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Rehabilitation Following Anterior Cruciate Ligament and Posterolateral Corner Reconstruction with Medial and Lateral Meniscus Re

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Rehabilitation Following Anterior Cruciate Ligament and Posterolateral Corner Reconstruction with Medial and Lateral Meniscus Re Rehabilitation Following Anterior Cruciate Ligament and Posterolateral Corner Ryan Sweeney, PTA, DPT1 Chris Crank, PT2 Reconstruction with Medial and Lateral Tom McGahan, PT, MOMT2 Meniscus Repairs in A High School Athlete: R. Scott Van Zant, PT, PhD3 A Retrospective Case Report 1Doctoral Student Graduate, University of Findlay, Findlay, OH 2Physical Therapist, Kings Daughters Medical Center, Ashland, KY 3Associate Professor, Physical Therapy Department, University of Findlay, Findlay, OH ABSTRACT ing an athlete to sport in a short 7-month onary ligament, oblique popliteal ligament, Background and Purpose: Complex timeframe. and the fabellofibular ligament.7,9 Injuries and extensive knee injury in athletes pose to this area of the knee make up 16% of all a unique challenge in rehabilitation. The Key Words: knee rehabilitation, complex ligamentous knee injuries.10 These structures purpose of this case report was to describe knee injury resist varus forces of the knee and rotation of the rehabilitation of a high school athlete the tibia.5 Inability to restore PLC function who suffered a sport contact injury damag- INTRODUCTION could alter knee biomechanics and result in ing the anterior cruciate ligament (ACL), Injuries to the anterior cruciate ligament poor ACL outcomes, leading to early degen- medial and lateral menisci, and postero- (ACL) are prevalent in athletes with an esti- erative changes in the knee.5,10,11 Posterolateral lateral knee compartment. Methods: The mated occurrence between 100,000 and corner injuries typically occur with athletic patient was a 17-year-old male athlete who 300,000 annually.1,2 Approximately 50% injuries, motor vehicle accidents, and falls.7,10 underwent right ACL reconstruction, medial these injuries are seen in individuals between There is a paucity of research regarding and lateral menisci repair, and posterolateral 15 and 25 years of age participating in high the rehabilitation of patients experiencing knee compartment reconstruction. Seven velocity sporting activities.3 Approximately concurrent ACL and PLC reconstructive days postoperatively at initial evaluation he 30% of ACL injuries occur as a result of surgery. A systematic review by Bonanzinga ambulated toe-touch weight bearing, using external contact forces, and these type of et al10 identified only 6 studies that reported axillary crutches, with the knee immobilized injuries are more commonly associated with patient outcomes from this procedure, and by a brace locked at 0° extension. Passive injury to secondary knee structures, such as only 2 of those studies discussed, even in gen- knee range of motion (ROM) was 5° to 60°, the meniscus, articular cartilage, or the col- eral terms, postsurgical rehabilitation of the with strength in available range graded 2/5 lateral ligaments.2 patients involved. Return to sports following via manual muscle test (MMT). The patient When injury to secondary knee struc- an isolated PLC reconstruction requires sym- was treated for 7 months for a total of 54 tures occurs concurrently with the ACL, metrical strength, stability, and ROM when sessions. Physical therapy focused on passive subsequent rehabilitation following surgical compared to the contralateral limb, which and active ROM, therapeutic exercise (pro- reconstruction can be affected. For example, typically required 6 to 9 months to achieve. gressing from basic to sport specific), neu- significant tears to and subsequent repairs Common restrictions in combined ACL and romuscular re-education, manual therapy, of the meniscus typically require slower PLC reconstruction rehabilitation protocols and modalities. Findings: At discharge pas- progression of weight bearing (WB), range include bracing for the first 2 to 4 weeks sive ROM was +1-130°, active ROM 0° to of motion (ROM), and introduction of postsurgery and passive ROM allowed after 128°, and MMT of all R knee motions were therapeutic activity.4 Concurrent injury to 1 to 4 weeks.10-12 Typically after 6 weeks, the 5/5. From 4 months to discharge isokinetic the lateral collateral ligament (LCL), a rela- rehabilitation protocols follow that of a stan- testing (60°/sec) of peak torque hamstrings tively uncommon occurrence, will also delay dard ACL protocol.10,11 to quadriceps ratio increased bilaterally (R rehabilitation progression, with WB being Myer et al13 have reported that return to LE: 43% to 61%; L LE: 57% to 72%). At delayed up to 4 weeks and resisted hamstring sports following ACL reconstruction gen- discharge isokinetic knee extension peak activation delayed 6 to 8 weeks following erally lacks standardized objective criteria. torque-body mass ratio (180°/sec) was 66% surgery.4 The decision is often based on graft stabil- right (R) lower extremity (LE) and 67% left The posterolateral corner (PLC) of the ity, patient confidence, postsurgical timeline, (L) LE, all tibiofemoral stability tests were knee is another secondary injury area of con- and the medical team’s subjective opinion. negative, and the patient returned to sport. cern with ACL injuries.5 It is common for Although a return to sport following iso- Clinical Relevance: A 7-month progressive injuries to the PLC to be missed as a part lated ACL reconstruction may be possible multi-modal rehabilitation plan was able to of the injury diagnosis, and may therefore as early as 3 to 4 months postsurgery, they return a young athlete to sport following a be a contributing cause for ACL graft fail- indicate that athletes may not have sufficient complex and extensive knee injury. Conclu- ure.6-8 The PLC is comprised of the iliotibial functional stability to prevent reinjury. Func- sion: A progressive rehabilitation plan fol- band, biceps femoris muscle, LCL, popliteus tional stability deficits may include decreased lowing extensive reconstructive repair of a muscle, popliteofibular ligament, lateral gas- muscular strength, joint position sense, pos- complex knee injury was successful in return- trocnemius muscle, lateral joint capsule, cor- tural stability, and force attenuation, and may 76 Orthopaedic Practice volume 32 / number 2 / 2020 8745_OP_April.indd 18 3/23/20 12:58 PM be evident for 6 months to 2 years following plateau, complete tear of the lateral head of protocol, approximately 7 months in length, reconstructions. Standardized objective crite- the gastrocnemius muscle at its musculoten- was generally divided into 4 rehabilitation ria of functional stability and neuromuscular dinous junction, complete disruption of the phases: (1) early rehabilitation (0-4 weeks), control may improve successful early return lateral retinaculum of the patella, a vertically (2) controlled ambulation (4-10 weeks), (3) to sports and long-term outcomes.14 oriented peripheral tear in the posterior horn advanced activity (10-16 weeks), and (4) Cvjetkovic et al14 state that isokinetic of the medial meniscus, and a similarly ori- return to activity (16-30 weeks) (see Table 2). testing can serve as an important objective ented tear to the central portion of the poste- An initial home exercise program was criterion of dynamic stability of the knee rior horn of the lateral meniscus. The patient prescribed (to be performed twice daily) joint and can therefore estimate the quality underwent arthroscopic reconstruction of the that consisted of quadriceps sets, straight leg of rehabilitation outcome following ACL ACL 21 days after the injury that consisted of raises, sidelying hip abduction (all 3 sets of reconstruction. Isokinetic assessment is safe an autograft from hamstring tendon, medial 10 repetitions), and passive knee ROM (10 to administer and can detect hamstring to and lateral meniscal repairs, and open recon- repetitions). quadriceps ratio imbalances that would call struction of the PLC using a cadaveric Achil- During the early rehabilitation phase, for the delay in an individual’s return to sport les tendon allograft to reconstruct the LCL. the patient was seen in the clinic 3 times timeframe.14 In post-pubescent adolescents per week for a total of 9 treatment episodes and adults, normative values for knee exten- Examination following the initial evaluation. Physical sion peak torque-body mass ratio at 180°/s Physical therapy documentation was therapy interventions (Table 3) included are 58% to 75% for men and 50% to 65% attained retrospectively. Seven days postop- manual therapy and modality interventions for women.13 When determining an objec- eratively, the patient presented to physical to achieve full extension ROM, gradual tive return to sport timeframe following ACL therapy ambulating using bilateral axillary increase flexion ROM to 90°, increase soft reconstruction, it is recommended that male crutches and restrictions of toe-touch WB, tissue elasticity and extensibility, restore athletes achieve an isokinetic (180°/s) testing and wore a total ROM knee brace locked at 0° patellar mobility, decrease swelling and pain, criteria of 60% knee extension peak torque- extension. The patient exhibited gross ROM improve muscle activation and recruitment, body mass ratio, with female athletes achiev- deficits (Table 1), and strength of both ham- and improve gait mechanics within protocol ing a similar criteria of 50%.13 strings and quadriceps muscles, measured limits of 30% WB, ambulation using bilat- While there exists extensive research via manual muscle testing (MMT)16 within eral axillary crutches, and total ROM brace regarding rehabilitation of isolated ACL inju- the limited ROM, was 2/5. Edema was not locked in full extension. A NeuroCom®
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