Knee arthroscopy from a
physios perspective
¢ Young
patient
¢ Active
lifestyle
¢ Traumatic
injury
¢ Athlete
¢ Functional
Goal Setting: Patient may need to attain functional independence in BADL’s and
also in relation to work demands and rarely to attain the sports activities
being played.
Indications for
Arthroscopic Repair/ Reconstruction:
¢ Injured
ligament (different healing capabilities)
¢ Location
& size of lesion
¢ Degree
of instability experienced by patient
¢ Other
associated injury – meniscal tear, articular damage etc
¢ Patients
desired level of function
¢ Risk
of re-injury
¢ Prevention
of future impairment
Arthroscopy – Physiotherapist’s
consideration
Indication
for ligament surgery –
Failed
conservative management, early degenerative changes seen, pain/ loss of
function.
Type
of ligament surgery:
Intra
articular, extra articular, combined procedures
Grafts
used:
Autograft,
allograft, synthetic, area of harvesting etc.
Pre-operative
physiotherapy
¢ Deficits
in pre-operative quadriceps strength influence function 6 months after ACL
reconstruction
David
Logerstedt et al, The Knee, 2013
Pre-operative
management & goals
‘Injuries around the Knee’
Symposium: Sancheti Parag et al, Br J Sports Med, 2010
¢ Oedema
Control
¢ Minimize
muscular atrophy
¢ Maintain
ROM as much possible
¢ Protected
ambulation
¢ Patient
education
¢ Restoration
of joint stability & motion
¢ Pain
free & stable weight bearing
¢ Sufficient
post-operative strength & endurance to meet functional demands
¢ Ability
to return to pre injury activities
Post-operative
management
- Maximum
protection phase – Weeks 1 – 4
- Moderate
protection phase – Weeks 4 – 8
- Minimum
Protection phase – Weeks 8 & beyond
Maximum protection
phase – weeks 1 – 4
TREATMENT
GOALS:
¢ Protect
healing tissues
¢ Prevent
reflex inhibition of muscles
¢ Reduce
joint effusion
¢ ROM
0 – 110°
¢ Active
control of ROM
¢ Weight
bearing 75% to tolerance (depends on specificity of tissue repaired)
¢ Early
controlled weight bearing does not compromise knee joint stability and provides
a better outcome in terms of VMO function
Tyler
TF Clin Orthop Relat Res, 1998
Intervention
Early:
Days 1 – 14
¢ RICE
¢ Gait
training – crutches PWB
¢ Passive
to active ROM (with range limiting braces if required)
¢ Using
CPM for ROM does not offer any additional benefits
Rosen
MA Am J Sports Med, 1992
¢ Patellar
mobilization
¢ Muscle
setting exercises – Quads, hams, adductors at multiple angles
¢ Assisted
SLR in supine (with brace when needed)
¢ Ankle
pumps
Late:
weeks 2 – 4
¢ Continue
previous exercises
¢ Full
weight bearing & closed chain exercises for hip & knee muscles (with
permission)
(Not
in meniscal injuries)
¢ Low
resistance PRE in open chain activities
¢ Core
stabilisation exercises
¢ Aerobic
conditioning – static cycles
¢ Physiotherapy
is equally effective as arthroscopic partial menisectomy for meniscal tears and
OA knees
Katz
et al. Engl J Med. 2013
¢ In
a RCT, home exercise program alone was better versus arthroscopy in addition to
home exercise program for chronic patello-femoral pain syndrome
Kettunen
et al Br J Sports Med. 2012
¢ Post-operative
physical therapy accelerated rehab in arthroscopic partial menisectomy:
Systemic Review with Metanalysis
Dias
et al J Orthop Sports Phys Ther 2013
¢ Electromyographic
feedback along with conventional exercise
therapy speeds up the rehab process
Akkaya
N et al Clin Rehabil. 2012
BRACING
¢ Using
a functional brace or a neoprene sleeve post arthroscopic repair helps in
improving joint position sense in early rehab phase
Beynnon
BD, J Orthop Sports Phys Ther, 2002;
Brandson
S et al Scand J Med Sci Sports, 2001
Moderate protection
phase weeks 4 – 10
TREATMENT GOALS:
¢ Full
pain free ROM
¢ Strength
Gr. 4/5
¢ Dynamic
joint (knee) control
¢ Improved
kinaesthetic awareness
¢ Normalise
gait pattern & ADL function
¢ Home
exercises program
Intervention
Early
– weeks 5 – 6:
¢ Multiple
angle isometrics
¢ Advanced
closed chain strengthening & PRE
¢ Stretching
exercises
¢ Endurance
training
¢ Proprioceptive
training – single leg, tilt board
¢ Stabilization
exercises with elastic bands
Proprioceptive training
and core strengthening
¢ Both
form important aspects of phase 2 rehabilitation.
Lephart
SM Am J Sports Med, 1997
¢ Lack
of core strengthening and proprioceptive training post arthroscopic cruciate
reconstruction have been found to be associated with reduced stability and
performance in patients
Cinar-Medeni
O, Am J Phys Med Rehabil, 2014
Intervention
Late
– weeks 7 – 10:
¢ Continue
with previous exercises
¢ Advance
strengthening (PNF patterns)
¢ Endurance
& flexibility training
¢ Advanced
proprioceptive training
¢ Walking/
jogging
¢ Initiate
plyometric training (with permission in athletes)
Minimum
protection phase weeks 11 - 24:
TREATMENT GOALS:
¢ Increase
strength, power & endurance
¢ Improve
neuromuscular control, dynamic stability & balance
¢ Improve
cardio pulmonary fitness
Joint stability
achieved by neuro musculoskeletal system
Intervention
¢ Continue
stretching program
¢ Advanced
PRE. Initiate isokinetic training if desired.
¢ Advanced
close chain exercises & plyometric drills.
¢ Advanced
proprioceptive training.
¢ Progressive
agility drills (fig of 8, specific drills)
¢ Progress
running program
Return to activity phase
– 6 months & beyond
TREATMENT GOALS:
¢ Increase
strength, power & endurance
¢ Regain
ability to function at highest desired level
¢ Maintenance
program
¢ Reduce
risk of re-injury
Balance and Proprioceptive Training
Plyometric Training (Sports Specific)
Intervention
¢ Progress
PRE & flexibility exercises
¢ Advanced
agility drills
¢ Sports
or occupation specific drills
¢ Need
of protective bracing prior to return to work or sports.
Current trends in
rehabilitation
¢ Shift
towards individually tailored/ modified programs depending on functional
requirement of the individual
¢ Functional
training programs – exercises similar to ADL’s of the individual
¢ Limited
Use of CPM machines
¢ Cryotherapy
pre-op/ post-op beneficial to control pain and swelling
¢ Functional
Testing to assess joint stability
¢ Emphasis
on Proprioceptive Training
¢ Patient
Perceived joint stability most important criteria for Prognosis
¢ Time
not a major factor in determining treatment progression
¢ ROM,
muscle strength and patient perceived joint stability most important criteria
for exercise progression
¢ Delayed
Surgery – faster strength recovery
Wasilewski et al 1993 , Shelbourne and Foulk 1995
Things to remember!
¢ No
fixed Protocol for rehab
¢ Modify
Exercises by regular patient evaluation
¢ Task
Specific and Functional Exercises more effective
¢ Rehabilitation
greatly influenced by level of motivation of the patient and compliance to the
exercise program
Dr. Parag Sancheti
Dr. Apurv Shimpi (PT)
Dr. Anand Gangwal (PT)
