[ 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

njuries to the posterolateral corner (PLC) of the knee are most ent and distinct biomechanics of each commonly associated with athletic traumas, motor vehicle accidents, structure, the PLC is inherently complex and falls.10 PLC injuries account for 16% of knee ligament injuries47 both anatomically and functionally. A thorough understanding of the anatomy, and often occur in combination with other ligament injuries.11,16 I biomechanics, and healing physiology is Overlooking this injury can lead to residual instability, which may lead essential for the successful treatment and to chronic pain or surgical failure in the presence of cruciate ligament rehabilitation of PLC injuries for patients reconstruction.18,25,26,42,43,56,57,60,62 The most common mechanisms to return to the highest level of function. The aim of this manuscript is the anato- leading to PLC injuries include a blow to ternal rotation torque applied with the my and biomechanics of the PLC, and to the anteromedial aspect of the knee knee in flexion11 or in hyperexten- review the evaluation, surgical treatment, with the knee at or near full ex- sion. The PLC is comprised of and rehabilitation of PLC injuries. tension, contact and noncontact various muscles and ligaments, knee hyperextension injuries, and with the exact structures varying, Anatomy and valgus contact force applied to a depending on the source of the Biomechanics flexed knee.44 Another mechanism description. Given the multitude of injury consists of a severe tibial ex- of structures involved and the inher- he description of the anatomy of the PLC varies depending on the source and nomenclature that is SYNOPSIS: Injuries to the posterolateral corner proprioception, and dynamic function of the knee. T t of the knee pose a significant challenge to sports The purpose of this paper is to provide an overview used. The PLC provides both static and medicine team members due to their complex of the anatomy, biomechanics, and mechanism dynamic stability to the knee to prevent nature. Identifying posterolateral corner injuries of injury for posterolateral corner injuries, with excessive hyperextension, varus angula- is paramount to determining proper surgical a review of clinical examination techniques for tion, and tibial external rotation. The management of the injured athlete, with the goal of identifying these injuries. Furthermore, a review of PLC is especially important for providing preventing chronic pain, instability, and/or surgical current surgical management and postoperative failure. Postoperative rehabilitation is based on the stability at lower angles of knee flexion specific structural involvement and surgical pro- guidelines is provided. (45°) in weight-bearing activities. Fur- cedures. A firm understanding of the anatomy and thermore, the PLC has been shown to t LEVEL OF EVIDENCE: Diagnosis/therapy, level biomechanics of the structures of the posterolat- 5. J Orthop Sports Phys Ther 2010;40(8):502-516. augment the contribution of the posterior eral corner is essential for successful rehabilitation doi:10.2519/jospt.2010.3269 cruciate ligament (PCL) to tibiofemoral outcomes. Emphasis is placed on protection of posterior stability, especially at 30° of the healing surgical repair/reconstruction, with KEY WORDS: fibular collateral ligament, multi- t 11,23,24,75 gradual restoration of range of motion, strength, ligamentous knee injuries, rehabilitation knee flexion. 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]

502 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 502 7/21/10 12:20 PM following anatomic structures and their provides an important secondary stabi- contribution to stability of the knee will lizer role to varus stability.65 The coro- be reviewed: iliotibial band (ITB), biceps nary ligament of the lateral femoris muscle, fibular collateral liga- extends from the popliteal hiatus to the ment (FCL), popliteus muscle, popliteo- popliteomeniscal fascicle. This is also fibular ligament, lateral gastrocnemius referred to as the meniscotibial portion muscle, lateral capsule, coronary of the posterolateral capsule. This struc- ligament, oblique popliteal ligament, and ture is important to provide resistance to the fabellofibular ligament. hyperextension and tibial posterolateral rotation.74 It also secures the posterior Static Structures horn of the meniscus to the .65 The The 3 most important stabilizing struc- oblique popliteal ligament is formed from tures providing static (passive) and a combination of an expansion of the dynamic (active) posterolateral knee semimembranosus complex and a por- stability are the popliteus tendon, pop- tion of the posterior oblique ligament.65 liteofibular ligament, and FCL ligament Muscular contraction of the semimem- (FIGURE 1).9 branosus muscle assists in the tightening The FCL serves as the primary static of this ligament. Anatomically, it forms stabilizer to varus opening at the knee part of the floor of the and from 0° to 30° of knee flexion,65 and it attaches to the posterolateral capsule at also provides a checkrein to external ro- the fabella region. The fabellofibular liga- tation of the tibia.45 This extracapsular ment spans from the lateral aspect of the structure originates just proximal and fabella and attaches to the fibular head.65 posterior to the lateral femoral epicondyle If there is no fabella, it originates from and spans roughly 7 cm to its insertion on the tendon of the lateral gastrocnemius.65 the fibular head.29,65 The popliteus muscle Clinically, it is thought to be an important originates from the posteromedial aspect lateral knee stabilizer in extension.65 of the proximal tibia,7,41 and its proximal tendon has multiple points of insertion Dynamic Structures collectively called the popliteus complex. FIGURE 1. Illustration demonstrating the isolated The dynamic structures of the knee that fibular collateral ligament, popliteus tendon, One such attachment to the posterome- popliteofibular ligament, and lateral gastrocnemius assist with posterolateral stability include dial aspect of the fibula is known as the tendon (lateral view, right knee). Reprinted with the popliteus muscle, the ITB, biceps popliteofibular ligament. This ligament is permission from the American Journal of Sports femoris, and the lateral gastrocnemius a static stabilizer resisting varus, external Medicine.46 tendon. The contribution of the popliteus rotation, and posterolateral tibial rota- complex to posterolateral knee stability is tion.46,54 Along with the popliteus muscle, and serves as both a dynamic and static described above, as it provides static and this ligament is considered a crucial stabi- stabilizer to the knee against external dynamic contributions to knee stability. lizer to the posterolateral knee and, there- tibial rotation.65 The ITB is a dense fibrous extension of fore, typically is surgically reconstructed Other static contributors to postero- the covering the when torn. The popliteus complex also lateral knee stability include the pos- and tensor fascia latae muscle. The ITB has a tibial attachment and 3 connections, terolateral joint capsule, the coronary originates from the anterior superior iliac or popliteomeniscal fascicles, to the lat- ligament, oblique popliteal ligament, spine, anterior border of the , and eral meniscus. Together, these structures and fabellofibular ligament. The postero- the external lip of the iliac crest.65 The in- stabilize the and prevent lateral joint capsule includes portions of sertion is located on the lateral intermus- medial entrapment of the meniscus when the posterior and the lateral joint capsule, cular septum, lateral aspect of the patella, varus forces are applied at the knee.69 The and spans from the anterior border of the and the anterolateral aspect of the lateral main tendinous attachment of the poplit- popliteus tendon’s insertion on the fe- tibial plateau at Gerdy’s tubercle.65 Dur- eus tendon is to the at the anterior mur to the lateral gastrocnemius attach- ing knee motion, the ITB moves anterior aspect of the popliteus sulcus, just pos- ment.65 The posterior capsule attaches in extension and posterior in flexion. terior to the lateral femoral condyle ar- to around the lateral femoral condyle. Along with the lateral ligaments and lat- ticular cartilage surface.41 The popliteus The mid-third lateral capsular ligament eral capsular structures, the ITB aids in provides dynamic internal tibial rotation is a thickening of the lateral capsule and lateral knee stability to prevent excessive

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 503

06_Lunden.indd 503 7/21/10 12:20 PM [ clinical commentary ]

varus in positions of knee extension. the knee and localized pain at the fibular acute PLC injuries. However, studies The is com- head or joint line upon palpation. looking at varus knee alignment66,78 estab- posed of a long and short head. The long lish a good foundation for the importance head originates from the ischial tuberos- Mechanism of Injury of critically observing and correcting ab- ity.65 The short head originates from the Mechanisms resulting in PLC injuries normal gait patterns as a means to protect middle third of the linea aspera and the include a posterolateral-directed force to the long-term health of the medial com- lateral supracondylar ridge of the femur. the anteromedial tibia, knee hyperexten- partment cartilage of the knee. The long head has 5 major insertions at sion,20 and/or severe tibial external rota- In addition to the increased adduc- the knee,65 divided into 2 tendinous and 3 tion while the knee is partially flexed. The tion moment found in the gait pattern of fascial components. The tendinous com- forces involved during the injury and the patients with PLC injuries, patients also ponents insert on the lateral and anterior patient’s anatomic makeup will dictate often demonstrate a knee hyperextension aspects of the fibular styloid. The fascial which specific structures are injured. In thrust during the loading response into component connects the long and short knee hyperextension injuries the pos- the early stance phase of gait. This hyper- heads of the biceps femoris to the postero- terior capsule is often strained or torn, extension thrust gait pattern observed in lateral aspect of the FCL. The short head followed by injury to the PLC and finally individuals with an ACL-deficient knee of the biceps femoris has multiple inser- the PCL.3 In a cadaveric biomechanical or those who are post-ACL reconstructive tions including a muscular attachment model, Csintalan et al11 demonstrated surgery is often referred to as a “quadri- onto the long head tendon, FCL, and the that external rotation injuries with the ceps avoidance pattern.”2 With this ab- ITB.65 Both heads assist the knee with knee partially flexed may result in tears normal gait pattern, a decrease in knee flexion and lateral rotation and aid in to the popliteus tendon, popliteofibular flexion moment and increase in hip flex- dynamic stability in preventing varus an- ligament, FCL, and the ACL. Following ion moment have been observed during gulation, controlling tibial internal rota- PLC injury, pain may be reported at the loading response.2 It has been postulated tion, and working synergistically with the medial and/or lateral joint line, or the that the hyperextension thrust is used as medial to prevent excessive posterolateral aspect of the knee. Often a strategy to stabilize the ACL-deficient tibiofemoral anterior translation. Surgi- described is functional instability which knee2,77; however, the lack of a proper cal repair of the biceps femoris is needed may include a feeling of the knee giving deceleration moment achieved through with avulsions from the fibula. If intact, a way into hyperextension with stairs or knee flexion and eccentric quadriceps portion of the biceps femoris tendon can graded ambulation.29 Perception of in- activation during loading response may be used as a tenodesis to the lateral femo- stability can also result with cutting or result in increased compressive forces at ral epicondyle to reconstruct the FCL. It pivoting movements. the tibiofemoral joint.66 is worth noting that the common pero- In the individual with a PLC injury, neal lies deep to the biceps femoris Gait the hyperextension thrust gait pattern tendon and can be involved with PLC in- Due to the knee instability resulting from may be the result of significant genu re- juries. The lateral gastrocnemius tendon an injury to the PLC, the gait pattern is curvatum instability rather than quadri- originates around the supracondylar pro- often altered to an extent that the patient ceps weakness, due to injury to multiple cess of the distal femur.41,65 At the knee, cannot employ a muscular compensation static and dynamic posterior lateral sta- this structure blends with the posterior strategy to effectively stabilize the knee. bilizing structures. Further complicating capsule and popliteofibular ligament to A varus thrust of the knee is often seen the gait pattern of a patient with a PLC assist with posterolateral stability.46 during the loading-response phase of gait injury is the fact that these patients may in individuals with a chronic posterolat- also present with a footdrop gait pattern Evaluation eral knee injury, especially those with due to an injury to the common peroneal underlying varus osseous alignment. The nerve. With the known deleterious effects t is important for clinicians to ac- varus thrust gait pattern is likely associ- of faulty gait mechanics on the health of curately evaluate and assess posterolat- ated with a lift-off of the lateral compart- the knee’s articular cartilage, it is critical Ieral knee injuries. Failure to diagnose ment of the knee, which has been shown to address the muscular control and re- and treat a PLC injury in a patient who to significantly increase medial compart- cruitment deficits to normalize lower ex- has a PCL or anterior cruciate ligament ment joint stresses and ultimately hasten tremity kinematics and minimize medial (ACL) tear requiring reconstruction can medial compartment cartilage wear if compartment knee joint stresses. result in failure of the cruciate ligament left untreated.68,78 Currently, there are no graft.10,18,25,42,43,56,57,60,62 Examination of in- studies specifically addressing the effects Associated Injuries juries to the PLC may reveal diffuse ten- of acutely induced high adduction mo- Because of the risk for vascular injuries derness over the posterolateral region of ments, as seen in patients with traumatic with knee trauma, it is important to

504 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 504 7/21/10 12:20 PM screen for vascular compromise. There- fore, it is critical to palpate for pedal and posterior tibial pulses at the and and/or to perform an ankle- brachial 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. FIGURE 3. The prone dial test. With the patient prone, the examiner rotates the tibia through the foot Weakness is often seen in ankle dorsi- and observes the amount of tibial external rotation flexion, foot eversion, and great toe ex- FIGURE 2. Posterolateral drawer test. The patient is present at 30° of knee flexion (pictured) and 90° of tension, presenting with a resultant drop positioned supine, with the knee flexed 80° to 90° knee flexion. foot and steppage gait. The prevalence of and the foot externally rotated 15°. While the clinician peroneal nerve injuries in patients with stabilizes the patient’s foot, a posterolateral drawer force is applied. PLC injuries has been reported to be 13% and should not be overlooked.44 Depend- tation at 90°, which would be utilized ing on the amount of motor deficit, pero- to assess a PCL injury.30 Sensitivity and neal nerve injuries may be treated with specificity values have not been reported an ankle foot orthosis initially, and a for the posterolateral drawer test in diag- tibialis anterior or extensor hallucis lon- nosing PLC injuries. gus tendon transfer may be performed The Dial test may be performed with in patients who have no return of motor the patient positioned either supine or function following completion of PLC prone7,73 and has been shown to have rehabilitation. substantial agreement within and be- tween testers.32 If a PCL-PLC combined Special Tests injury is suspected, performing the Dial FIGURE 4. The external rotation recurvatum test. There are several special tests for PLC test with the patient in prone or adding With the patient supine, the examiner stabilizes injuries that can and should be used to an anteriorly directed force to the tibia the patient’s distal femur with 1 hand and lifts the help confirm a diagnosis. We will review while testing in the supine position can patient’s great toe with the other hand, to observe the amount of . the posterolateral drawer, Dial, external increase the amount of tibial external ro- rotation recurvatum, varus stress, reverse tation observed and would presumably is indicative of a potential injury to the pivot-shift, and standing apprehension increase the sensitivity of the test.32,73 PLC, or more specifically, the popliteus tests. However, sensitivity and specificity val- complex.1 A positive test at both 30° and The posterolateral drawer test is per- ues have not been reported for the Dial 90° of knee flexion indicates both a PCL formed with the patient in supine, with test. With the patient supine, the knee is and PLC injury.1,73 the knee flexed to 80° to 90° and the foot flexed off the edge of the examining table The external rotation recurvatum test externally rotated 15°. While the clinician to 30° and then 90° with the stabi- may be used to detect a concomitant PLC- stabilizes the patient’s foot, a posterolat- lized against the table.55 The foot is exter- ACL injury.30,40 The external rotation re- eral drawer force is applied (FIGURE 2).30 A nally rotated, while the examiner records curvatum test is performed by lifting a positive posterolateral drawer test, indi- the amount of external rotation of the tib- supine patient’s great toe, while gently cated by increased posterolateral rotation ial tubercle compared to the uninvolved stabilizing the distal thigh and observ- compared to the contralateral knee, may limb (FIGURE 3). An increase of greater ing the relative amount of genu recurva- implicate injury to the popliteus tendon, than or equal to 15°, as compared to the tum present.30,43,48 The test is considered popliteofibular ligament, and FCL. This contralateral side, is considered positive.1 positive if the amount of genu recurvatum should not be confused with testing the A Dial test that is positive at 30° of knee measured by either a goniometer or heel knee in neutral rotation or internal ro- flexion but normal at 90° of knee flexion height off the examination table is greater

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 505

06_Lunden.indd 505 7/21/10 12:20 PM [ clinical commentary ]

and the mid-third lateral capsular liga- ment.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 con- tralateral 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 me- dially 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 FIGURE 5. The varus stress test. With the patient giving-way sensation, indicates a positive supine, the distal thigh is stabilized against the exam test.10 The standing apprehension test table, while the examiner palpates the lateral joint FIGURE 6. The reverse pivot shift test. With the line. The knee is flexed to 30° (pictured) off the edge patient supine, the examiner flexes the knee to 45° was reported to have 100% sensitivity of the exam table and a varus stress is applied to the and a valgus plus external rotation force is applied for reproducing posterolateral instability knee through the foot/ankle. The test is repeated at to the knee (A). The patient’s knee is then extended in patients with a history of an ACL re- (B). If the tibia posterolaterally subluxes, the iliotibial 0° of knee flexion (not pictured). construction or other arthroscopic knee band will reduce it as it goes from a flexor to an 18 extensor of the knee. surgery. Specificity for the standing ap- than the contralateral knee. The postero- prehension test has not been reported. It lateral structures potentially involved examiner feels an increased amount of should be noted that injury to the ana- with a positive test include the coronary translation as compared to the contralat- tomical structures of the PLC was not ligament to the lateral meniscus, popliteus eral knee. The injury is graded according confirmed either by imaging studies or tendon, and the structures which attach to to the amount of subjective translation operative examination, thus the standing the fibular head: fabellofibular ligament, (or joint opening) and the perceived qual- apprehension test should only be consid- biceps femoris, popliteofibular ligament, ity of resistance at the endpoint. A grade ered useful to reproduce a patient’s symp- and FCL. Caution is warranted in inter- I FCL sprain shows mild gapping with a toms of knee instability. preting the external rotational recurva- firm endpoint, grade II shows moderate tum test, as it has been shown to have a gapping with an endpoint, and a grade Imaging high incidence of false negative results for III shows gapping without an endpoint. In cases where there is significant edema ACL-PLC injuries,40 and it is rarely posi- A positive varus stress test at 30° is in- present, a clinical exam may be equivo- tive in patients with PCL-PLC or isolated dicative of a complete tear of the FCL cal and diagnostic imaging will assist in PLC injuries.72 Specifically, the sensitivity (FIGURE 5). A positive varus stress test at 0° making a diagnosis. Furthermore, diag- of the external rotation recurvatum test of knee extension indicates a more severe nostic imaging is a useful tool to assist for ACL-PLC injuries has been reported injury, which may include the PCL,23,24 with identification of specific anatomical as 30%, while the specificity was 100%.40 FCL, meniscotibial ligament, popliteus structures involved. Plain radiographs The varus stress test is performed tendon, and the superficial layer of the may reveal a fibular head fracture, lat- with the patient supine, with the proxi- ITB.44 However, data on the sensitiv- eral joint space widening, or avulsions of mal femur stabilized on the examination ity and specificity of the varus stress test the lateral capsule. Magnetic resonance table. The examiner stabilizes the tibia have not been reported. imaging that includes a coronal oblique from unwanted rotation and applies a A positive reverse pivot shift may in- image plane in all sequences of the entire varus stress to the knee through the foot/ dicate an injury to the PLC. Specifically, fibular head and styloid process can be a ankle, first with the knee at 30° of flexion the reverse pivot shift test is positive with helpful diagnostic tool in assessing struc- and repeated with the knee extended to injuries to the following anatomic struc- tural integrity of the PLC, as it has been 0°. The test is considered positive if the tures of the PLC: FCL, popliteus complex, found to accurately assess the integrity

506 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 506 7/21/10 12:20 PM 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 Grading Scales for PLC injury to a left knee. White arrow points to a TABLE disruption of the fibular collateral ligament. Orange Injuries of the Knee arrow points to an avulsion of the popliteus off of its insertion on the lateral femoral condyle. Black arrow Fanelli Scale for PLC Injury (location based) points to a complete tear of the lateral capsule with A: injury to popliteofibular ligament, popliteus tendon unrooting of the lateral meniscus. B: injury to popliteofibular ligament, popliteus tendon, and FCL C: injury to popliteofibular ligament, popliteus tendon, and FCL, lateral capsular avulsion, and cruciate of most of its components (FIGURE 7).34,79 Imaging can also be very useful in de- ligament disruption termining avulsion versus midsubstance Hughston Scale for Collateral Ligament Injury (instability based) injuries. Stress radiographs are very help- 1+: varus opening, 0-5 mm* ful to assess for chronic PLC injuries. 2+: varus opening, 5-10 mm* LaPrade et al36 evaluated the use of varus 3+: varus opening, 10 mm* stress radiographs with the knee at 20° Varus stress radiographs (sectioning based) of flexion to provide objective and repro- FCL: varus opening, 2.7 mm* ducible measures of lateral compartment FCL, popliteus tendon: varus opening, 3.5 mm* gapping, and reported a grade III PLC in- FCL, popliteus tendon, popliteofibular ligament: varus opening, 4 mm* jury should be suspected if an increased Abbreviations: FCL, fibular collateral ligament; PLC, posterolateral corner. * Increased opening compared to contralateral knee. opening of approximately 4 mm is found (FIGURE 8). son classification (old American Medical clude the popliteofibular ligament and Classification Association) is a subjective clinical-based popliteus tendon, and only an increase in Injuries to the PLC can be graded using test and that the actual numbers quoted knee (tibial) external rotation is observed 2 different classifications proposed by for the amount of instability are inaccu- upon clinical testing. Type B injuries in- Hughston28 and Fanelli17 that are based rate. While we recognize that this grading clude the popliteofibular ligament, pop- on the amount of excessive laxity or struc- scale is very important for making clini- liteus tendon, and FCL, and, clinically, tures involved (TABLE). cal decisions, it is also important that the an increase in tibial external rotation is Hughston28 reported 3 grades to clas- amount of instability is much less than present along with mild varus opening to sify collateral ligament injuries of the that which was subjectively proposed by varus stress testing at 30° of flexion. Type knee. Grade 1+ instability is indicated both the American Medical Association C injuries involve the popliteofibular by opening of the affected joint by an and Dr Hughston in their grading scales. ligament, popliteus tendon, FCL, lateral amount of 0 to 5 mm with varus stress; If one reads an article on a surgical proce- capsular avulsion, and cruciate ligament grade 2+ is indicated by opening of 6 to dure that does not return the knee stabil- (ACL and/or PCL) disruption. With type 10 mm; and grade 3+ with an opening of ity back to less than 2 mm, the procedure C PLC injuries, the clinical exam reveals greater than 10 mm. Our own section- would be regarded as a failure under increased tibial external rotation and ing studies have revealed a fault in the stress radiograph grading, while subjec- marked varus instability at 30° of knee old subjective grading scales that were tively it may be felt to be acceptable. flexion. Once the grade of injury is es- not based on actual science (TABLE).36 It The Fanelli17 scale classifies injuries tablished, the clinician can determine is important to point out that the Hught- into type A, B, or C. Type A injuries in- the course of management. Grade 1+ and

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 507

06_Lunden.indd 507 7/21/10 12:20 PM [ clinical commentary ]

2+ PLC injuries may respond to conser- agement, restoration of range of motion, outcomes for acute versus chronic PLC vative management; however, grade 3+ and quadriceps muscle activation. Pa- injuries, we treat patients with grade 3+ PLC injuries are best treated with surgi- tients are progressed to the second phase PLC injuries surgically. cal reconstruction. of rehabilitation once knee extension is restored to within normal limits of the Surgical Treatment Nonsurgical Management contralateral knee, knee flexion is greater than 120°, and they are able to perform a urgical treatment of the PLC onservative management of supine straight leg raise (SLR) without a can vary, depending on the struc- PLC injuries is not well document- knee extension lag. The second phase of Stural involvement and the time Ced in the literature. This is most rehabilitation is devoted to normalization frame of the procedure from the date of likely due to the fact that PLC injuries are of gait mechanics and increasing muscle injury. However, the goals of the recon- typically combined with an injury to one strength. Lower extremity strengthening struction are the same for all the proce- of the cruciate ligaments, for which sur- exercises are particularly focused on the dures: to have a stable, well-aligned knee gical management is indicated. In addi- quadriceps, hamstrings, gastrocnemius, and to restore the preinjury kinematics tion, patients with isolated grade 1+ and and popliteus. During later phases of of the knee joint.9 Surgical management 2+ PLC injuries, for which conservative rehabilitation, emphasis is placed on the of isolated acute PLC injuries has been treatment may also be appropriate, often lateral hamstrings and lateral gastroc- reported to result in more successful out- may not present for treatment. Deleo et nemius to control varus moments at the comes than chronic injuries.6,10,39,75 Acute al12 presented a case study of an 18-year- knee. Emphasis is also placed on control injuries include grade 3+ PLC injuries re- old female who sustained a noncontact of tibial external rotation with the medial constructed within 3 weeks of the injury. grade II FCL sprain with concomitant hamstrings by having the patient perform All major structures of the PLC should posterolateral instability. The patient traditional strengthening exercises modi- be evaluated, including the ITB, biceps was able to return to her previous level fied with the tibia positioned in internal tendon, popliteus, FCL, popliteofibular of activity, which included reserve officer rotation.50 Furthermore, a program of hip ligament, and the peroneal nerve.9 Surgi- training, 23 weeks following her injury, and lumbopelvic stabilization exercises is cal approaches can vary, and an extensive with 9 weeks of intensive physical ther- included. Patients are typically advanced report is beyond the scope of this paper. apy (23 visits) that included fibular head from the second phase, when normal In general, it is recommended that an- mobilization followed by taping of the gait pattern has been restored. Phase 3 atomic repairs or reconstructions of the fibular head and perturbation training, of PLC rehabilitation is devoted to neu- PLC structures be performed. Similar to in addition to transcutaneous electrical romuscular control and strengthening the outcomes following reconstructions nerve stimulation and range-of-motion with functional movement patterns. Par- of the cruciate ligaments, it has been and strengthening exercises. ticular emphasis is placed on control of found that the outcomes of delayed pri- Our approach to conservative man- knee varus and tibial external rotation mary repairs and sling procedures of the agement of PLC injuries is to initiate an at lower angles (45°) of knee flexion PLC structures also have less than opti- accelerated form of the postsurgical re- in weight bearing. Verbal, manual, and mal outcomes as compared to anatomic habilitation outlined in detail below. The visual cueing with the use of a mirror reconstructions.37 Primary repairs of the program is accelerated compared to the or video feedback are all utilized to in- FCL may be performed within the first 2 postsurgical PLC program, as progres- crease the patient’s control with weight- to 3 weeks after injury. After this time, sion for the conservative management of bearing activities. Functional testing and the avulsed structures retract so that the PLC injuries is not dependent on allograft training, including timed balance and tissue cannot be restored to its native healing timelines but is based on anthro- single-limb squat for depth, and hop anatomic location.37 Furthermore, the pometric measures, functional progres- testing (single- and triple-crossover hops torn structure becomes necrotic after 3 sion, and symptom and impairment for distance and timed hop for speed), weeks and does not hold sutures well.37 resolution. Briefly, the rehabilitation of are performed.64 Once patients achieve Therefore, primary repairs of the FCL the isolated PLC is based on the patient’s a limb symmetry index of greater than are not recommended at greater than presentation. For patients who have in- 85% on functional testing, they are pro- 3 weeks following injury and require a creased gapping on stress radiographs gressed to phase 4 rehabilitation. Finally, reconstruction. But, regardless of when but who don’t have a complete FCL tear, phase 4 of PLC rehabilitation is devoted the surgery is performed, midsubstance the use of a medial compartment unload- to sport-specific drills, with a gradual re- tears of the FCL cannot be repaired and er brace for high-level athletic activities turn-to-play program. Due to the rarity require a reconstruction. Our recom- may be indicated. As with all knee inju- of reported treatment of isolated grade 1+ mended technique for a FCL reconstruc- ries, the goals for phase 1 are edema man- and 2+ PLC injuries and superior surgical tion follows the description by Coobs

508 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 508 7/21/10 12:20 PM 9 A B the ITB is split in line with its fibers and heads of the biceps femoris. Reconstruc- retracted to expose the proximal attach- tion of a coexisting cruciate ligament ments of the FCL and popliteus tendon.9 tear should be concurrently addressed A second fascial incision is made parallel with a combined injury. It is important to the long head of the biceps femoris.9 for therapists to consult the physician Dissection occurs to reveal the popliteo- and/or review the operative notes due to fibular ligament’s attachment site.9 Two variation and complexity among surgical grafts from a split al- procedures. Therapists should also have lograft are used for reconstruction. The understanding and appreciation of the first is used to reconstruct the popliteus postoperative precautions and restric- tendon and the second to reconstruct tions. This will lead to a better under-

FIGURE 9. The posterolateral knee reconstruction both the popliteofibular ligament and standing of this region of the knee and 9 procedure. (A) Lateral view, right knee; (B) posterior the FCL. These structures have been assist with optimal outcomes. view, right knee. Abbreviations: FCL, fibular collateral found to be the most important stabiliz- ligament; PFL, popliteofibular ligament; PLT, popliteus ing structures and act in concert with the Postsurgical tendon. Reprinted with permission from the American cruciate ligaments to provide overall knee Rehabilitation Journal of Sports Medicine.38 stability.64 et al,7 in which an autogenous semiten- Chronic PLC injuries tend to be a ostsurgical rehabilitation of dinosus graft is harvested and sized to more complex problem than acute inju- PLC reconstruction typically spans fit into reconstruction tunnels reamed ries. This can be due to extensive scar- P6 to 9 months. At the initial visit, at the anatomic attachment sites of the ring, secondary changes to surrounding patients need to be aware of the rehabili- FCL. For complete nonrepairable acute structures, and potential limb malalign- tation timetable, help create attainable ligament tears or chronic attenuation of ment.10 A multistep procedure with a goals, and become an active participant the main posterolateral knee structures, correction of a genu varum deformity in both the clinical treatments and their multiple repair and reconstructive proce- initially needs to be considered. This can individual home exercise program. Phy- dures have been reported, including FCL be addressed through a proximal tibial sician guidelines, such as weight-bearing reconstruction,75 FCL reinforcement with osteotomy and should be done prior to restrictions, allowable knee motion rang- the use of an allograft,58 femoral bone- soft tissue reconstruction. The goal is es, avoidance of knee hyperextension, block advancement,29 proximal tibial os- to prevent excessive loads on the lateral and avoidance of tibial external rota- teotomy,35,59 biceps femoris tenodesis,5,15,76 capsular structures that are to be poten- tion, should be reviewed and reinforced. popliteus tendon and popliteofibular lig- tially reconstructed after the osteotomy Restrictions may vary with individual ament reconstruction,75 popliteus recess heals.35,55,75 Some, but not all, of the other physicians and structures involved. It is procedures, and ITB or biceps femoris techniques to reconstruct/approximate the physical therapist’s responsibility to graft.75,76 However, an anatomic recon- the FCL are Achilles tendon allograft, obtain this information and utilize it to struction of the FCL, popliteus tendon, bone patellar bone autograft, and teno- guide the treatment. and popliteofibular ligament are recom- desis of the biceps femoris tendon. Surgi- Rehabilitation in advance of the sur- mended (FIGURE 9).38 cal repair of the FCL may be performed gery or “prehabilitation” is an optimal At the University of Minnesota Sports if it is avulsed off of its femoral or fibular course of care and should be considered, Medicine Institute, we advocate the sur- attachments. Midsubstance tears of the when possible, to allow for better surgical gical procedure developed in our biome- FCL can be augmented with a portion of outcomes by preventing contractures that chanics lab,38 for which clinical outcomes the biceps femoris or reconstructed. If may affect postsurgical range-of-motion have been published by LaPrade et al.37 the ligament is absent or if chronic PLC or intraoperative difficulty in obtaining A brief overview of a procedure is sum- injury is present, a reconstruction may be native graft placement. Patients are seen marized below. The initial incision to ex- indicated.75 prior to surgery to regain range of mo- pose the PLC begins as an 8- to 10-cm The popliteus complex may be re- tion, to increase quadriceps control, to hockey stick-shaped incision, originating constructed with autograft, review and provide patients with a post- over Gerdy’s tubercle.9 Multiple fascial Achilles tendon autograft, or ITB auto- operative rehabilitation protocol and re- incisions can then be used to access the graft. Sutures can be used to repair tears strictions, and to discuss any questions specific components of the PLC. The sur- to the coronary ligament of the posterior patients might have entering the proce- gical approach to repair of posterolateral horn of the lateral meniscus, the pop- dure. Patients can utilize aquatic centers injuries should take a deep to superficial liteomeniscal fascicles, portions of the to increase range of motion and mobility approach. The superficial fascial layer of ITB, and portions of the long and short prior to surgery, by being able to stress

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 509

06_Lunden.indd 509 7/21/10 12:20 PM [ clinical commentary ]

their more effectively, without the range of motion, and quadriceps activa- to 10 seconds with each repetition, with associated pain from full weight bearing. tion. Edema control can be addressed full relaxation of the limb for 2 to 3 sec- This paper will follow the guidelines through cryotherapy, compression, el- onds between repetitions. SLRs may also of Robert F. LaPrade, MD, PhD for a evation, and skeletal muscular pumping, be performed with a goal to achieve simi- posterolateral reconstruction involving repetitive ankle dorsiflexion, and plantar lar values of repetitions and frequency as the popliteus tendon, popliteofibular flexion. The patient remains with the the quadriceps-setting exercise. SLRs are ligament, and the FCL (APPENDIX). These knee in full extension for the initial 1 to to be completed in the knee immobilizer guidelines may be modified with a con- 2 weeks. This is to allow for the prolif- until a SLR can be performed with the current knee ligament injury. Postop- eration of fibroblasts and the formation absence of knee extension lag. It is cru- erative restrictions for the first 6 weeks of collagen and ground substance (fibro- cial to regain quadriceps function early postoperatively include being non-weight plasia), which will result in the forma- in the rehabilitation process. Core (lum- bearing and remaining in the knee im- tion of granulation tissue. Patients can bopelvic and hip) strengthening, such as mobilizer at all times other than for then progress with protective motion to abdominal and gluteal setting exercises, range-of-motion exercises. For the first stimulate collagen formation and align- can begin immediately and progress as 4 months postoperatively, closed kinetic ment.21 Range of motion begins with the strength allows and should be performed chain (squatting) exercises are limited to patient passively or actively assisting the while wearing the extension splint. SLR 70° or less knee flexion, tibial external ro- motion of flexion and extension at the exercises in sidelying and prone can be- tation is avoided, and resistive or repeti- knee. Patellofemoral mobilizations in all gin initially at patient tolerance and are tive hamstring exercises with the knee directions are important for prevention performed while in the knee immobilizer. in flexion are avoided. Patients are kept of arthrofibrosis and to maximize range- Patients should wear a knee immo- non-weight bearing for 6 weeks to allow of-motion gains in the initial phases of bilizer at all times during the initial 6 for healing of the reconstruction and to rehabilitation. Excessive hyperextension weeks. Exceptions include when per- prevent stretching of the graft from varus should be avoided to prevent excessive forming range-of-motion exercises and forces placed on the graft during ambu- posterior stress at the knee. Consulting quadriceps isometrics with the knee in lation.45 The rationale for hamstring with the treating physician as to optimal extension. The patient can typically be- avoidance is primarily based on surgeons’ extension goals to be achieved is recom- gin gentle active, active-assisted, and/or anecdotal information. Markolf et al49 mended. After 105° of knee flexion is passive range-of-motion exercises at the have demonstrated that activation of the achieved, stationary cycling can be used. end of the first or second postoperative hamstrings significantly increased mean Initially, the bicycle is to be used to ob- week. Goals should be set at achieving 0° forces applied to the PCL, when the knee tain fluid motion using a low constant re- to 90° of flexion by 2 weeks and full range was in more than 30° of flexion. Patients sistance. Cycling cleats are not allowed. of motion by 6 weeks. Full extension on should be educated in the avoidance of Patients begin with 5-minute sessions a mat/floor is permitted, but stretching tibial external rotation to prevent over- and slowly work up to 20 minutes a day. into hyperextension should be avoided. stretching of the surgical reconstruction. Significant soreness or effusion is an in- At the completion of the sixth week This includes avoidance of sitting with dicator to reduce the duration and/or postoperatively, the patient will typically the legs crossed, sitting with an excessive frequency. follow up with the physician. Reevalua- toe-out posturing, or pivoting away from Early quadriceps activation can be tion of the knee’s structural integrity will the fixed weight-bearing surgical lower achieved with isometric exercises. Elec- occur via clinical examination, and the extremity. Patients often inquire as to a tromyographic biofeedback,13,53 neuro- weight-bearing restriction will be lifted timeline for driving. If the left knee is re- muscular electrical stimulation,19,70,71 if appropriate. Criteria for progression constructed, driving can occur after the taping,22 or other techniques may be uti- to phase 2 or the weight-bearing phase first week. If the right knee is reconstruct- lized to increase quadriceps recruitment. are based on allograft healing timelines.67 ed, patients can begin driving around 7 to Our clinic has found the best success in The early phase of graft healing is from 0 8 weeks postoperatively, when specified facilitating quadriceps activation through to 4 weeks postoperatively and is marked impairments have resolved enough to al- the use of electromyographic biofeed- by increasing necrosis, with decreasing low them to exhibit a normal gait pattern. back. Patients should strive to perform mechanical strength of the graft, until The patient should be comfortable with up to 30 repetitions of quadriceps sets, the sixth week postoperatively.67 There- brief, rapid, lower extremity movements 5 to 6 times a day, as symptoms allow. To fore, weight bearing is restricted during to negotiate braking. ensure quality of exercise, not quantity of this time. The proliferative phase of graft After reviewing the initial restrictions exercise, patients should be encouraged healing is from week 4 to week 12, when with the patient, the rehabilitation focus to work to the point of muscle fatigue by cell numbers increase and revasculariza- should center on edema control, gentle holding the quadriceps contraction for 8 tion occurs.67 Therefore, in function, of

510 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 510 7/21/10 12:20 PM the strength deficits present in most pa- tients following PLC surgery, full–body- weight squats are typically instituted at the 12-week mark. Resisted hamstring activity and closed kinetic chain exercises at depths greater than 70° of knee flex- ion are restricted until the fourth month postoperatively, because of the possible FIGURE 10. Bridge on stability ball. This exercise may continued graft vulnerability to stretch- be used during earlier phases of rehabilitation of posterolateral knee reconstructions to strengthen the FIGURE 11. T-reach exercise. This exercise may ing with these activities. The ligamenti- hamstrings. An extension splint must be worn during be used during later phases of rehabilitation for zation phase of graft healing occurs from this exercise for the first 6 weeks postoperatively. posterolateral knee reconstruction to strengthen the approximately 12 weeks to 12+ months hamstring muscle groups. Rotation through the hip postoperatively and involves graft re- community mobility. By the end of the can be added to increase difficulty and preferentially modeling toward restoration of the physi- second week of allowed weight bear- strengthen the lateral or medial hamstring muscles. ological and mechanical properties of the ing (eighth week postoperatively), the native graft.67 However, at this point, the patient should be able to discontinue forces of the lower extremity. This might later phases are guided more by objective crutch usage. Normalization of gait and involve manual perturbation or simply strength and proprioceptive measures confidence on the lower extremity should maintaining balance on varying surfaces than graft healing timelines. be the focus. Particular focus should be with a taught resistive band placed me- At 6 weeks postoperatively, patients placed on the loading and midstance dially or laterally above the knee. Also may progress to phase 2 of rehabilita- phase of gait to ensure a return to nor- during this time, weight-bearing and tion, if they have no signs of effusion, mal kinematics and kinetics of the lower low-impact closed kinetic chain exercises can demonstrate a supine SLR without extremity. A primary goal is to abolish with the knee in less than 70° of flexion a knee extension lag, exhibit 0° of knee the varus thrust pattern often observed can be added. This includes using a leg extension, and have greater than 120° of presurgically.59,61 Quadriceps activation press with up to 25% of the patient’s knee flexion. Therapists will assist the for deceleration of body mass during the body weight, with emphasis on eccentric patient with a weight-bearing progres- loading phase of gait and control of limb quadriceps strengthening for muscular sion and crutch weaning. Weight-shift- position throughout the stance phase are endurance initially, with progression to ing exercises in sitting or standing with critical. Electromyographic biofeedback concentric strengthening for muscular upper extremity support are advisable of the quadriceps muscle group during strength and power. Repetitions should in the early stages of weight bearing. gait simulation drills or actual gait train- be performed until fatigue and termi- Dependence on upper extremity sup- ing can be a useful tool for restoring a nated if symptoms arise. Closed kinetic port is reduced until the patient is ul- normal pattern of muscle activation. chain exercises should be progressed timately able to balance independently Video-based gait analysis is also a useful from double-limb support to single- on the surgical limb and ambulate with tool for restoring normal gait mechanics. limb support per the patient’s strength an even stride length and symmetrical Eccentric hamstring control during mid- and alignment control. Static holds in a stance time. Crutch weaning is best per- stance and terminal stance is important squat or lunge position may be useful if formed over a 2-week time frame for a to avoid an uncontrolled thrust into hy- the patient exhibits symptoms or a lack of gradual return to full weight bearing. A perextension. Thus, it is important that control with dynamic exercises. As with scale may be used as a biofeedback tool hamstring strengthening with the knee any phase of the rehabilitation following to monitor actual weight-bearing forces extended (to protect the allografts from PLC reconstruction, progression should through the surgical extremity as the unwanted posteriorly directed forces) be not only be based on strength and control patient progresses toward full–body- initiated in the early phases of rehabili- but also symptom tolerance, as evident weight acceptance. This will allow time tation with mat-based exercises (FIGURE through pain and effusion. for the patient to build confidence and 10) and progressed to weight-bearing ex- It is important to keep the leg press stability on the surgical limb. The pa- ercises and varying angles of knee flex- from exceeding a maximum of 70° of tient should be able to ambulate without ion in the later phases of rehabilitation knee flexion. Flexion beyond this depth a limp prior to discontinuing crutch use. (FIGURE 11). is thought to increase the stress on the A fluid gait pattern is first established Balance exercises should start during posterior healing repair or reconstruction using 2 crutches and subsequently re- week 7. Higher-level balance activities procedure.33 This stress is a result of the duced to 1 crutch. This will further prog- should include patients demonstrating cam effect of the posterior aspect of the ress to utilization of crutches solely for an ability to control for varus and valgus femoral condyles on the posterior aspect

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 511

06_Lunden.indd 511 7/21/10 12:20 PM [ clinical commentary ]

of the knee.33 Swimming can begin at 8 than 20 minutes and increase 5 minutes weeks. Although a flutter kick is techni- per week. The surgeon may give clear- cally an open kinetic chain hamstring ac- ance for jogging/running and initiation tivity, the majority of the motion is at the of plyometric exercises after that point hip, with very little knee flexion. There- as strength allows. One of the criteria fore, theoretically, the hamstrings do not for clearance to initiate plyometric exer- apply much force on the graft, so there is cises and jogging is that patients need to little concern of stretching out the graft be able to ambulate pain free 3 to 5 km, with this activity at this time point. Pa- with bouts of brisk walking and navigat- tients are to avoid breast and side stroke ing uneven terrain. Patients also need to techniques, along with any whip kick mo- demonstrate proper mechanics and con- tions in the pool. Finally, isolated open trol with single-limb squatting to at least chain hamstring exercises should be 60° of knee flexion for 20 repetitions. avoided over the initial 4 months post- Also at 4 months, stationary cycling can operatively. The rationale here is to avoid be performed with increased resistance. potential deleterious effects of hamstring The goal is to feel fatigue in the contraction on the PLC reconstruction.33 following 20 minutes of bicycling. This Closed kinetic chain hamstring strength- can be done up to 3 to 5 times per week. ening is allowed due to cocontraction of Forward, lateral, and retro step-ups at the quadriceps muscles to counteract the greater than 70° of knee flexion can be posterior translation of the tibia by the initiated at 4 months. Here, the patient hamstrings. A clear understanding of the begins with the surgical lower extremity expectations and restrictions by both the on the step and, using the surgical limb, physical therapist and patient will estab- extends the lower extremity to ascend the lish the foundation to a successful surgi- step. Step height and repetitions are in- FIGURE 12. Lunge exercise with a medial chop, with a cal outcome. creased in 5-cm increments as tolerated. weighted medicine ball. Patients are cued to maintain At 3 months postoperatively, patients A lunge progression at greater than 70° proper knee alignment centered over the second toe will typically follow up with the physi- of knee flexion can begin after 4 months. controlling for varus forces and strain. cian for further clinical examination and Depth and plane of movement can vary, clearance for further activities, if the based on exercise control and symptomo- sports simulation activities. With the patient has evidence of adequate joint logy. Lunging repetitions will move from patient positioned supine and the knee stability per the clinical examination, stationary to walking and can be done flexed from 20° to 35°, KT-1000 ar- exhibits a normal gait pattern, and has while performing diagonal (chopping) thrometer values are taken at 10, 20, minimal to no effusion at rest and fol- movements. Lightweight or medicine and 30 lb of force, directed anteriorly, lowing activity. For therapy, patients can balls can be held to increase difficulty. and a manual maximum value. Testing begin using a squat rack with 50% body This chopping motion should occur both with a posterior force of 20 lb is also per- weight, while continuing to maintain towards and away from the lead lower ex- formed. Isokinetic testing is performed depth above 70° of knee flexion. Patients tremity. Emphasis will be on controlling using 3 different speeds: 120°/s, 180°/s, can progress to full body weight over varus stresses due to the nature of the in- and 240°/s. The concentric/concentric the course of the next 3 weeks. Clear- jured structures. A chopping pattern di- setting is used. Sports simulation test- ance is typically provided at 4 months for rected medially away from the lead limb ing consists of squat and anterolateral patients to squat with increased depth will promote varus control (FIGURE 12). and anteromedial reaches, single-limb (70° of knee flexion). stance with eyes closed, single-limb At the 4-month period, patients can Functional Testing/Return to Play squat for depth, retro step-up for height, begin a daily walking program at a brisk The patient will follow up with the phy- single-limb hop for distance, timed hop, pace. Criteria for progressing to a daily sician at 5 to 6 months postoperatively and crossover triple hop for distance.64 walking program include adequate low- for further evaluation and varus stress The objective test values along with er extremity knee range for normal gait radiographs.36 Functional testing is per- clinical observation during the testing kinematics, being able to demonstrate a formed between 5 and 7 months post- aid to assist with return-to-play and normal gait pattern, and the absence of operatively. This consists of KT-1000 -sport decisions. Athletes are allowed increased joint effusion with prolonged arthrometer testing (with concomitant to return to an interval sport program walking. Walking should start at no more ACL injury), isokinetic testing, and if limb symmetry indices of greater than

512 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 512 7/21/10 12:20 PM 85% for both isokinetic and sport simu- therapist. This program will vary with rior lateral corner reconstruction. Am J Orthop lation/functional testing are achieved. the individual’s activities and goals. This (Belle Mead NJ). 2003;32:171-176. The athlete’s jumping and landing is in addition to any practice and team 6. Clancy WG, Jr., Sutherland TB. Combined poste- techniques during functional testing weight-training session. Finally, use of rior cruciate ligament injuries. Clin Sports Med. 1994;13:629-647. should be closely monitored. If the ath- a medial unloader brace/valgus-pro- 7. Coobs BR, LaPrade RF, Griffith CJ, Nelson BJ. lete exhibits tendencies to land on an ducing brace may be warranted during Biomechanical analysis of an isolated fibular extended knee with either a varus or sport for proprioceptive input and to de- (lateral) collateral ligament reconstruction us- valgus angulation, the athlete should go crease varus stresses to facilitate normal ing an autogenous semitendinosus graft. Am J Sports Med. 2007;35:1521-1527. http://dx.doi. through training sessions to correct this mechanics with running, cutting, and org/10.1177/0363546507302217 technique.4,14,27,51,52,63 In addition, the ath- pivoting activities, especially in patients 8. Cooper DE. Tests for posterolateral instability of lete’s lumbopelvic and lower extremity with a revision PLC reconstruction and/ the knee in normal subjects. Results of examina- strength should be retested with manual or a high body mass index. tion under anesthesia. J Bone Joint Surg Am. 1991;73:30-36. muscle testing to determine if the faulty 9. Cooper JM, McAndrews PT, LaPrade RF. Pos- jump/landing mechanics observed are CONCLUSION terolateral corner injuries of the knee: anatomy, more a result of muscular weakness or diagnosis, and treatment. Sports Med Arthrosc. motor planning/neuromuscular control. linically, injuries to the PLC 2006;14:213-220. http://dx.doi.org/10.1097/01. jsa.0000212324.46430.60 Varus and posterior (for concurrent PCL or “dark side” of the knee are be- 10. Covey DC. Injuries of the posterolateral reconstruction) knee stress radiographs Ccoming more recognized. Undi- corner of the knee. J Bone Joint Surg Am. will confirm reconstruction stability and agnosed PLC injuries may lead to poor 2001;83-A:106-118. confirm if it is safe to proceed with ad- outcomes or failures of cruciate recon- 11. Csintalan RP, Ehsan A, McGarry MH, Fithian DF, Lee TQ. Biomechanical and anatomical 31 vanced activities. Physician clearance structions, chronic instability with result- effects of an external rotational torque ap- is required before cutting, pivoting, or ing early onset osteoarthritis, and chronic plied to the knee: a cadaveric study. Am J hopping activities are performed both pain. More recently, our understanding Sports Med. 2006;34:1623-1629. http://dx.doi. in and out of clinic. Before resumption of the anatomy, biomechanics, diagno- org/10.1177/0363546506288013 12. DeLeo AT, Woodzell WW, Snyder-Mackler L. Resi- of practice or return to play, we recom- sis, and management of PLC injuries has dent’s case problem: diagnosis and treatment of mend supervised training of cutting and increased. The intent of this paper is to posterolateral instability in a patient with lateral pivoting drills with verbal51 and video63 provide therapists with a better under- collateral ligament sprain. J Orthop Sports Phys feedback from the physical therapist or standing of the injury, the components Ther. 2003;33:185-191; discussion 191-185. 13. Draper V. Electromyographic biofeedback and athletic trainer. Observations made dur- of the PLC, surgical reconstruction, and recovery of quadriceps femoris muscle function ing in-clinic visits and functional testing a suggested treatment approach. t following anterior cruciate ligament reconstruc- regarding the patient’s return to normal tion. Phys Ther. 1990;70:11-17. anthropometric measurements and 14. Earl JE, Monteiro SK, Snyder KR. Differences in references lower extremity kinematics between a bilateral physical performance factors will help drop-vertical jump and a single-leg step-down. guide the therapist regarding the timing J Orthop Sports Phys Ther. 2007;37:245-252. 1. Bae JH, Choi IC, Suh SW, et al. Evaluation of http://dx.doi.org/10.2519/jospt.2007.2202 of patient discharge from formal physi- the reliability of the dial test for posterolateral 15. Fanelli GC, Edson CJ. Combined posterior cruci- cal therapy to a self-directed exercise rotatory instability: a cadaveric study using ate ligament-posterolateral reconstructions with program. Patients should be aware that an isotonic rotation machine. Arthroscopy. Achilles tendon allograft and biceps femoris it may take up to 2 years to recover from 2008;24:593-598. http://dx.doi.org/10.1016/j. tendon tenodesis: 2- to 10-year follow-up. arthro.2007.12.003 an injury and surgical reconstruction of Arthroscopy. 2004;20:339-345. http://dx.doi. 2. Berchuck M, Andriacchi TP, Bach BR, Reider B. the PLC, especially with a concurrent org/10.1016/j.arthro.2004.01.034 Gait adaptations by patients who have a defi- 16. Fanelli GC, Edson CJ. Posterior cruciate ligament cruciate ligament reconstruction, or for cient anterior cruciate ligament. J Bone Joint injuries in trauma patients: part II. Arthroscopy. patients who required a staged recon- Surg Am. 1990;72:871-877. 1995;11:526-529. struction after an osteotomy. Therefore, 3. Bizot P, Meunier A, Christel P, Witvoet J. [Experi- 17. Fanelli GC, Feldmann D. Management of com- mental capsulo-ligamentar lesions of the knee it is important to instruct patients on bined anteriorcruciate ligament/posterior cruci- during passive hyperextension. Biomechanical ate ligament/posterolateral complex injuries of the importance of continued compli- aspects. A lesional evaluation and consequenc- the knee. Oper Tech Sports Med. 1999;7:143-149. ance with their home exercise program es]. Rev Chir Orthop Reparatrice Appar Mot. 18. Ferrari DA, Ferrari JD, Coumas J. Posterolateral and/or independent strengthening pro- 1995;81:211-220. instability of the knee. J Bone Joint Surg Br. 4. Chappell JD, Limpisvasti O. Effect of a neu- gram after formal physical therapy has 1994;76:187-192. romuscular training program on the kinetics 19. Fitzgerald GK, Piva SR, Irrgang JJ. A modified ceased. Athletes receiving clearance for and kinematics of jumping tasks. Am J Sports neuromuscular electrical stimulation protocol participation in sport and competition Med. 2008;36:1081-1086. http://dx.doi. for quadriceps strength training following ante- should continue to maintain a home ex- org/10.1177/0363546508314425 rior cruciate ligament reconstruction. J Orthop ercise program established by a physical 5. Clancy WG, Jr., Shepard MF, Cain EL, Jr. Poste- Sports Phys Ther. 2003;33:492-501.

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 513

06_Lunden.indd 513 7/21/10 12:20 PM [ clinical commentary ]

20. Fornalski S, McGarry MH, Csintalan RP, Fithian appearance of individual structures of the pos- 46. LaPrade RF, Wentorf F. Diagnosis and treatment DC, Lee TQ. Biomechanical and anatomical as- terolateral knee. A prospective study of normal of posterolateral knee injuries. Clin Orthop Relat sessment after knee hyperextension injury. Am knees and knees with surgically verified grade III Res. 2002;110-121. J Sports Med. 2008;36:80-84. http://dx.doi. injuries. Am J Sports Med. 2000;28:191-199. 47. LaPrade RF, Wentorf FA, Fritts H, Gundry C, High- org/10.1177/0363546507308189 35. LaPrade RF, Hamilton C, Engebretsen L. tower CD. A prospective magnetic resonance 21. Garth WP, Jr, Pomphrey M, Jr, Merrill K. Treatment or acute and chronic combined imaging study of the incidence of posterolateral Functional treatment of patellar dislocation anterior cruciate ligament and posterolateral and multiple ligament injuries in acute knee in an athletic population. Am J Sports Med. knee ligament injuries. Sports Med Arthrosc. injuries presenting with a hemarthrosis. Ar- 1996;24:785-791. 1997;5:91-99. throscopy. 2007;23:1341-1347. http://dx.doi. 22. Gilleard W, McConnell J, Parsons D. The effect of 36. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. org/10.1016/j.arthro.2007.07.024 patellar taping on the onset of The reproducibility and repeatability of varus 48. Larson RL. Physical examination in the diagno- obliquus and activity stress radiographs in the assessment of isolated sis of rotatory instability. Clin Orthop Relat Res. in persons with patellofemoral pain. Phys Ther. fibular collateral ligament and grade-III postero- 1983;38-44. 1998;78:25-32. lateral knee injuries. An in vitro biomechanical 4 9. Markolf KL, O’Neill G, Jackson SR, McAl- 23. Gollehon DL, Torzilli PA, Warren RF. The role of study. J Bone Joint Surg Am. 2008;90:2069- lister DR. Effects of applied quadriceps and the posterolateral and cruciate ligaments in the 2076. http://dx.doi.org/10.2106/JBJS.G.00979 hamstrings muscle loads on forces in the stability of the human knee. A biomechanical 37. LaPrade RF, Johansen S, Agel J, Risberg MA, anterior and posterior cruciate ligaments. Am J study. J Bone Joint Surg Am. 1987;69:233-242. Moksnes H, Engebretsen L. Outcomes of an Sports Med. 2004;32:1144-1149. http://dx.doi. 24. Grood ES, Stowers SF, Noyes FR. Limits of anatomic posterolateral knee reconstruction. org/10.1177/0363546503262198 movement in the human knee. Effect of sec- J Bone Joint Surg Am. 2010;92:16-22. http:// 50. Mohamed O, Perry J, Hislop H. Synergy of me- tioning the posterior cruciate ligament and dx.doi.org/10.2106/JBJS.I.00474 dial and lateral hamstrings at three positions of posterolateral structures. J Bone Joint Surg Am. 38. LaPrade RF, Johansen S, Wentorf FA, Enge- tibial rotation during maximum isometric knee 1988;70:88-97. bretsen L, Esterberg JL, Tso A. An analysis of flexion. Knee. 2003;10:277-281. 25. Harner CD, Hoher J, Vogrin TM, Carlin GJ, Woo an anatomical posterolateral knee reconstruc- 51. Myer GD, Ford KR, McLean SG, Hewett TE. The SL. The effects of a popliteus muscle load on tion: an in vitro biomechanical study and effects of plyometric versus dynamic stabiliza- in situ forces in the posterior cruciate ligament development of a surgical technique. Am J tion and balance training on lower extremity bio- and on knee kinematics. A human cadaveric Sports Med. 2004;32:1405-1414. http://dx.doi. mechanics. Am J Sports Med. 2006;34:445-455. study. Am J Sports Med. 1998;26:669-673. org/10.1177/0363546503262687 http://dx.doi.org/10.1177/0363546505281241 2 6. Harner CD, Vogrin TM, Hoher J, Ma CB, Woo SL. 39. LaPrade RF, Konowalchuk B, Wentorf FA. Pos- 52. Myer GD, Ford KR, Palumbo JP, Hewett TE. Biomechanical analysis of a posterior cruciate terolateral corner injuries. In: Schenck RC, Jr, Neuromuscular training improves performance ligament reconstruction. Deficiency of the pos- ed. Multiple Ligamentous Injuries of the Knee in and lower-extremity biomechanics in female terolateral structures as a cause of graft failure. the Athlete. Rosemont, IL: American Academy of athletes. J Strength Cond Res. 2005;19:51-60. Am J Sports Med. 2000;28:32-39. Orthopaedic Surgeons; 2002. http://dx.doi.org/10.1519/13643.1 27. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Ply- 40. LaPrade RF, Ly TV, Griffith C. The external rota- 53. Ng GY, Zhang AQ, Li CK. Biofeedback exercise ometric training in female athletes. Decreased tion recurvatum test revisited: reevaluation of improved the EMG activity ratio of the me- impact forces and increased hamstring torques. the sagittal plane tibiofemoral relationship. Am dial and lateral vasti muscles in subjects with Am J Sports Med. 1996;24:765-773. J Sports Med. 2008;36:709-712. http://dx.doi. patellofemoral pain syndrome. J Electromyogr 2 8. Hughston JC, Andrews JR, Cross MJ, Moschi A. org/10.1177/0363546507311096 Kinesiol. 2008;18:128-133. http://dx.doi. Classification of knee ligament instabilities. Part 41. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. org/10.1016/j.jelekin.2006.08.010 II. The lateral compartment. J Bone Joint Surg The posterolateral attachments of the knee: a 54. Nielsen S, Helmig P. Posterior instability of the Am. 1976;58:173-179. qualitative and quantitative morphologic analy- knee joint. An experimental study. Arch Orthop 29. Hughston JC, Jacobson KE. Chronic posterolat- sis of the fibular collateral ligament, popliteus Trauma Surg. 1986;105:121-125. eral rotatory instability of the knee. J Bone Joint tendon, popliteofibular ligament, and lateral 55. Noyes FR, Barber SD, Simon R. High tibial os- Surg Am. 1985;67:351-359. gastrocnemius tendon. Am J Sports Med. teotomy and ligament reconstruction in varus 30. Hughston JC, Norwood LA, Jr. The posterolateral 2003;31:854-860. angulated, anterior cruciate ligament-deficient drawer test and external rotational recurvatum 42. LaPrade RF, Muench C, Wentorf F, Lewis JL. The knees. A two- to seven-year follow-up study. Am test for posterolateral rotatory instability of the effect of injury to the posterolateral structures J Sports Med. 1993;21:2-12. knee. Clin Orthop Relat Res. 1980;82-87. of the knee on force in a posterior cruciate liga- 56. Noyes FR, Barber-Westin SD. Posterior cruciate 31. Jackman T, LaPrade RF, Pontinen T, Lender PA. ment graft: a biomechanical study. Am J Sports ligament revision reconstruction, part 1: causes Intraobserver and interobserver reliability of Med. 2002;30:233-238. of surgical failure in 52 consecutive operations. the kneeling technique of stress radiography 43. LaPrade RF, Resig S, Wentorf F, Lewis JL. The Am J Sports Med. 2005;33:646-654. http:// for the evaluation of posterior knee laxity. Am J effects of grade III posterolateral knee complex dx.doi.org/10.1177/0363546504271210 Sports Med. 2008;36:1571-1576. http://dx.doi. injuries on anterior cruciate ligament graft force. 57. Noyes FR, Barber-Westin SD. Revision anterior org/10.1177/0363546508315897 A biomechanical analysis. Am J Sports Med. cruciate surgery with use of bone-patellar 32. Jung YB, Lee YS, Jung HJ, Nam CH. Evaluation 1999;27:469-475. tendon-bone autogenous grafts. J Bone Joint of posterolateral rotatory knee instability using 44. LaPrade RF, Terry GC. Injuries to the posterolat- Surg Am. 2001;83-A:1131-1143. the dial test according to tibial positioning. eral aspect of the knee. Association of anatomic 58. Noyes FR, Barber-Westin SD. Surgical recon- Arthroscopy. 2009;25:257-261. http://dx.doi. injury patterns with clinical instability. Am J struction of severe chronic posterolateral com- org/10.1016/j.arthro.2008.10.007 Sports Med. 1997;25:433-438. plex injuries of the knee using allograft tissues. 33. LaPrade RF. Posterolateral Knee Injuries: 45. LaPrade RF, Tso A, Wentorf FA. Force mea- Am J Sports Med. 1995;23:2-12. Anatomy, Evaluation, and Treatment. New York, surements on the fibular collateral ligament, 59. Noyes FR, Barber-Westin SD, Hewett TE. High NY: Thieme Medical Publishers, Inc; 2006. popliteofibular ligament, and popliteus tibial osteotomymore and ligamentinfor reconstruc-mation 34. LaPrade RF, Gilbert TJ, Bollom TS, Wentorf F, tendon to applied loads. Am J Sports Med. tion for varus angulated anterior cruciate www.jospt.org Chaljub G. The magnetic resonance imaging 2004;32:1695-1701. @ligament-deficient knees. Am J Sports Med.

514 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 514 7/21/10 12:20 PM 2000;28:282-296. 67. Scheffler SU, Unterhauser FN, Weiler A. Graft ate ligament-deficient knee. Br J Sports Med. 6 0 . Noyes FR, Barber-Westin SD, Roberts CS. Use of remodeling and ligamentization after cruciate 2007;41:481-485; discussion 485. http://dx.doi. allografts after failed treatment of rupture of the ligament reconstruction. Knee Surg Sports Trau- org/10.1136/bjsm.2006.030767 anterior cruciate ligament. J Bone Joint Surg matol Arthrosc. 2008;16:834-842. http://dx.doi. 74. Terry GC, LaPrade RF. The posterolateral aspect Am. 1994;76:1019-1031. org/10.1007/s00167-008-0560-8 of the knee. Anatomy and surgical approach. 61. Noyes FR, Dunworth LA, Andriacchi TP, Andrews 68. Sharma L, Song J, Felson DT, Cahue S, Shami- Am J Sports Med. 1996;24:732-739. M, Hewett TE. Knee hyperextension gait abnor- yeh E, Dunlop DD. The role of knee alignment in 75. Veltri DM, Warren RF. Operative treatment of malities in unstable knees. Recognition and disease progression and functional decline in posterolateral instability of the knee. Clin Sports preoperative gait retraining. Am J Sports Med. knee osteoarthritis. JAMA. 2001;286:188-195. Med. 1994;13:615-627. 1996;24:35-45. 6 9. Simonian PT, Sussmann PS, van Trommel M, 76. Wang CJ, Chen HS, Huang TW, Yuan LJ. Out- 6 2. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL, Warren RF. Popliteomeniscal fas- come of surgical reconstruction for posterior Wickiewicz TL. Reconstruction of the chronically ciculi and lateral meniscal stability. Am J Sports cruciate and posterolateral instabilities of the insufficient anterior cruciate ligament with the Med. 1997;25:849-853. knee. Injury. 2002;33:815-821. central third of the patellar ligament. J Bone 70. Snyder-Mackler L, Delitto A, Bailey SL, Stralka 77. Wexler G, Hurwitz DE, Bush-Joseph CA, Andriac- Joint Surg Am. 1991;73:278-286. SW. Strength of the quadriceps femoris muscle chi TP, Bach BR, Jr. Functional gait adaptations 6 3. Onate JA, Guskiewicz KM, Marshall SW, Giuliani and functional recovery after reconstruction of in patients with anterior cruciate ligament C, Yu B, Garrett WE. Instruction of jump-landing the anterior cruciate ligament. A prospective, deficiency over time. Clin Orthop Relat Res. technique using videotape feedback: alter- randomized clinical trial of electrical stimula- ing lower extremity motion patterns. Am J tion. J Bone Joint Surg Am. 1995;77:1166-1173. 1998;166-175. Sports Med. 2005;33:831-842. http://dx.doi. 71. Snyder-Mackler L, Delitto A, Stralka SW, Bailey 78. Wu DD, Burr DB, Boyd RD, Radin EL. Bone org/10.1177/0363546504271499 SL. Use of electrical stimulation to enhance and cartilage changes following experimental 6 4 . Reid A, Birmingham TB, Stratford PW, Alcock recovery of quadriceps femoris muscle force varus or valgus tibial angulation. J Orthop Res. GK, Giffin JR. Hop testing provides a reliable and production in patients following anterior 1990;8:572-585. http://dx.doi.org/10.1002/ valid outcome measure during rehabilitation cruciate ligament reconstruction. Phys Ther. jor.1100080414 after anterior cruciate ligament reconstruc- 1994;74:901-907. 79. Yu JS, Salonen DC, Hodler J, Haghighi P, Trudell tion. Phys Ther. 2007;87:337-349. http://dx.doi. 72. Staubli HU, Jakob RP. Posterior instability of D, Resnick D. Posterolateral aspect of the knee: org/10.2522/ptj.20060143 the knee near extension. A clinical and stress improved MR imaging with a coronal oblique 6 5. Sanchez AR, 2nd, Sugalski MT, LaPrade RF. radiographic analysis of acute injuries of the technique. Radiology. 1996;198:199-204. Anatomy and biomechanics of the lateral side of posterior cruciate ligament. J Bone Joint Surg the knee. Sports Med Arthrosc. 2006;14:2-11. Br. 1990;72:225-230. 6 6. Saunders JB, Inman VT, Eberhart HD. The major 73. Strauss EJ, Ishak C, Inzerillo C, et al. Effect of more information determinants in normal and pathological gait. J tibial positioning on the diagnosis of postero- www.jospt.org Bone Joint Surg Am. 1953;35-A:543-558. lateral rotatory instability in the posterior cruci- @

journal of orthopaedic & sports physical therapy | volume 40 | number 8 | august 2010 | 515

06_Lunden.indd 515 7/21/10 12:20 PM [ clinical commentary ]

appendix

Protocol for Rehabilitation of a Posterolateral Knee Reconstruction

Procedure on motion, beginning with 5 minutes every other day and increasing to 20 minutes The popliteus tendon, the popliteofibular ligament, and fibular collateral ligament are daily, based on the knee’s response to increased activity. If soreness or effusion is reconstructed. evident reduce time or days utilizing the bike. This protocol can be combined with cruciate reconstruction protocols adhering to all Weeks 13-16 restrictions for each protocol. At this time the patient should have a normal gait pattern, without the presence of a Postoperative Restrictions limp or Trendelenburg sign. 1. Patient remains in the knee immobilizer in full-knee extension at all times during 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. maximum of 70°. 3. Patient to avoid tibial external rotation, and external rotation of the foot/ankle, espe- 2. Squat rack/squat machine: using weight up to 50%, body weight 10 repetitions, again cially in sitting for the first 4 months postoperatively. not exceeding 70° of knee flexion. Slow progression to full body weight. 4. Patient avoids open-chain hamstring exercises until 4 months postoperatively. 3. Closed kinetic chain exercise progression: double-limb squatting, lunges, single-limb Postoperative Red Flags squatting, etc. All exercises performed with less than 70° of knee flexion. Signs and symptoms of infection (excessive swelling, body temperature [fever] 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. per week. 2. Quadriceps sets and straight leg raises (SLRs) performed in the knee immobilizer. 2. Resistance can be added to bicycling as tolerated. Biking done 3 to 5 times per week Quadriceps sets can be performed hourly up to 30 repetitions and SLR up to 30 for 20 minutes, and the lower extremities should feel fatigued post biking. repetitions 4 to 5 times per day. 3. Advanced closed kinetic chain exercise progression: addition of unstable surface, 3. Four times a day gentle passive and active assisted ROM exercises. Goal is 90° of movement patterns, resistance, etc. knee flexion by the end of 2 weeks, and 0° of knee extension. 4. Return to run program once patient is able to perform 20 repetitions of involved lower 4. Core (lumbopelvic and hip) stabilization exercises in knee immobilizer that do not extremity single-limb squatting to greater than 60°of knee flexion with good control. increase knee forces in varus, hyperextension, or tibial external rotation. 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 ment of patient function and a complete recovery from the surgery. crutches. Discontinue knee immobilizer if able to perform SLR without a knee exten- Functional testing often performed at this time. A progressive return-to-play program sion lag. is initiated if the limb symmetry index is greater than 85% with functional testing and 2. Initiate use of stationary exercise bike if 105° of knee flexion ROM is achieved. Working satisfactory varus stress radiographs.

516 | august 2010 | volume 40 | number 8 | journal of orthopaedic & sports physical therapy

06_Lunden.indd 516 7/21/10 12:20 PM