sling procedures of the
PLC structures also have less than optimal outcomes as compared to anatomic
reconstructions.37 Primary repairs of the
FCL may be performed within the first 2
to 3 weeks after injury. After this time,
the avulsed structures retract so that the
tissue cannot be restored to its native
anatomic location.37 Furthermore, the
torn structure becomes necrotic after 3
weeks and does not hold sutures well.37
Therefore, primary repairs of the FCL
are not recommended at greater than
3 weeks following injury and require a
reconstruction. But, regardless of when
the surgery is performed, midsubstance
tears of the FCL cannot be repaired and
require a reconstruction. Our recommended technique for a FCL reconstruction follows the description by Coobs
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A
B
FIGURE 9. The posterolateral knee reconstruction
procedure. (A) Lateral view, right knee; (B) posterior
view, right knee. Abbreviations: FCL, fibular collateral
ligament; PFL, popliteofibular ligament; PLT, popliteus
tendon. Reprinted with permission from the American
Journal of Sports Medicine.38
et al,7 in which an autogenous semitendinosus graft is harvested and sized to
fit into reconstruction tunnels reamed
at the anatomic attachment sites of the
FCL. For complete nonrepairable acute
ligament tears or chronic attenuation of
the main posterolateral knee structures,
multiple repair and reconstructive procedures have been reported, including FCL
reconstruction,75 FCL reinforcement with
the use of an allograft,58 femoral boneblock advancement,29 proximal tibial osteotomy,35,59 biceps femoris tenodesis,5,15,76
popliteus tendon and popliteofibular ligament reconstruction,75 popliteus recess
procedures, and ITB or biceps femoris
graft.75,76 However, an anatomic reconstruction of the FCL, popliteus tendon,
and popliteofibular ligament are recommended (FIGURE 9).38
At the University of Minnesota Sports
Medicine Institute, we advocate the surgical procedure developed in our biomechanics lab,38 for which clinical outcomes
have been published by LaPrade et al.37
A brief overview of a procedure is summarized below. The initial incision to expose the PLC begins as an 8- to 10-cm
hockey stick-shaped incision, originating
over Gerdy’s tubercle.9 Multiple fascial
incisions can then be used to access the
specific components of the PLC. The surgical approach to repair of posterolateral
injuries should take a deep to superficial
approach. The superficial fascial layer of
the ITB is split in line with its fibers and
retracted to expose the proximal attachments of the FCL and popliteus tendon.9
A second fascial incision is made parallel
to the long head of the biceps femoris.9
Dissection occurs to reveal the popliteofibular ligament’s attachment site.9 Two
grafts from a split Achilles tendon allograft are used for reconstruction. The
first is used to reconstruct the popliteus
tendon and the second to reconstruct
both the popliteofibular ligament and
the FCL.9 These structures have been
found to be the most important stabilizing structures and act in concert with the
cruciate ligaments to provide overall knee
stability.64
Chronic PLC injuries tend to be a
more complex problem than acute injuries. This can be due to extensive scarring, secondary changes to surrounding
structures, and potential limb malalignment.10 A multistep procedure with a
correction of a genu varum deformity
initially needs to be considered. This can
be addressed through a proximal tibial
osteotomy and should be done prior to
soft tissue reconstruction. The goal is
to prevent excessive loads on the lateral
capsular structures that are to be potentially reconstructed after the osteotomy
heals.35,55,75 Some, but not all, of the other
techniques to reconstruct/approximate
the FCL are Achilles tendon allograft,
bone patellar bone autograft, and tenodesis of the biceps femoris tendon. Surgical repair of the FCL may be performed
if it is avulsed off of its femoral or fibular
attachments. Midsubstance tears of the
FCL can be augmented with a portion of
the biceps femoris or reconstructed. If
the ligament is absent or if chronic PLC
injury is present, a reconstruction may be
indicated.75
The popliteus complex may be reconstructed with hamstring autograft,
Achilles tendon autograft, or ITB autograft. Sutures can be used to repair tears
to the coronary ligament of the posterior
horn of the lateral meniscus, the popliteomeniscal fascicles, portions of the
ITB, and portions of the long and short
heads of the biceps femoris.9 Reconstruction of a coexisting cruciate ligament
tear should be concurrently addressed
with a combined injury. It is important
for therapists to consult the physician
and/or review the operative notes due to
variation and complexity among surgical
procedures. Therapists should also have
understanding and appreciation of the
postoperative precautions and restrictions. This will lead to a better understanding of this region of the knee and
assist with optimal outcomes.
Postsurgical
Rehabilitation
P
ostsurgical rehabilitation of
PLC reconstruction typically spans
6 to 9 months. At the initial visit,
patients need to be aware of the rehabilitation timetable, help create attainable
goals, and become an active participant
in both the clinical treatments and their
individual home exercise program. Physician guidelines, such as weight-bearing
restrictions, allowable knee motion ranges, avoidance of knee hyperextension,
and avoidance of tibial external rotation, should be reviewed and reinforced.
Restrictions may vary with individual
physicians and structures involved. It is
the physical therapist’s responsibility to
obtain this information and utilize it to
guide the treatment.
Rehabilitation in advance of the surgery or “prehabilitation” is an optimal
course of care and should be considered,
when possible, to allow for better surgical
outcomes by preventing contractures that
may affect postsurgical range-of-motion
or intraoperative difficulty in obtaining
native graft placement. Patients are seen
prior to surgery to regain range of motion, to increase quadriceps control, to
review and provide patients with a postoperative rehabilitation protocol and restrictions, and to discuss any questions
patients might have entering the procedure. Patients can utilize aquatic centers
to increase range of motion and mobility
prior to surgery, by being able to stress
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[
clinical commentary
their knees more effectively, without the
associated pain from full weight bearing.
This paper will follow the guidelines
of Robert F. LaPrade, MD, PhD for a
posterolateral reconstruction involving
the popliteus tendon, popliteofibular
ligament, and the FCL (APPENDIX). These
guidelines may be modified with a concurrent knee ligament injury. Postoperative restrictions for the first 6 weeks
postoperatively include being non-weight
bearing and remaining in the knee immobilizer at all times other than for
range-of-motion exercises. For the first
4 months postoperatively, closed kinetic
chain (squatting) exercises are limited to
70° or less knee flexion, tibial external rotation is avoided, and resistive or repetitive hamstring exercises with the knee
in flexion are avoided. Patients are kept
non-weight bearing for 6 weeks to allow
for healing of the reconstruction and to
prevent stretching of the graft from varus
forces placed on the graft during ambulation.45 The rationale for hamstring
avoidance is primarily based on surgeons’
anecdotal information. Markolf et al49
have demonstrated that activation of the
hamstrings significantly increased mean
forces applied to the PCL, when the knee
was in more than 30° of flexion. Patients
should be educated in the avoidance of
tibial external rotation to prevent overstretching of the surgical reconstruction.
This includes avoidance of sitting with
the legs crossed, sitting with an excessive
toe-out posturing, or pivoting away from
the fixed weight-bearing surgical lower
extremity. Patients often inquire as to a
timeline for driving. If the left knee is reconstructed, driving can occur after the
first week. If the right knee is reconstructed, patients can begin driving around 7 to
8 weeks postoperatively, when specified
impairments have resolved enough to allow them to exhibit a normal gait pattern.
The patient should be comfortable with
brief, rapid, lower extremity movements
to negotiate braking.
After reviewing the initial restrictions
with the patient, the rehabilitation focus
should center on edema control, gentle
range of motion, and quadriceps activation. Edema control can be addressed
through cryotherapy, compression, elevation, and skeletal muscular pumping,
repetitive ankle dorsiflexion, and plantar
flexion. The patient remains with the
knee in full extension for the initial 1 to
2 weeks. This is to allow for the proliferation of fibroblasts and the formation
of collagen and ground substance (fibroplasia), which will result in the formation of granulation tissue. Patients can
then progress with protective motion to
stimulate collagen formation and alignment.21 Range of motion begins with the
patient passively or actively assisting the
motion of flexion and extension at the
knee. Patellofemoral mobilizations in all
directions are important for prevention
of arthrofibrosis and to maximize rangeof-motion gains in the initial phases of
rehabilitation. Excessive hyperextension
should be avoided to prevent excessive
posterior stress at the knee. Consulting
with the treating physician as to optimal
extension goals to be achieved is recommended. After 105° of knee flexion is
achieved, stationary cycling can be used.
Initially, the bicycle is to be used to obtain fluid motion using a low constant resistance. Cycling cleats are not allowed.
Patients begin with 5-minute sessions
and slowly work up to 20 minutes a day.
Significant soreness or effusion is an indicator to reduce the duration and/or
frequency.
Early quadriceps activation can be
achieved with isometric exercises. Electromyographic biofeedback,13,53 neuromuscular electrical stimulation, 19,70,71
taping,22 or other techniques may be utilized to increase quadriceps recruitment.
Our clinic has found the best success in
facilitating quadriceps activation through
the use of electromyographic biofeedback. Patients should strive to perform
up to 30 repetitions of quadriceps sets,
5 to 6 times a day, as symptoms allow. To
ensure quality of exercise, not quantity of
exercise, patients should be encouraged
to work to the point of muscle fatigue by
holding the quadriceps contraction for 8
]
to 10 seconds with each repetition, with
full relaxation of the limb for 2 to 3 seconds between repetitions. SLRs may also
be performed with a goal to achieve similar values of repetitions and frequency as
the quadriceps-setting exercise. SLRs are
to be completed in the knee immobilizer
until a SLR can be performed with the
absence of knee extension lag. It is crucial to regain quadriceps function early
in the rehabilitation process. Core (lumbopelvic and hip) strengthening, such as
abdominal and gluteal setting exercises,
can begin immediately and progress as
strength allows and should be performed
while wearing the extension splint. SLR
exercises in sidelying and prone can begin initially at patient tolerance and are
performed while in the knee immobilizer.
Patients should wear a knee immobilizer at all times during the initial 6
weeks. Exceptions include when performing range-of-motion exercises and
quadriceps isometrics with the knee in
extension. The patient can typically begin gentle active, active-assisted, and/or
passive range-of-motion exercises at the
end of the first or second postoperative
week. Goals should be set at achieving 0°
to 90° of flexion by 2 weeks and full range
of motion by 6 weeks. Full extension on
a mat/floor is permitted, but stretching
into hyperextension should be avoided.
At the completion of the sixth week
postoperatively, the patient will typically
follow up with the physician. Reevaluation of the knee’s structural integrity will
occur via clinical examination, and the
weight-bearing restriction will be lifted
if appropriate. Criteria for progression
to phase 2 or the weight-bearing phase
are based on allograft healing timelines.67
The early phase of graft healing is from 0
to 4 weeks postoperatively and is marked
by increasing necrosis, with decreasing
mechanical strength of the graft, until
the sixth week postoperatively.67 Therefore, weight bearing is restricted during
this time. The proliferative phase of graft
healing is from week 4 to week 12, when
cell numbers increase and revascularization occurs.67 Therefore, in function, of
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the strength deficits present in most patients following PLC surgery, full–bodyweight squats are typically instituted at
the 12-week mark. Resisted hamstring
activity and closed kinetic chain exercises
at depths greater than 70° of knee flexion are restricted until the fourth month
postoperatively, because of the possible
continued graft vulnerability to stretching with these activities. The ligamentization phase of graft healing occurs from
approximately 12 weeks to 12+ months
postoperatively and involves graft remodeling toward restoration of the physiological and mechanical properties of the
native graft.67 However, at this point, the
later phases are guided more by objective
strength and proprioceptive measures
than graft healing timelines.
At 6 weeks postoperatively, patients
may progress to phase 2 of rehabilitation, if they have no signs of effusion,
can demonstrate a supine SLR without
a knee extension lag, exhibit 0° of knee
extension, and have greater than 120° of
knee flexion. Therapists will assist the
patient with a weight-bearing progression and crutch weaning. Weight-shifting exercises in sitting or standing with
upper extremity support are advisable
in the early stages of weight bearing.
Dependence on upper extremity support is reduced until the patient is ultimately able to balance independently
on the surgical limb and ambulate with
an even stride length and symmetrical
stance time. Crutch weaning is best performed over a 2-week time frame for a
gradual return to full weight bearing. A
scale may be used as a biofeedback tool
to monitor actual weight-bearing forces
through the surgical extremity as the
patient progresses toward full–bodyweight acceptance. This will allow time
for the patient to build confidence and
stability on the surgical limb. The patient should be able to ambulate without
a limp prior to discontinuing crutch use.
A fluid gait pattern is first established
using 2 crutches and subsequently reduced to 1 crutch. This will further progress to utilization of crutches solely for
FIGURE 10. Bridge on stability ball. This exercise may
be used during earlier phases of rehabilitation of
posterolateral knee reconstructions to strengthen the
hamstrings. An extension splint must be worn during
this exercise for the first 6 weeks postoperatively.
community mobility. By the end of the
second week of allowed weight bearing (eighth week postoperatively), the
patient should be able to discontinue
crutch usage. Normalization of gait and
confidence on the lower extremity should
be the focus. Particular focus should be
placed on the loading and midstance
phase of gait to ensure a return to normal kinematics and kinetics of the lower
extremity. A primary goal is to abolish
the varus thrust pattern often observed
presurgically.59,61 Quadriceps activation
for deceleration of body mass during the
loading phase of gait and control of limb
position throughout the stance phase are
critical. Electromyographic biofeedback
of the quadriceps muscle group during
gait simulation drills or actual gait training can be a useful tool for restoring a
normal pattern of muscle activation.
Video-based gait analysis is also a useful
tool for restoring normal gait mechanics.
Eccentric hamstring control during midstance and terminal stance is important
to avoid an uncontrolled thrust into hyperextension. Thus, it is important that
hamstring strengthening with the knee
extended (to protect the allografts from
unwanted posteriorly directed forces) be
initiated in the early phases of rehabilitation with mat-based exercises (FIGURE
10) and progressed to weight-bearing exercises and varying angles of knee flexion in the later phases of rehabilitation
(FIGURE 11).
Balance exercises should start during
week 7. Higher-level balance activities
should include patients demonstrating
an ability to control for varus and valgus
FIGURE 11. T-reach exercise. This exercise may
be used during later phases of rehabilitation for
posterolateral knee reconstruction to strengthen the
hamstring muscle groups. Rotation through the hip
can be added to increase difficulty and preferentially
strengthen the lateral or medial hamstring muscles.
forces of the lower extremity. This might
involve manual perturbation or simply
maintaining balance on varying surfaces
with a taught resistive band placed medially or laterally above the knee. Also
during this time, weight-bearing and
low-impact closed kinetic chain exercises
with the knee in less than 70° of flexion
can be added. This includes using a leg
press with up to 25% of the patient’s
body weight, with emphasis on eccentric
quadriceps strengthening for muscular
endurance initially, with progression to
concentric strengthening for muscular
strength and power. Repetitions should
be performed until fatigue and terminated if symptoms arise. Closed kinetic
chain exercises should be progressed
from double-limb support to singlelimb support per the patient’s strength
and alignment control. Static holds in a
squat or lunge position may be useful if
the patient exhibits symptoms or a lack of
control with dynamic exercises. As with
any phase of the rehabilitation following
PLC reconstruction, progression should
not only be based on strength and control
but also symptom tolerance, as evident
through pain and effusion.
It is important to keep the leg press
from exceeding a maximum of 70° of
knee flexion. Flexion beyond this depth
is thought to increase the stress on the
posterior healing repair or reconstruction
procedure.33 This stress is a result of the
cam effect of the posterior aspect of the
femoral condyles on the posterior aspect
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[
]
clinical commentary
of the knee.33 Swimming can begin at 8
weeks. Although a flutter kick is technically an open kinetic chain hamstring activity, the majority of the motion is at the
hip, with very little knee flexion. Therefore, theoretically, the hamstrings do not
apply much force on the graft, so there is
little concern of stretching out the graft
with this activity at this time point. Patients are to avoid breast and side stroke
techniques, along with any whip kick motions in the pool. Finally, isolated open
chain hamstring exercises should be
avoided over the initial 4 months postoperatively. The rationale here is to avoid
potential deleterious effects of hamstring
contraction on the PLC reconstruction.33
Closed kinetic chain hamstring strengthening is allowed due to cocontraction of
the quadriceps muscles to counteract the
posterior translation of the tibia by the
hamstrings. A clear understanding of the
expectations and restrictions by both the
physical therapist and patient will establish the foundation to a successful surgical outcome.
At 3 months postoperatively, patients
will typically follow up with the physician for further clinical examination and
clearance for further activities, if the
patient has evidence of adequate joint
stability per the clinical examination,
exhibits a normal gait pattern, and has
minimal to no effusion at rest and following activity. For therapy, patients can
begin using a squat rack with 50% body
weight, while continuing to maintain
depth above 70° of knee flexion. Patients
can progress to full body weight over
the course of the next 3 weeks. Clearance is typically provided at 4 months for
patients to squat with increased depth
(70° of knee flexion).
At the 4-month period, patients can
begin a daily walking program at a brisk
pace. Criteria for progressing to a daily
walking program include adequate lower extremity knee range for normal gait
kinematics, being able to demonstrate a
normal gait pattern, and the absence of
increased joint effusion with prolonged
walking. Walking should start at no more
than 20 minutes and increase 5 minutes
per week. The surgeon may give clearance for jogging/running and initiation
of plyometric exercises after that point
as strength allows. One of the criteria
for clearance to initiate plyometric exercises and jogging is that patients need to
be able to ambulate pain free 3 to 5 km,
with bouts of brisk walking and navigating uneven terrain. Patients also need to
demonstrate proper mechanics and control with single-limb squatting to at least
60° of knee flexion for 20 repetitions.
Also at 4 months, stationary cycling can
be performed with increased resistance.
The goal is to feel fatigue in the thighs
following 20 minutes of bicycling. This
can be done up to 3 to 5 times per week.
Forward, lateral, and retro step-ups at
greater than 70° of knee flexion can be
initiated at 4 months. Here, the patient
begins with the surgical lower extremity
on the step and, using the surgical limb,
extends the lower extremity to ascend the
step. Step height and repetitions are increased in 5-cm increments as tolerated.
A lunge progression at greater than 70°
of knee flexion can begin after 4 months.
Depth and plane of movement can vary,
based on exercise control and symptomology. Lunging repetitions will move from
stationary to walking and can be done
while performing diagonal (chopping)
movements. Lightweight or medicine
balls can be held to increase difficulty.
This chopping motion should occur both
towards and away from the lead lower extremity. Emphasis will be on controlling
varus stresses due to the nature of the injured structures. A chopping pattern directed medially away from the lead limb
will promote varus control (FIGURE 12).
Functional Testing/Return to Play
The patient will follow up with the physician at 5 to 6 months postoperatively
for further evaluation and varus stress
radiographs.36 Functional testing is performed between 5 and 7 months postoperatively. This consists of KT-1000
arthrometer testing (with concomitant
ACL injury), isokinetic testing, and
FIGURE 12. Lunge exercise with a medial chop, with a
weighted medicine ball. Patients are cued to maintain
proper knee alignment centered over the second toe
controlling for varus forces and strain.
sports simulation activities. With the
patient positioned supine and the knee
flexed from 20° to 35°, KT-1000 arthrometer values are taken at 10, 20,
and 30 lb of force, directed anteriorly,
and a manual maximum value. Testing
with a posterior force of 20 lb is also performed. Isokinetic testing is performed
using 3 different speeds: 120°/s, 180°/s,
and 240°/s. The concentric/concentric
setting is used. Sports simulation testing consists of squat and anterolateral
and anteromedial reaches, single-limb
stance with eyes closed, single-limb
squat for depth, retro step-up for height,
single-limb hop for distance, timed hop,
and crossover triple hop for distance.64
The objective test values along with
clinical observation during the testing
aid to assist with return-to-play and
-sport decisions. Athletes are allowed
to return to an interval sport program
if limb symmetry indices of greater than
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85% for both isokinetic and sport simulation/functional testing are achieved.
The athlete’s jumping and landing
techniques during functional testing
should be closely monitored. If the athlete exhibits tendencies to land on an
extended knee with either a varus or
valgus angulation, the athlete should go
through training sessions to correct this
technique.4,14,27,51,52,63 In addition, the athlete’s lumbopelvic and lower extremity
strength should be retested with manual
muscle testing to determine if the faulty
jump/landing mechanics observed are
more a result of muscular weakness or
motor planning/neuromuscular control.
Varus and posterior (for concurrent PCL
reconstruction) knee stress radiographs
will confirm reconstruction stability and
confirm if it is safe to proceed with advanced activities.31 Physician clearance
is required before cutting, pivoting, or
hopping activities are performed both
in and out of clinic. Before resumption
of practice or return to play, we recommend supervised training of cutting and
pivoting drills with verbal51 and video63
feedback from the physical therapist or
athletic trainer. Observations made during in-clinic visits and functional testing
regarding the patient’s return to normal
anthropometric measurements and
physical performance factors will help
guide the therapist regarding the timing
of patient discharge from formal physical therapy to a self-directed exercise
program. Patients should be aware that
it may take up to 2 years to recover from
an injury and surgical reconstruction of
the PLC, especially with a concurrent
cruciate ligament reconstruction, or for
patients who required a staged reconstruction after an osteotomy. Therefore,
it is important to instruct patients on
the importance of continued compliance with their home exercise program
and/or independent strengthening program after formal physical therapy has
ceased. Athletes receiving clearance for
participation in sport and competition
should continue to maintain a home exercise program established by a physical
therapist. This program will vary with
the individual’s activities and goals. This
is in addition to any practice and team
weight-training session. Finally, use of
a medial unloader brace/valgus-producing brace may be warranted during
sport for proprioceptive input and to decrease varus stresses to facilitate normal
mechanics with running, cutting, and
pivoting activities, especially in patients
with a revision PLC reconstruction and/
or a high body mass index.
CONCLUSION
C
linically, injuries to the PLC
or “dark side” of the knee are becoming more recognized. Undiagnosed PLC injuries may lead to poor
outcomes or failures of cruciate reconstructions, chronic instability with resulting early onset osteoarthritis, and chronic
pain. More recently, our understanding
of the anatomy, biomechanics, diagnosis, and management of PLC injuries has
increased. The intent of this paper is to
provide therapists with a better understanding of the injury, the components
of the PLC, surgical reconstruction, and
a suggested treatment approach. t
6.
7.
8.
9.
10.
11.
12.
13.
14.
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clinical commentary
]
appendix
Protocol for Rehabilitation of a Posterolateral Knee Reconstruction
Procedure
The popliteus tendon, the popliteofibular ligament, and fibular collateral ligament are
reconstructed.
This protocol can be combined with cruciate reconstruction protocols adhering to all
restrictions for each protocol.
Postoperative Restrictions
1.Patient remains in the knee immobilizer in full-knee extension at all times during
on motion, beginning with 5 minutes every other day and increasing to 20 minutes
daily, based on the knee’s response to increased activity. If soreness or effusion is
evident reduce time or days utilizing the bike.
Weeks 13-16
At this time the patient should have a normal gait pattern, without the presence of a
limp or Trendelenburg sign.
The physician should be notified if patient is lacking 5° or more of extension or has
the first 6 weeks postoperatively other than when working on knee range of motion
less than 110° of flexion.
(ROM) or performing quadriceps exercises.
1.Leg press up to 25% of the patient’s body weight to fatigue. Knee flexion allowed to a
2. Patient remains non-weight bearing for 6 weeks.
3.Patient to avoid tibial external rotation, and external rotation of the foot/ankle, especially in sitting for the first 4 months postoperatively.
4. Patient avoids open-chain hamstring exercises until 4 months postoperatively.
Postoperative Red Flags
Signs and symptoms of infection (excessive swelling, body temperature [fever]
maximum of 70°.
2.Squat rack/squat machine: using weight up to 50%, body weight 10 repetitions, again
not exceeding 70° of knee flexion. Slow progression to full body weight.
3.Closed kinetic chain exercise progression: double-limb squatting, lunges, single-limb
squatting, etc. All exercises performed with less than 70° of knee flexion.
4. Daily biking or swimming. If swimming, no whipkicks or flip turns.
greater than 101°, increasing redness around the surgical incisions) calf swelling or tender-
Phase 3
ness, lack of full knee extension, complaints of knee instability, complaints of catching or
Months 4-6 (Weeks 16-24)
locking, and increased effusion following activity/therapy.
Physical therapy goals: improve quadriceps strength and function, increase endur-
Phase 1
ance, improve coordination, improve proprioception.
Weeks 1-2
1.Walking program: 20 to 30 minutes daily with a medium to brisk pace. Add 5 minutes
1. Edema management: ice, compression, elevation.
2.Quadriceps sets and straight leg raises (SLRs) performed in the knee immobilizer.
Quadriceps sets can be performed hourly up to 30 repetitions and SLR up to 30
repetitions 4 to 5 times per day.
3.Four times a day gentle passive and active assisted ROM exercises. Goal is 90° of
knee flexion by the end of 2 weeks, and 0° of knee extension.
4.Core (lumbopelvic and hip) stabilization exercises in knee immobilizer that do not
increase knee forces in varus, hyperextension, or tibial external rotation.
per week.
2.Resistance can be added to bicycling as tolerated. Biking done 3 to 5 times per week
for 20 minutes, and the lower extremities should feel fatigued post biking.
3.Advanced closed kinetic chain exercise progression: addition of unstable surface,
movement patterns, resistance, etc.
4.Return to run program once patient is able to perform 20 repetitions of involved lower
extremity single-limb squatting to greater than 60°of knee flexion with good control.
5.Plyometric progression: supported jumping, jumping, leaping, hopping, etc.
Weeks 3-6
Month 7 and Beyond (Week 28)
1. Continue with passive and active assisted ROM exercises 4 to 6 times per day. Patient
Goals: achieve maximum strength of operative extremity.
should achieve full extension at this time, and 120° of flexion.
1. Maintenance of home exercise program 3 to 5 times per week.
2. Continue with quadriceps sets and SLRs.
Note: Physician will give clearance for cutting and pivoting and sports simulation ac-
Phase 2
tivities as appropriate. Physician clearance is based on favorable outcomes with imaging
Weeks 7-12
studies, clinical exam findings, and functional progression with therapy. The coordination
1.Start partial weight bearing using crutches. Goal is to ambulate full weight bearing
of care between the surgeon and physical therapy staff is critical for a complete assess-
without crutches within 2 weeks. Patient must be walking without a limp to discharge
crutches. Discontinue knee immobilizer if able to perform SLR without a knee extension lag.
2.Initiate use of stationary exercise bike if 105° of knee flexion ROM is achieved. Working
ment of patient function and a complete recovery from the surgery.
Functional testing often performed at this time. A progressive return-to-play program
is initiated if the limb symmetry index is greater than 85% with functional testing and
satisfactory varus stress radiographs.
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