Post-surgical PCL Rehabilitation

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					Post-surgical PCL Rehabilitation
    Andrew Mallon & Mike Eleneski
Anatomy
            Anatomy
• Distal attachment to posterior tibial spine
• Proximal attachment lateral aspect
  medial femoral condyle
• Two bands
   – Anterolateral- larger, tightest @80-90
   – Posteromedial- loose 80-90, tightest full ext
           Anatomy
• ACL vs PCL
  – Shorter and less oblique than ACL
  – 120-150% cross-sectional area of ACL
  – PCL tightest full knee flexion, ACL full
    extension
      Biomechanics
• Primary function
  – Prevent posterior translation of tibia on the
    fixed femur, etc.
  – Absorbs 93% of posterior displacement in full
    extension
• Secondary functions
  – Prevent lateral translation of the tibia on the
    fixed femur
  – Prevent medial rotation of tibia (greatest @ 90)
  – Resist valgus and varus loads
         Mechanism
• Typical- fall on flexed knee
• Hyperextension
      Procedure

• The current controversies with PCL
  surgical technique are:
  – Tunnel versus inlay technique
  – Posterior inlay with single versus
    double tunnel
  – Allograft versus autograft
   Procedure- options
• Tunnel Technique
 Procedure- options
• Inlay technique
   – Single bundle
   – Double bundle
          Research
• ONLAY BETTER
       Research
• DOUBLE BUNDLE BETTER
              Long-term Goals

•   Protect graft site
•   Reduce effects of immobilization
•   Restore full ROM
•   Restore full strength
•   Return to full activity
General Considerations

  • No open chain hamstring work.
  • Approximately 8-12 weeks for graft to bone
     healing time.
  • Caution against posterior tibial translation
  • Typically no CPM.
     -why?
  • Typically begin ambulation without assistive
     devices at 8 weeks (if in conjunction with
     posterolateral capsule tear or LCL repair assistive
     device use for 3 mo).
  Phase 1: Weeks 0-4
• Pain management
  – Narcotic analgesics per physician
  – Ice
  – Electric stimulation
     • IFC
     • Sensory
     • 20 min
Phase 1: Weeks 0-4
• Inflammation control
  – Ice
  – Compression
  – Elevation
 Phase 1: Weeks 0-4
• Weight-bearing as tolerated with
  crutches
• Brace typically locked in extension at
  all times for 1st week
  Phase 1: Weeks 0-4
• ROM
  –   NO passive extension (post. tibial translation)
  –   Begin PROM at week 1
  –   Patella mobilizations
  –   Hamstring stretching
  –   Calf stretching
   Phase 1: Weeks 0-4
• Passive ROM
  – Supine flexion- maintain anterior translation
    on proximal tibia
     • NO wall slides or self-assisted flexion
  – Joint mobilization if extension lag
     • NO prone or supine hyperext hangs
Phase 1: Weeks 0-4
• Strength
  – Electric stimulation
  – Quadriceps setting
  – SLR
  – Ankle- therabands
Phase 1: Weeks 0-4
– Electric stimulation
   • Russian current
   • 10 contractions(5:1)
   • Motor level
 Phase 1: Weeks 0-4
– Quadriceps setting
– Russian stimulation
– SLR
   •   Flexion
   •   Adduction
   •   Abduction
   •   No extension
       (active OKC hamstring contraction)
  Phase 1: Weeks 0-4
• Cardiovascular maintenance
  – UBE
  – Airdyne handles
  Phase 1: Weeks 0-4
• Suture Removal
   – Optimal time for suture removal
     Location
     No. days
      Face 3–5
      Scalp 7
      Chest and extremities 8–10
      High tension (joints, hands) 10-14
      Back 10–14

• Scar tissue mobilization
   – Friction massage over scar may be
     start approximately 1 week post
     suture removal
  Phase 1: Weeks 0-4
• Effleurage- edema
  reduction
  – Begin after suture removal
    to decrease risk of infection
 Progression Criteria
• No signs of active inflammation.
• Good quadriceps strength
• Approximately 60 degrees knee
  flexion
• No patellofemoral pain
• Full knee extension
Phase 2: Weeks 4-12
• Short-term goals
  – Increase flexion
  – Increase quadriceps strength
  – Maintain lower extremity flexibility
  – Begin Gait training
Phase 2: Weeks 4-8
• Continue pain and inflammation
  control techniques.
• Weeks 4-6 Brace unlocked for
  walking in controlled environments
• Weeks 6-8 brace unlocked
 Phase 2: Weeks 4-8
• ROM
  – Continue patella mobilization
  – Continue prom flexion only
  – Addition of wall slides and self-assisted
    passive flexion
 Phase 2: Weeks 4-8
• Strength
  –   Russian stimulation
  –   Quadriceps setting
  –   SLR all directions
  –   OKC knee ext *0-70 ONLY
  Progression Criteria
• Increased strength
• 90 degrees knee flexion
• No patellofemoral pain
 Phase 3: Weeks 8-12
• Short-term goals
  – Increase flexion to 120 deg
  – Increase quadriceps strength
  – Maintain lower extremity flexibility
  – Begin Gait training
  Phase 3: Weeks 8-12
• Week 8 – brace and crutches
  discontinued with surgeon clearance
 Phase 3: Weeks 8-12
• Strength- add
  – Seated calf raises
  – CKC terminal knee extension
  – Leg press 0-90 degrees
 Phase 3: Weeks 8-12
• Cardiovascular conditioning
   – Begin use of bike and elliptical
• Neuromuscular control
   – Progressive balance regimen
    Progression Criteria
•   Near full, painfree ROM.
•   Normal gait.
•   Good quadriceps strength.
•   No patellofemoral pain.
Phase 4: months 3-6
• Goals
  – Restore residual loss of ROM
  – Increase strength
  – Improve neuromuscular control
  – Progress functionally
  Phase 4: months 3-6
• Continue ROM exercises
• Progress NMC exercises
 Phase 4: months 3-6
• Strength- add
  – Resisted squats, lunges, split squat to 90
     • Watch knee crossing toes(^ PCL strain)
  – CKC hamstrings
  – Weighted standing calf raises
 Phase 4: months 3-6
• Cardiovascular
  – Treadmill walking> running
 Progression Criteria
• Full ROM
• Strength within 10% bilaterally
• No patellofemoral pain
    Phase 5: months 6-9
•   Goals
•   Maintain/ improve strength
•   Maintain flexiblity/ROM
•   Functionally prepare athlete for
    return to play
 Phase 3: months 3-9
• Plyometric progression
  – Step ups
  – Bounding
  – Lateral hops
  – Depth jump
Phase 5: months 6-9
• Agility
   – Agility ladder
   – Cone drills
 Phase 5: months 6-9
• Sport specific activities
       Return to Play
•   Full ROM
•   Strength approx 10% bilaterally
•   No pain
•   Fully functional
Maintenance
Questions
          References
•    Bergfeld, J. Kambic,H. McAllister, D. Parker R. Valdevit, A.
    A BIOMECHANICAL COMPARISON OF POSTERIOR
    CRUCIATE LIGAMENT RECONSTRUCTION TECHNIQUES
•   Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation.
    Philadelphia, PA: Mosby Inc; 2003: 300-302.
•    Don Johnson MD, 2003 Update on PCL Surgery
    Techniques
•   Graham, S. Kambic, H. *Valdevit, A. *Parker, R. *Bergfeld,
    J. The Cleveland A BIOMECHANICAL COMPARSION OF
    POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONS
    USING A SINGLE AND DOUBLE BUNDLE TIBIAL INLAY
    TECHNIQUE *Clinic Foundation, Cleveland, Ohio.
•   Levange, P. Norkin, C. Joint Structure and Function 4th
    ed.F,A. Davis Co. Philadelphia, PA. 2005

				
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posted:9/1/2012
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