GEOFFREY S. VAN THIEL, MD/MBA
Assistant Professor - Rush University Medical Center
Team Physician - US National Soccer Teams
Team Physician - Chicago Blackhawks Medical Network - Ice Hogs
www.VanThielMD.com - [email protected]
Fax: (815) 381-7489 – Phone: (815) 381-7365
SPORTS MEDICINE SURGERY – HIP ARTHROSCOPY
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− Cutting edge information on the arthroscopic treatment of the hip, knee and shoulder −
R EHABILITATIONPROTOCOL
PosterolateralCornerReconstruction
Overview
Theposterolateralcornerkneereconstructionincludesreplacementofthepopliteus
tendonandthelateralcollateralligamentwithallografttissue.Thesestructuresfunction
topreventabnormalvarusopening,externalrotation,andposterolateralrotationofthe
injuredknee.Thus,itisimportantduringtheearlypostoperativeperiodthatstressnotbe
placedonthesegraftswiththesemotions.Thepatientneedstoobtainappropriatemuscle
strengthtopreventabnormalmotionoftheirkneebeforetheligamentreconstructioncan
betested.
Thisrehabprogramservesasageneralguidelineforpatientswhoundergothis
reconstructionwiththeunderstandingthatitmaybemodifiedintheindividualpatient's
caseorwithotherconcurrentkneeligamentsurgery.Itisveryimportanttorecognizethat
thesegraftscantakeuptotwoyearstohealsothesepatientsmustbefollowedupvery
closely.
AdditionalLigamentReconstructions
Sinceacuteandchronicposterolateralkneeinjuriesmostcommonlyoccurincombination
withotherligamentinjuries,someportionsofthisrehabprogram(suchasthetypeof
motionallowed)maybemodifiedbecauseofthetreatmentofotherconcurrentknee
ligamentinjuries.Forthisreason,thisrehabprogramservesasageneralguidelinefor
patientswhoundergothisreconstructionwiththeunderstandingthatitmaybemodified
intheindividualpatient'scase.
BraceUseandWeightbearing
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Brace:Thehingedkneebracewillbewornforthefirst6weeks.Itshouldbelocked
inextensionatalltimesexceptforrangeofmotionexercises.Thisincludes
ambulationandsleep.
Weightbearing:Touchdownfootflatweightbearingistobemaintaineduntil6
weekspostopwiththeuseofcrutches.
InitialModifyingFactors:
1. Avoidanceoftibialexternalrotationisnecessary(avoidexternalrotationofthe
foot/ankle,especiallywhensitting).
2. Avoidanceofisolatedhamstringexercises(duringkneeflexion)toavoidextra
posteriorandposterolateralstressonthehealingreconstructivetissuesfor4
monthspostoperatively.
PostopWeeks1-2
Elevationofthekneeabovetheleveloftheheartshouldbeperformedtominimize
swelling.Anicepackoracommercialcoldcompressiondevicewillalsobeutilizedtohelp
inpaincontrolandtominimizeswellingoftheoperativesite.
StrengtheningExercises
• Patientsaretoinitiatetheuseofquadricepssetsandstraightlegraiseswhich
shouldonlybeperformedintheirbrace.Quadricepssets,inwhichthepatient
maximallyfirestheirquadriceps(asiftheyaregoingtoperformastraightlegraise)
areperformedhourlytotolerance,whilestraightlegraisesinthebraceare
performed4-5timesdaily.
• Earlyinitiationofthesequadricepsexerciseswillhelptominimizepostoperative
quadricepsatrophyandkneeeffusions.
• Anklepumps
MotionExercises
• Ingeneral,thepatientisallowedtounlocktheirkneebracestartingattwoweeks
postoptoworkongentleROMexercises4timesdailyfrom0-90ºofkneeflexion.
• Patella/Tendonmobilization
PostopWeeks3-6
Duringthistime,patientswillbeworkingonfurtherquadricepsstrengtheningexercisesas
wellasincreasingtheirkneeROMtofullmotionastolerated.Ambulationwillcontinueto
bewiththeuseofcrutches.
MotionExercises
• Patientswillworkonmaintenanceoffullkneeextensionseveraltimesdaily.The
patientshouldalsoworkonincreasingtherangeofmotionoftheirkneewhile
workingonmotionwithanunlockedkneebrace5-6timesdailyto90º,orgreater,
bytheendofthethirdweek.
• Thegoalisforpatientstoachieveafullrangeofmotionoftheirkneebytheendof
weeksix.
Exercises
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Quadricepssetsandstraightlegraisesinthekneebracewillcontinuetobethemain
formofexerciseduringthisperiod.Ifthepatientcanperformastraightlegraise
withoutanyextensionsag(i.e.,thekneecanbeheldoutperfectlystraightin
extension),theyareallowedtoinitiatetheirquadricepssetsandstraightlegraising
exercisesoutsidethebrace.
Otherwise,theyshouldcontinuetodotheseinthebracewith30setsofquadriceps
sets,5-6timesdaily,and10-20straightlegraisesets,5-6timesdaily.
Patella/Tendonmobilization
Anklepumps
PostopWeeks7-12
Patientsareallowedtoinitiateweightbearingandlow-impactclosedchainedexercises
duringthistimeperiod.Itisimportantthatextrastressnotbeplacedonthe
reconstructionduringthistimeperiodsothatitwillheal.Evenforthebestof
reconstructiveprocedures,theyareindangerofstretchingoutandfailingifextrastressis
placedontheseligamentreconstructionsbyapatientwhodoesnotdevelopappropriate
motorstrength.Therefore,patientsshouldbeencouragedtocontinuetousethecrutches
untiltheycanwalkwithoutalimp.Theyshouldavoidanysignificantactivitiesuntiltheir
strengthgainsaremaximized.
Exercises
• Patientscontinuewithquadricepssetsandstraightlegraises.Quadricepssetswith
10-30repetitionsshouldbeperformed5-6timesdaily.Straightlegraiseswith1030repetitionsshouldbeperformed5-6timesdaily.Legpressesatone-quarterbody
weightmaybeperformedtoamaximumof70ºofkneeflexion.
• Doublekneebends
• Doublelegbridges
• Reverselunge–staticholds
• Beginningcordexercises
• Legpresstomax.70°kneeflexion
Allowedat8weeks
• Treadmill–walking7%incline
• Swimmingwithfins–lightflutterkick
ExerciseBike/StationaryCycling
• Theuseofanexercisebikemaybeinitiatedoncethepatientachieves105-110ºof
kneeflexion.Theinitialgoalofthisexerciseistoworkonfluidmotionratherthan
anincreaseinstrength.Thepatientshouldfirststartoutwithatotalof5minutes
ontheexercisebikeeveryotherday.Theymayincreasetheirtimeontheexercise
bikeaswellasworkupto20minutesdailybasedontheirkneeresponsetothis
activity.Ifthereisanysignificantsorenessoreffusions(swelling)developing,the
patientshouldbackoffofthetotalminutesanddaysutilizingtheexercisebike.
PostopWeeks13-16
Goals
1. Fullkneerangeofmotion.Patientneedstoseesurgeonifextensiondeficit>5ºor
flexion<110º.
2. Normalgaitpattern.
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3. Increaseinfunctionalstrengtheningprogram.
ExerciseProgram
1. Continuewithpreviousexercisesdailyoreveryotherdayastolerated.
2. Weightroomactivities:
a. Legpressmachine:continuetoworkwith20kg(45lbs)to50kgand
performtofatigue.Legflexionallowedtoamaximumof70ºofkneeflexion.
b. Squatrack/squatmachine:Halfsquats(notpast70ºkneeflexion)at½body
weight,10repetitions.Progresstofullbodyweightastolerated.
c. Continuebikingand/orswimmingprogramonadailybasis.Nowhipkicks
orflipturnsallowed.
PostopMonths4-6
Goals
1. Improvedquadricepsstrength/function
2. Increaseendurance
3. Improvecoordination/proprioception
ExerciseProgram
• Walkingprogram:20-30minutesdailywithmediumtobriskpace.Add5minutes
perweek.Mayprogresstorunningprogramundersurgeonsupervisiondepending
onotherconcurrentinjuries/surgeriesorevidenceofanyunderlyingarthritis.This
mustbeindividualizedaccordingtothepatient.Thepatientneedstobeableto
walkfastonuneventerrainwithoutpainpriortostartingjogging.Whenapatient
canwalk2to3mileswithoutproblems,joggingmaybeinitiated.Startwitha100
yardjog,followedby500yardsofwalking.Thisshouldberepeated5timesand
thenallowthekneetorest2to3daystoassessitssymptoms.Anincreaseof100
yardspersessionisgraduallyallowedovertime.
• Biking:Increasetheresistanceastolerated.Perform3-5times/weekat20minutes
persession.Onesthighs/legsshouldfeeldrainedonceoffthebike.
• Step-ups:Putfootofoperativekneeonstepandstepuponthestep.Repeatwithan
increaseinrepetitionsuntildoing100step-upsperday.Attempttotaketwiceas
longtostep-downfromthestepasonetakestostep-up.Increasestepheightas
tolerated.
WalkingandJogging
• Thismustbeindividualizedaccordingtothepatient.Thepatientneedstobeableto
walkfastonuneventerrainwithoutpainpriortostartingjogging.Whenapatient
canwalk2to3mileswithoutproblems,joggingmaybeinitiated.Startwitha100
yardjog,followedby500yardsofwalking.Thisshouldberepeated5timesand
thenallowthekneetorest2to3daystoassessitssymptoms.Anincreaseof100
yardspersessionisgraduallyallowedovertime.Patientswitharthritisorother
concurrentkneeligamentreconstructionswillhavethisprogrammodifiedtoalow
impactexerciseprogram.
PostopMonths7
• Continueonmaintenanceexerciseprogram3-5times/week.
• Nocompetitionorpivotsportsuntilclearedbysurgeon.
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Oneneedstostrivetoachievemaximumstrengthoftheoperationextremity.Even
wellplacedandfunctioninggraftscouldstretchoutovertimeifonereliesonthe
graftstomakethekneestableratherthanhavingappropriatelystrengthened
musclesprovidestabilitytotheknee.Forthisreason,patientswhohavethese
complexsurgeriesshouldparticipateinaregularlifetimeexerciseprogramto
maximizetheirsurgicaloutcome.
PatientscompleteBiodexandfunctionaltestingandhavevarusstressx-raysto
evaluatehealingpriortoclearanceforcompetition.
AdaptedfromDr.RobertLaPrade–TheSteadmanClinic
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