REHABILITATION PROGRAMME FOLLOWING PATELLAR TENDON REPAIR - DR JUSTIN ROE
www.justinroe.com.au
Protocol Prepared by Catherine Moore sports physiotherapist North Sydney Orthopaedic and Sports Medicine Centre
Moore Health, Shop 2c/780 Bourke St Redfern 2016 Suite 2 The Mater Clinic, 3 Gillies St Wollstonecraft NSW 2065
Phone: 93193808 info@moorehealth.com.au Phone: 02 9437 5999 e: ls[email protected]
STAGE
GOALS
PHYSIOTHERAPY
Stage I
Reduce swelling
Wearing hinge brace set at 0-30 degrees 24 hours per day
Acute Recovery
Isometric quadriceps strengthening
Day 1 to Day 10-14
Full passive extension
Quadriceps – Straight leg raise exercise
Establish thigh muscle control
Ice therapy
Partial weight bearing on crutches in extension brace
Passive extension exercises, active flexion, heel slides, Range of Motion 0-45 degrees.
Cocontraction exercises in extension
Phase 2
Reduce swelling
Wearing brace adjusted to 0-45 degrees for 24 hours per day
2 to 4 weeks
Good scar healing
Ice therapy
Full extension
Gentle patella mobilisations +/- taping if wound healing allows
Increase quadriceps strengthening in 0-45 degrees
Compression
Increase hamstring strength in 0-45 degrees
Manual therapy
Range of motion 0-45 degrees Gait re-education
Improve quadriceps strength (decrease knee extension lag)
Exercise – Active assisted range of motion (0-45 degrees),
Wean off crutches
hamstring curls (0-45 degrees) ,
continue quadriceps activation, Cocontraction execises
hip abduction,
adduction exercises,
heel raises.
basic proprioceptive and balance exercises
Phase 3
Full extension
Active assisted range of motion 0-60 degrees
4 to 6 weeks
Normal gait
Hamstring curls 0-90 with light weight
Brace off at night, no crutches and graduated full weight bearing
Continue all rehabilitation as above
Range of motion 0-90 degrees (graduated progression)
Progress hamstring, pelvic stability, heel raises, core stability, proprioception, balance exercises
REHABILITATION PROGRAMME FOLLOWING PATELLAR TENDON REPAIR - DR JUSTIN ROE
www.justinroe.com.au
Protocol Prepared by Catherine Moore sports physiotherapist North Sydney Orthopaedic and Sports Medicine Centre
Moore Health, Shop 2c/780 Bourke St Redfern 2016 Suite 2 The Mater Clinic, 3 Gillies St Wollstonecraft NSW 2065
Phone: 93193808 info@moorehealth.com.au Phone: 02 9437 5999 e: ls[email protected]
STAGE
GOALS
PHYSIOTHERAPY
Phase 4
Range of motion 0-120 degrees
Wear brace at full range of motion then gradually wean off brace
6 to 8 weeks
Improvement in proprioception
Active assisted range of motion 0-120 degrees
Wean off brace
Straight leg raise without weight (Attention to quadriceps -VMO control)
Improve motor control
Sitting quadriceps activation with sit to stand (no brace)
Improve standing balance
Graduated leg weight exercises start at 1kg to straight leg raise
Improve single legged control
Add step down quadriceps control exercises
Leg press with light weight
Shallow squats/ wall squats
Stationary bike 5- 10 mins begin
Continue pelvic, core, balance and proprioception exercises
Walking – forwards and backwards on flat graduating distance starting at 50 metres
Treadmill moderate speed and slight incline
Hydrotherapy exercises – squats, deep water running, gait retraining, flutter kicks with knees extended and upper
body strengthening
walking retraining
Phase 5
Full knee range of motion
Removal of brace all together (but could occur earlier if achieved in phase 4, check with surgeon)
8 to 12 weeks
Improve functional walking
Continue all above exercises with no brace
Improve muscular strength and function
Hamstrings curls with full range, light to moderate resistance (theraband or resistance machine)
Progress quadriceps step downs
Leg press (0-90 degrees) light to moderate resistance (gym)
Dura discs and trampoline for dynamic proprioception and balance retraining
Continue and advance motor control exercises eg pilates
Treadmill and stationary bike progression to 20-30 minutes
Hydrotherapy ( 2 x per week)
Gradually increase walking distances no slopes, start 15 minutes
Phase 6
Establish endurance and ensure correct muscle synergy (motor control patterns)
Quadriceps/gluteal control in standing/step ups/step downs
3-4 months
Reverse compensatory habits (especially with walking and standing)
Motor control exercises for everyday activities (sit to stand, stairs, walking)
Establish all activities of daily living with ease, i.e. sit to stand, stairs, walking
Continue as above hydro, Pilates, fitness work
Graduated return to cycling
Hydrotherapy
Increase walking speed, short distances, no down slopes for 15-20 minutes graduated programme
Phase 7
Equal quadriceps and hamstring flexibility
Continue motor control exercises, proprioceptive and balance exercises
4-6 months
ensure normal gait pattern 30 – 40 minutes
Add more dynamic, functional exercises – figure of 8s, gentle loops, large zigzags in controlled environment
Treadmill walking progressions
Quadriceps and hip flexor stretches
Continue hydrotherapy (add swimming laps)
Continue and progress Pilates programme
Plyometric ( jumping) exercises
Add surface changes and speed progressions
Running on treadmill and stationary/exercise bike outside ( work up to 30mins)
Cycling 1 hour on flat and gradually increase
REHABILITATION PROGRAMME FOLLOWING PATELLAR TENDON REPAIR - DR JUSTIN ROE
www.justinroe.com.au
Protocol Prepared by Catherine Moore sports physiotherapist North Sydney Orthopaedic and Sports Medicine Centre
Moore Health, Shop 2c/780 Bourke St Redfern 2016 Suite 2 The Mater Clinic, 3 Gillies St Wollstonecraft NSW 2065
Phone: 93193808 info@moorehealth.com.au Phone: 02 9437 5999 e: ls[email protected]
STAGE
GOALS
PHYSIOTHERAPY
Phase 8
Gradual return to sport specific drills and training
Continue agility, functional/dynamic drills – sports specific if needed
6 months +
Equal leg strength, balance and motor control side to side
Plyometric ( jumping) exercises
Improve walking distance, speed and agility
Direction change exercises (shuttle runs, figure of 8s, side to side steps)
Increasing cycling/walking/ jogging programme
Add down slopes and hills and stairs
Return to training for particular sport graduating from straight line then progress to directional
Progress surface changes and speed progressions
Contact sport in 12 months
Running on treadmill and stationary bike
Cycling increasing endurance, speed and strength
Appendix
Co-Contraction Exercises
Open -v- Closed Chain Exercises
Plyometrics
Risks and Complications
DR JUSTIN ROE, ORTHOPAEDIC SURGEON
02 9409 0500
www.justinroe.com.au
Deep Vein Thrombosis – these are clots in the deep veins of the leg due to immobilisation and surgery where wound healing and swelling is present. This may present as hot, tender, swollen, red calf pain. These symptoms need to be addressed
Unusual swelling and bruising
Damage to nerves or blood vessels – this may present as tingling, numbness or sensation changes around the wound area.
Please contact your treating Dr or your GP immediately if you are concerned about any of the above.
In relation to the knee these exercises ensure that both the hamstring muscle group and the quadriceps muscle group contract simultaneously to achieve a bracing effect on the knee joint. Not only will these two groups be contracting, however, but
stabilisers above and below will also contract such as gluteals, psoas, TFL, adductors and calf muscles. To initially teach a co-contraction, it is easiest to place a rolled pillow under the knee and ask the patient to push into the pillow. This will switch on the
hamstrings and gluteals. They should then tighten the quadriceps. A co-contraction should initially be held for approximately 15 seconds.
Closed kinetic chain exercises are performed with the foot placed on a surface (eg floor, step, pedal) and the entire limb is bearing an axial load. Joint compression occurs when the limb is loaded by body weight and this provides inherent joint stability and
allows more strenuous strengthening without the degree of shearing forces, or anterior tibial displacement that occurs with conventional open kinetic chain exercises. Closed chain exercises performed with co-contraction of hamstrings and quadriceps also
lessen the patello-femoral joint forces. The closed exercises place functional stresses on the joint and entire limb. These exercises can easily be designed to be specific to normal weight bearing activities used for ACL as well as sport.
Plyometrics exercises are characterised by very powerful muscle contractions in response to a dynamic loading or stretching of the muscles involved in the exercise. The muscles are pre-loaded with an eccentric contraction before a powerful concentric
contraction. Plyometrics help to improve muscle power in the later stage of rehabilitation. Examples are box drop jumps, bounding and hopping.
Post operative complications are not common but can occur and it is important for every patient to be aware of the potential warning signs.
Infection i.e. redness, swelling and or pain in the knee area