Author: Jorit Wijnmaalen, DPT, MBA, MTC, CEAS Educator: Jorit
Wijnmaalen (Dr. J) John van Ooyen, PT, MTC FPTA Approved for 9.5
CEUs (2012)
Slide 2
The Setting Specific Orthopedic Exercise Course is the new
version of our Anatomy of Exercise course and now includes exercise
protocols for most major Orthopedic and Spine Surgeries. We have
added more material to the course and it has been submitted for
FPTA approval for 9.5 CEU's. This course is required for the CORS
certification, but if you have taken The Anatomy of Exercise in
2012 or 2011, you do not need to take this course to become
eligible for the CORS certification. This hands-on exercise course
will review in depth clinical protocols that are currently in place
for the various, common orthopedic procedures including joint
replacement, ligamentous and tendon repairs surgeries and many
spine surgeries. This clinical review will include protocols as
they are applied in the various rehab settings including Inpatient
Acute Care, Subacute Rehab and Skilled Nursing settings, Homecare
and Outpatient. About this course:
Slide 3
SunCoast Seminars Why do we need to know and understand the
anatomy of muscle? This will allow the clinician to specify their
exercise program geared towards the function of the muscle.
Different muscles have different functions and these functions are
in part defined by the anatomy of the muscle. There are
approximately 639 skeletal muscles in the human body. There are
different types of muscles, each with their distinct anatomy.
Understanding the anatomy of the muscle will help the clinician
understand how different (intrinsic and extrinsic) factors can
impact muscles and exercising. We are looked upon as the experts
when it comes to exercise therapy. Understanding the anatomy of
muscles is an important part of being an exercise expert.
Slide 4
Program Objectives: Reviewing muscular anatomy and physiology
This will include a review of tissue healing Discuss how extrinsic
factors such as medication, progression, exercise objectives etc.
may affect the exercise therapy program Discuss how intrinsic
factors including disease processes age, vital signs etc. may
affect muscles and exercise programs. Discuss the basics of
exercise therapy Discuss common exercise principles Open chain vs.
closed chain Eccentric isometric concentric
Slide 5
A few rules: We are in a hospital and should be aware of any
codes that might be called. Bathrooms are right outside of this
room We will break for lunch are around noon Please turn off all
cell phones. I would like to make this lecture as interactive as
possible. Please feel free to ask questions, share your
experiences, opinions etc. with the rest of the group. SunCoast
Seminars
Slide 6
About the educator: Background Education Work experience
Hobbies SunCoast Seminars
Slide 7
5 educators Dr. Brian Healy Dr. Willem Stegeman Dr. Jorit
Wijnmaalen John Van Ooyen, PT Dr. Nathan A. Possert, PT, DPT About
SunCoast Seminars
Slide 8
More courses: Orthopedic Joint Replacement course: 9.5 CEU
Comprehensive Management of back & neck pain: 9.5 CEU Clinical
Imaging for the Rehab Specialist, 9.5 CEU Joint Replacement,
online: 7 CEU Thoracic Outlet Syndrome: 6.0 CEU, Online HIV/Medical
Errors/Abuse: 4 CEU The Anatomy of Excercise: online An
Introduction to Manual Therapy : 9.5 CEU Setting Specific
Orthopedic Exercises : 9.5 CEUs CORS: 9.0 CEUs About SunCoast
Seminars
Smooth muscles These muscles are very important in
physiological regulation. Help to regulate the flow of blood. Help
control BP They control the movement of food through the digestive
system. Control of the uterus during labor Contraction of a smooth
muscle cell is generated by a sliding mechanism of the
myofilaments. Contraction is involuntary and may be initiated by
Nerve impulse Hormones (i.e. cardiac function) Mechanical change to
the muscle
Slide 11
SunCoast Seminars Smooth Muscles : Crucial difference with
skeletal muscles: nervous control is absolutely required for
skeletal muscles, smooth muscles can, to a degree, work without
nervous stimulation! Lastly, these muscles are not striated (the
myofilaments are arranged into light and dark bands as in striated
muscles). Striations are formed by alternating segments of thick
and thin protein filaments, which are anchored by segments called
T-lines
Slide 12
SunCoast Seminars Cardiac Muscles : This muscle may look like a
skeletal muscles (especially the contraction of it since they are
striated as well) but it acts much like smooth muscle (it does not
require nervous system input to function) The attachment site
between cells is called an intercalated disc, which is present only
in cardiac muscle cells and allows forces to be transmitted from
one cell to the next.
Slide 13
SunCoast Seminars Skeletal Muscles: Striated (banded) type.
This distinctive banding pattern of striated muscle is an effect
that comes from the alignment of sarcomeres in register across the
myofibrils Skeletal muscles are under voluntary control; no
skeletal muscle works without orders from the nervous system
Skeletal muscles have elongated muscle cells (fibers) with multiple
nuclei lying along the periphery of the cell. The sarcoplasm of
each cell is contained by a sacrolemma (plasma membrane) and an
external lamina. Each muscle contains many myofibrils and each
myofibril contains thin actine and thick myosin myofilaments. These
muscles normally make up the largest portion of a person's lean
body mass
Slide 14
SunCoast Seminars Skeletal Muscles These are the muscles that
are responsible for all voluntary movements (movements controlled
by the central nervous system and which typically are directed at
some sort of interaction with the environment) These muscles only
contract in response to instructions from the central nervous
system (with a few exceptions) In short, skeletal muscles have the
following functions: provide joints with the forces necessary to
produce movement to control movement to stabilize and protect
joints when loads are applied to them. generating heat, maintaining
normal body temperature, because they account for 40% of the body
mass.
Slide 15
Skeletal Muscles Skeletal muscles are a striated type of muscle
with a rich blood supply, extensive afferent and efferent
innervations and an extremely high metabolic capacity. Skeletal
muscles have a tremendous adaptive capacity that allows them to
hypertrophy, atrophy, increase in physiological length, decrease in
physiological length and change metabolic capacities. Out of the
three muscle types discussed, the skeletal muscle are the muscles
that we will be most concerned within this course.
Slide 16
Muscular anatomy and physiology Lets review!
Slide 17
The Anatomy review of a skeletal muscle Each muscle cell is
surrounded by a basal lamina and connective tissue. They are bound
to each other and to surrounding tissues by connective tissue to
form a gross "muscle". Skeletal muscle fibers are NOT joined by
cell junctions. The endomysium consists of the basal lamina and
thin connective tissue that surrounds individual muscle cells. The
perimysium consists of sheets of connective tissue which separate
the fibers into groups known as fascicles. The epimysium surrounds
the groups of fasicles that comprise the muscle.
Slide 18
Endomysium delicate connective tissue sheeth that encloses each
muscle fiber Fasciculus bundle of muscle fibers covered by
perimysium (coarser fibrous membrane) Epimysium covers bundle of
fasciculi (entire muscle); blends into either: Tendon cord of
dense, fibrous tissue attaching a muscle to a bone Aponeurosis
fibrous or membranous sheet connecting a muscle and the part is
moves (usually found on torso)
Slide 19
Slide 20
The Anatomy review of a skeletal muscle Connective tissue
transmits the mechanical force of muscle. Tendons connect muscle to
bone. The myotendinous junction occurs at the end of the muscle
cell where the terminal actin filaments connect to the plasma
membrane Skeletal muscle fibers are multi-nucleated cells that
arise by fusion of mono-nucleate myoblasts. The many nuclei are
located at the periphery of the cell. Mono-nucleate satellite
cells, associate with the muscle fiber and reside within the muscle
basal lamina. They promote limited regeneration of muscle in the
adult.
Slide 21
The muscle-tendon junction The Yellow line is corresponding to
the tendon. How do we classify this Connective tissue? Dense
Regular. The yellow arrows are pointing the nuclei of the
fibroblasts making the collagen. The blue line is showing where the
Striated Muscle is beginning
Slide 22
Innervation of a Skeletal Muscle Skeletal muscle is innervated
and highly vascularized, due to its high energy requirements. It is
penetrated of blood vessels into the epimysium with branches into
the peri- and endomysium.
Slide 23
Innervation of a Skeletal Muscle Motor end plates
(neuromuscular junctions) are specialized sites at which a nerve
contacts a muscle cell. The terminal branches of motor axons lie in
the surface of the muscle cell, where the plasma membrane is highly
folded. Muscle action begins at the motor end plate (or
neuromuscular junction), which is analogous to a synapse
Acetylcholine(ACh) binds to receptors localized in the muscle
membrane at the motor end plate, resulting in local depolarization
at the end plate. When this depolarization exceeds the threshold,
it will result in an action potential
Slide 24
Slide 25
Slide 26
Neuromuscular Junction or Motor End Plate axon of Motor
(Efferent) Neuron White arrow - Skeletal Muscle Fiber
Slide 27
Innervation of a Skeletal Muscle Additional proprioceptor
endings (Golgi tendon organs) are located at the point where muscle
fibers attach to tendon These Golgi tendon organs (GTO) respond to
tension (force) exerted by the muscle; activity in these axons
inhibits muscle contraction (they are for instance stretched when a
joint is swollen).
Slide 28
Slide 29
Nerve Conduction Both nerve cells and muscle cells are
excitable Their cell membrane can produce electrochemical impulses
and conduct them along the membrane. In muscle cells, this electric
phenomenon is also associated with the contraction of the cell The
origin of the membrane voltage is the same in nerve cells as in
muscle cells. In both cell types, the membrane generates an impulse
as a consequence of excitation. The long nerve fiber, the axon,
transfers the signal from the cell body to another nerve or to a
muscle cell The axon may be covered with an insulating layer called
the myelin sheath, which is formed by Schwann cells
Slide 30
Nerve Conduction This myelin sheath is not continuous but
divided into sections, separated at regular intervals by the nodes
of Ranvier The junction between an axon and the next cell with
which it communicates is called the synapse. Information proceeds
from the cell body uni-directionally over the synapse, first along
the axon and then across the synapse to the next nerve or muscle
cell (think about peripheral leasion) The part of the synapse that
is on the side of the axon is called the pre-synaptic terminal The
part on the side of the adjacent cell is called the postsynaptic
terminal. Between these terminals, there exists a gap. A chemical
neurotransmitter, released from the pre-synaptic cell, is
responsible for the impulse to transfer across the synapse.
Slide 31
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Slide 33
Nerve Conduction This transmitter, when released, activates the
postsynaptic terminal. The synapse between a motor nerve and the
muscle it innervates is called the neuromuscular junction
Slide 34
Nerve Conduction If a nerve cell is stimulated, the
trans-membrane voltage necessarily changes. The stimulation may be
excitatory (i.e., depolarizing; characterized by a decrease in the
normally negative resting voltage) or inhibitory (i.e.,
hyperpolarizing, characterized by an increase in the magnitude of
the membrane voltage). After stimulation the membrane voltage
returns to its original resting value If the excitatory stimulus is
strong enough, the trans-membrane potential reaches the threshold,
and the membrane produces a characteristic electric impulse, the
nerve impulse. Remember the Na+/K+ pump?
Slide 35
Nerve Conduction Many factors may affect nerve conductivity but
discussion of those factors would be outside the scope of this
lecture. Temperature Properties of the membrane Sodium levels Age
Anatomical changes because of disease (ALS)
Slide 36
Nerve Conduction A myelinated axon (surrounded by the myelin
sheath) can produce a nerve impulse only at the nodes of Ranvier In
these axons the nerve impulse propagates from one node to another
The myelin sheath increases the conduction velocity The conduction
velocity of the myelinated axon is directly proportional to the
diameter of the axon
Slide 37
Nerve Conduction
Slide 38
Slide 39
Types of Skeletal muscles Not all skeletal muscles are the
same. Some cells are thicker than others Some shorten faster Some
produce more tension Some fatigue more rapidly Looking at these
different features, there appear to be three major types of
skeletal muscles:
Slide 40
Types of Skeletal muscles Slow Twitch Fast Fatigue Resistant
Fast Twitch Fatigable
Slide 41
Slow Twitch These muscles produce the least amount of force.
They actually produce less than half the force produced by fast
twitch fatigue resistant fibers and are most resistant to fatigue.
Slow twitch muscles use oxygen for power and have a predominance of
aerobic enzymes. Slow twitch muscles are red, because they contain
lots of blood vessels. These muscle fibers are "hit", or engorged
with nitrogen-rich blood, during higher rep training, specifically
in sets of 12 to 20 reps. Slow twitch muscles are used for holding
posture
Slide 42
Fast Twitch (Type II) Fast Twitch fibers use anaerobic
metabolism to create fuel and so they are much better at generating
short bursts of strength or speed than slow muscles. These types of
muscles are best trained during sets of 2- 5 repetitions. They
fatigue more quickly. Fast twitch fibers generally produce the same
amount of force per contraction as slow muscles, but they get their
name because they are able to fire more rapidly. Having more fast
twitch fibers can be an asset to a sprinter since she needs to
quickly generate a lot of force (genetically determined, 50/50 on
average; some research suggests that some fibers might be able to
convert).
Slide 43
Two Types: Type IIa Fibers / Fast Fatigue Resistant These fast
twitch muscle fibers are also known as intermediate fast-twitch
fibers. They can use both aerobic and anaerobic metabolism almost
equally to create energy. In this way, they are a combination of
Type I and Type II muscle fibers. Produce forces greater than slow
twitch fibers but less than fast twitch fatigable fiber. These
fibers are more resistant to fatigue than fast fatigable but less
fatigue resistant than slow twitch fibers.
Slide 44
Type IIb Fibers These fast twitch fibers use anaerobic
metabolism to create energy and are the "classic" fast twitch
muscle fibers that excel at producing quick, powerful bursts of
speed. This muscle fiber has the highest rate of contraction (rapid
firing) of all the muscle fiber types, but it also has a much
faster rate of fatigue and can't last as long before it needs rest.
Produce the greatest amount of force Are least resistant to fatigue
Force produced is typically 2-3 times greater than fast twitch
fatigue resistant fibers
Slide 45
Slide 46
Low frequency stimulation of motor units of type II fibers
transforms these fibers in type I fibers (endurance training,
easier to accomplish) High frequency stimulation of motor units of
type I fibers transforms these fibers in type II fibers (strength
training, harder to accomplish) This is due to rest periods with
low frequent stimulation of type II fibers, only metabolism and
muscle fiber diameter stay increased.
Slide 47
Conclusion So the lesson here is quite simple. As we are
exercising our patients, we must keep in mind the main objective of
our exercise program. In order to recruit the largest possible
number of muscle fibers of both types during the exercise program,
we must vary the repetition ranges. Keeping in mind that on
average, there is a 50/50 split of these fibers so Any therapist,
who puts a patient on an exercise program that doesn't include a
variation of repetition ranges might significantly limit the
success of the exercise program.
Slide 48
Skeletal Muscle Fiber Arrangement It is important to realize
that there are different alignments of muscle fibers in the various
skeletal muscles. These different fiber arrangements will have an
effect on the length, mechanical properties and the number of
muscle fibers of a muscle. Muscle fibers can be arranged in
parallel or at angles to the tendon. Parallel fibered muscles are
muscle composed of parallel aligned fibers. These muscles have long
muscle fibers that can produce a large excursion on the tendon.
Fusiform Triangular Spiral Pinnated fibers muscles are muscles
composed of angled fibers Unipinnate Bipinnate Multipinnate
Slide 49
Slide 50
Structure & Function of a Skeletal muscle
Slide 51
The cell comprises a series of striped or striated, thread-like
myofibrils. Within each myofibril there are protein filaments that
are anchored by dark Z line. The fiber is one long continuous
thread-like structure. The smallest cross section of skeletal
muscle is called a sarcomere which is the functional unit within
the cell. It extends from one Z line to the next attached Z line.
The individual sarcomere has alternating thick myosin and thin
actin protein filaments. Myosin forms the center or middle of eache
M line. Thinner actin filaments form a zig zag pattern along the
anchor points or Z line.
Slide 52
Muscle Contraction Upon stimulation by an action potential,
skeletal muscles perform a coordinated contraction by shortening
each sarcomere. The best proposed model for understanding
contraction is the sliding filament model of muscle contraction.
Actin and myosin fibers overlap in a contractile motion towards
each other. ATP binds to the cross bridges between myosin heads and
actin filaments. The release of energy powers the swiveling of the
myosin head Myosin filaments have club-shaped heads that project
toward the actin filaments. Larger structures along the myosin
filament called myosin heads are used to provide attachment points
on binding sites for the actin filaments.
Slide 53
Muscle Contraction (cont.) The myosin heads move in a
coordinated style, they swivel toward the center of the sarcomere,
detach and then reattach to the nearest active site of the actin
filament. This is called a rachet type drive system. This process
consumes large amounts of adenosine triphosphate (ATP). Calcium
ions are required for each cycle of the sarcomere. Calcium is
released from the sarcoplasmic reticulum into the sarcomere when a
muscle is stimulated to contract. This calcium uncovers the actin
binding sites. When the muscle no longer needs to contract, the
calcium ions are pumped from the sarcomere and back into storage in
the sarcoplasmic reticulum
Slide 54
Slide 55
Slide 56
Slide 57
Images from Purves et al., Life: The Science of Biology, 4th
Edition, by Sinauer Associates (www.sinauer.com) and WH Freeman
(www.whfreeman.com)www.sinauer.comwww.whfreeman.com
Slide 58
Slide 59
Muscle contraction -In rest the average human body uses as much
energy as a 75W light bulb. -During 24 hours of resting one still
uses 1400-1800 kcal (25 mile stroll) -During extreme endurance
sports the body is able to burn 10500-15000 kcal -Muscle tissue is
a very effective power source: power versus weight for a jet motor
is 1:5 power versus weight for the biceps muscle is approx.
1:360
Slide 60
Muscle contraction (cont.) ATP is the main source of energy for
all muscle contraction. There are several chemical reactions that
take place to produce ATP. When a muscle is used, a chemical
reaction breaks down ATP to produce energy: ATP + Actin + Myosin
Actomyosin + Phosphate + ADP + Energy This is the chemical reaction
that produces energy, however, there is only enough ATP stored in
the muscle cell for two or three slow twitch contractions, or one
burst of power from a fast twitch contraction. Surprisingly muscles
store very limited reserves of ATP 4-6 seconds worth at most, just
enough to get you going.
Slide 61
ATP is the only energy source used directly for contractile
activities. It must be regenerated as fast as its broken down for
continuation of the contraction. Fortunately, after ATP is
hydrolyzed to ADP and inorganic phosphate in muscle fibers, its
generated in a second by one or more of the three pathways, (1)
direct phosphorylation of ADP by Creatine Phosphate (2) the
anaerobic pathway called glycolysis, which converts glucose to
lactic acid (3)Aerobic pathway, aerobic cellular respiration Muscle
contraction (cont.)
Slide 62
(1)Direct phosphorylation of ADP by Creatine Phosphate a
phosphate group transfers from CP to ADP, regenerating more ATP; CP
supplies exhaust in about 20 seconds Duration of energy provision
15 seconds (2) Anaerobic glycolysis and lactic acid formation
initial steps of glucose breakdown occur via glycolysis which is
anaerobic. Duration of energy provision Glucose -> pyruvic acid
with energy captured in ATP bonds (2ATP/ 1 glucose)
Slide 63
(3) Aerobic respiration: provides 95% of ATP at rest and during
light Exercise occurs in mitochondria & involves a series of
metabolic pathways that use oxygen called oxidative phosphorylation
glucose is broken down into CO2 & H2O some released energy is
captured in ATP bonds (get 36ATP/1 glucose) There is also another
way to look at those three steps, when we talk about the enzyme
systems. There are three enzyme systems that can create more ATP.
The enzyme system that is used depends on whether the type of
muscle is fast twitch or slow twitch, and whether the muscle is
used for strength, burst power, or endurance.
Slide 64
Muscle Contraction (Cont.) The Strength Enzyme System When
muscle strength is required, ATP is created quickly from the
following chemical reaction. The enzyme creatine kinase mediates
ATP production from the high energy molecule creatine phosphate by
an anaerobic reaction: CP + ADP ATP + Creatine The CP (Creatine
Phosphate) is depleted in just a few seconds. This is the reason
your maximum power can be maintained for only a few seconds. To
continue producing high strength power, the speed enzyme system
kicks in.
Slide 65
Muscle Contraction (Cont.) The Burst Power Enzyme System The
enzymes required for this reaction are depleted in less than two
minutes. This reaction is called Anaerobic Glycolysis because it
uses glucose without oxygen. Glucose 2ATP + 2 Lactate Continued
muscle usage requires the aerobic system to kick in. The aerobic
system uses oxygen and sugar for fuel. The ability to perform well
after about two minutes of maximum exertion depends on the aerobic
conditioning of the body which is trainable
Slide 66
Muscle Contraction (Cont.) The Endurance Enzyme System This
system consists of three processes: 1.Carbohydrate Metabolism:
Carbohydrates metabolize most efficiently and are therefore used
first 2.Fat Metabolism: If no carbohydrates are available, the body
metabolizes fat. 3.Amino Acid Protein Metabolism: If no fat is
available, the body metabolizes Amino Acids. The body stores
glucose and fatty acids for these reactions. In addition, the
cardiovascular system provides a continuous supply of oxygen.
Slide 67
Muscle Contraction (Cont.) The Endurance Enzyme System This
system consists of three processes: 1.Carbohydrate Metabolism:
Carbohydrates metabolize most efficiently and are therefore used
first 2.Fat Metabolism: If no carbohydrates are available, the body
metabolizes fat. 3.Amino Acid Protein Metabolism: If no fat is
available, the body metabolizes Amino Acids. The body stores
glucose and fatty acids for these reactions. In addition, the
cardiovascular system provides a continuous supply of oxygen.
Slide 68
Muscle Contraction (Cont.) Cardiac muscle is adapted to be
highly resistant to fatigue: it has a large number of mitochondria,
enabling continuous aerobic respiration. The heart is so tuned to
aerobic metabolism that it is unable to pump sufficiently in
ischaemic conditions. (It has no back up system). At basal
metabolic rates, about 1% of energy is derived from anaerobic
metabolism. This can increase to 10% under moderately hypoxic
conditions, but, under more severe hypoxic conditions, not enough
energy can be liberated by lactate production to sustain
ventricular contractions. Under basal aerobic conditions, 60% of
energy comes from fat (free fatty acids and triglycerides), 35%
from carbohydrates, and 5% from amino acids. However, these
proportions vary widely according to nutritional state. For
example, during starvation, lactate can be recycled by the
heart
Slide 69
Muscle Contraction (Cont.) Glycogen is stored in the muscles
and liver in sufficient quantities for about two hours of strenuous
exercise. This timeframe can be extended by aerobic physical
conditioning and high carbohydrate diet. After the glycogen stores
are used up, the body obtains its energy from fatty acid metabolism
and amino acid protein metabolism. These reactions are not
efficient, which consequently causes your strength and endurance to
drop drastically (hitting a brick wall or man with the
hammer).
Slide 70
Motor Units within a muscle A motor unit is defined as all of
the muscle fibers supplied by a single motoneuron, and therefore,
by a single axon and its branches Skeletal muscles are organized
into hundreds of motor units, each of which involves a motor
neuron, attached by a series of thin finger-like structures called
axon terminals. These attach to and control discrete bundles of
muscle fibers. A coordinated and fine tuned response to a specific
circumstance will involve controlling the precise number of motor
units used. While individual muscle units contract as a unit, the
entire muscle can contract on a predetermined basis due to the
structure of the motor unit. Motor unit coordination, balance, and
control frequently come under the direction of the cerebellum of
the brain. This allows for complex muscular coordination with
little conscious effort, such as when one drives a car without
thinking about the process.
Slide 71
Motor Units within a muscle Muscles responsible for fine
coordination have small motor units. Muscles responsible for gross
movements have large motor units. The smaller motor units are more
excitable than the larger ones, and are stimulated first when a
weak signal is sent by the CNS to contract a muscle As the strength
of the signal increases, more motor units are excited in addition
to larger ones, with the largest motor units having as much as 50
times the contractile strength as the smaller ones As more and
larger motor units are activated, the force of muscle contraction
becomes progressively stronger. This concept is know as the size
principle.
Slide 72
Motor Units within a muscle: Conclusion At low exercise
intensities, like walking or slow running, slow twitch fibers are
selectively utilized because they have the lowest threshold for
recruitment. If suddenly the pace is increased to a sprint, the
larger fast units will be recruited. In general, as the intensity
of exercise increases in any muscle, the contribution of the fast
fibers will increase. For the muscle, intensity translates to force
per contraction and contraction frequency/minute. Motor unit
recruitment is regulated by required force. In the unfatigued
muscle, a sufficient number of motor units will be recruited to
supply the desired force (wave contraction).
Slide 73
Motor Units within a muscle: Conclusion Initially desired force
may be accomplished with little or no involvement of fast motor
units. However, as slow units become fatigued and fail to produce
force, fast units will be recruited as the brain attempts to
maintain desired force production by recruiting more motor units.
Consequently, the same force production in fatigued muscle will
require a greater number of motor units. This additional
recruitment brings in fast, fatigable motor units. As a result,
fatigue will be accelerated toward the end of long or severe bouts
due to the increased lactate produced by the late recruitment of
fast units. (Again, the man with the hammer)
Slide 74
Contraction Strength For skeletal muscles, the force exerted by
the muscle is controlled by varying the frequency at which action
potentials are sent to muscle fibers. Action potentials do not
arrive at muscles synchronously, and during a contraction some
fraction of the fibers in the muscle will be firing at any given
time. Typically when a human is exerting a muscle as hard as they
are consciously able, roughly one-third of the fibers in that
muscle will be firing at once, but various physiological and
psychological factors (including Golgi tendon organs and Renshaw
cells) can affect that. This 'low' level of contraction is a
protective mechanism to prevent avulsion of the tendon - the force
generated by a 95% contraction of all fibers is sufficient to
damage the body.
Slide 75
Contraction Strength The repetitive firing of a motor unit
creates a train of impulses known as the motor unit action
potential train (MUAPT). To sustain muscle contraction, the motor
units must be repeatedly activated. As the firing rates of motor
units active in a contraction increase, the twitches associated
with each firing will eventually fuse to yield large forces The
firing rates of earlier recruited motor units are greater than
those of later recruited motor units at any given force value The
control to the muscle is not designed to generate constant- force
contractions.
Slide 76
Maximal Voluntary Contraction (MVC)
Slide 77
Contraction Strength So concluding, the strength of a muscular
contraction can be influenced 2 factors: 1.By increasing the number
and size of contractile units simultaneously, called multiple fiber
summation. 2.By increasing the frequency at which action potentials
are sent to muscle fibers, called frequency summation.
Concentric muscle contraction Muscle contraction in which the
muscles shorten while generating force. The insertion and origin of
the muscle are moving toward eachother. During a concentric
contraction muscle fibers slide across each other pulling the
Z-lines together During a concentric contraction, a muscle is
stimulated to contract according to the sliding filament mechanism.
This occurs throughout the length of the muscle, generating force
at the musculo-tendinous junction, causing the muscle to shorten
and changing the angle of the joint. In relation to the elbow, a
concentric contraction of the biceps would cause the arm to bend at
the elbow. A concentric contraction of the triceps would change the
angle of the joint in the opposite direction, straightening the
arm.
Slide 80
Eccentric Muscle Contraction During an eccentric contraction,
the muscle elongates while under tension. The origin and the
insertion of the muscle are moving away from eachother. The muscle
acts to decelerate the joint at the end of a movement or otherwise
control the repositioning of a load. This can occur involuntarily
(when attempting to move a weight too heavy for the muscle to lift)
or voluntarily (when the muscle is 'smoothing out' a movement).
Over the short-term, strength training involving both eccentric and
concentric contractions appear to increase muscular strength more
than training with concentric contractions alone. During an
eccentric contraction of the biceps muscle, the elbow starts the
movement while bent and then straightens as the hand moves away
from the shoulder. During an eccentric contraction of the triceps
muscle, the elbow starts the movement straight and then bends as
the hand moves towards the shoulder.
Slide 81
Eccentric Muscle Contraction Exercise featuring a heavy
eccentric load can actually result in greater muscular damage and
delayed onset muscle soreness one to two days after training.
Exercise that incorporates both eccentric and concentric muscular
contractions (i.e. involving a strong contraction and a controlled
lowering of the weight) can produce greater gains in strength than
concentric contractions alone. While unaccustomed heavy eccentric
contractions can easily lead to overtraining, moderate training may
confer protection against injury.
Slide 82
Isometric Muscle Contraction. An isometric contraction of a
muscle generates force without changing length. An example can be
found in the muscles of the hand and forearm grip an object; the
joints of the hand do not move but muscles generate sufficient
force to prevent the object from being dropped. Isometrics are done
in static positions, rather than being dynamic through a range of
motion. The joint and muscle are either worked against an immovable
force (overcoming isometric) or are held in a static position while
opposed by resistance (yielding isometric).
Slide 83
Eccentric Muscle Contraction Muscles are approximately 10%
stronger during eccentric contractions than during concentric
contractions Eccentric contractions are being researched for their
ability to speed rehab of weak or injured tendons. Achilles
tendinitis has been shown to benefit from high load eccentric
contractions. During virtually any routine movement, eccentric
contractions assist in keeping motions smooth. Muscles undergoing
heavy eccentric loading suffer greater damage when overloaded (such
as during muscle building or strength training exercise) as
compared to concentric loading. During an eccentric contraction,
the filaments slide past each other the opposite way, though the
actual movement of the myosin heads during an eccentric contraction
is not known.
Slide 84
Isotonic Muscle Concentration Isotonic contractions occur when
tension in the muscle remains constant despite a change in muscle
length. This can occur only when a muscle's maximal force of
contraction exceeds the total load on the muscle.
Slide 85
A: Concentric/eccentric B: Isometric
Slide 86
EXERCISING AND BUILDING MUSCLES Muscles change and develop with
regular exercise but the effects differ, depending on whether you
engage in strength, speed, or endurance training. Strength and
burst training causes the muscle fibers to enlarge. Individual
muscle fibers increase in diameter as a result of an increase in
intracellular protein fibrils. Endurance training causes more blood
vessel formation than does speed or strength training, which
produces an increased capacity for aerobic metabolism within the
muscle cell. This change is seen after a few weeks of training and
is maximized in about three months. The aerobic enzymes that
metabolize carbohydrates, fats, and proteins, double. It is
important to develop your strength and speed systems, but if you
want to continue past about two minutes of high intensity workouts,
you need to have your aerobic systems developed
Slide 87
EXERCISING AND BUILDING MUSCLES Effect of Exercise on Muscles:
Aerobic or endurance exercise Examples biking, jogging, swimming
laps Results in stronger more flexible muscles with greater
resistance to fatigue blood supply increases individual muscle
cells form more mitochondria and store more oxygen (makes overall
body metabolism more efficient Improves digestion and elimination
of wastes Enhances neuromuscular coordination Makes the skeleton
stronger Heart enlarges Fat deposits are cleared from blood vessel
walls Lungs become more efficient at gas exchange Does NOT cause
muscles to increase in size
Slide 88
EXERCISING AND BUILDING MUSCLES Effects of Exercise on Muscles:
Resistance or isometric exercise Examples weightlifting, theraband
or medicine ball training, bodyweight exercises like push-ups or
pull-ups, plyometrics Key is that muscles are being forced to
contract with as much force as possible or as quickly as possible
Muscles increase in size and strength Due to enlargement of
individual muscle cells (more contractile filaments), not because
more muscle fibers are made Size of reinforcing connective tissue
also increases to support increased muscle size
Slide 89
Muscle Functions Muscle tissue has four main properties:
Excitability or the ability to respond to stimuli Contractibility
or the ability to contract Extensibility or the ability of a muscle
to be stretched without tearing Elasticity or the ability to return
to its normal shape Through contraction, the muscular system
performs three important functions: Motion - walking, running etc.
Heat production - maintain normal body temperature Maintenance of
posture - standing, sitting etc.
Slide 90
Muscle Functions Muscles have two states Relaxed
Contracted.
Slide 91
Common Medications and their effect on Exercise Blood thinners:
Coumadin, Lovenox, Warfarin, Plavix Aspirin: Watch the side
effects. Do not take with NSAIDs (will negate the blood thinning
effect). Thinning of mucosa of the stomach wall, gastric
ulceration, increased bleeding risk Muscle relaxors: Flexeril,
Soma, Valium, Skelaxin Flexeril: Duration of action 12-24 hour
Skelaxin: Duration of action 4-6 hours Side effects: Drowsiness,
dizziness, vertigo, ataxia, dependency Parkinson's disease:
Levodopa, Dopamine agonists, Anti cholinergics Sinemet/dopamine:
arrhythmia's, postural hypotension Diuretics: Bumex, Lasix,
Aldactone Hypokalemia, hyponatremia, fluid depletion, orthostatic
hypotension
Slide 92
Common Medications and their effect on Exercise (continued)
Cardiac function controlling medication: Beta blockers (Tenormin,
Lopressor, Inderal, Betapace) Digitalis toxicity, dry cough,
bradycardia, hypotension BP controlling medication: Beta blockers,
Alpha blockers (Cardura, Minipress) Broncho constriction,
bradycardia, hypotension HR controlling medication: Norpace, Beta
blockers, Cordarone, Cardizem Increase of arrhythmia's, dizziness,
hypotension Pulmonary function controlling medication: Albuterol,
Epinephrine, Theo-Dur, Pulmicort, Decadron, Aerobid, Cortef
Osteoporosis, muscle wasting, skin breakdown, diabetes mellitis,
hypertension
Slide 93
The importance of a thorough evaluation The concept is very
simple here; without a complete and detailed evaluation, you cannot
develop an appropriate exercise program. This evaluation is ongoing
and does not stop after the initial evaluation (there is a reason
for that name) Understanding the true dysfunction and understanding
why that dysfunction exists will put the clinician in the position
to address the dysfunction effectively.
Slide 94
Different types of exercises with different objectives
Objectives/Goals of exercise: Strength Muscular Dystrophy
Coordination Firing Patterns Endurance ROM PROM vs. AROM Endfeel?
PROM of the Joint Muscle length (Muscle energy) Muscle tone
Decrease of muscle tone Increase of muscle tone Pain control
Slide 95
Components of an effective Exercise Program: Starts with a
thorough and complete evaluation (evaluate the complete chain. Have
clear outcome objectives. What are you looking to exercise Why are
you exercising that What outcome do you expect Depends on
patient/age/function/other intrinsic and extrinsic factors Measure
and document these objectives ongoing Dont over exercise. Exercise
to improve function not too complete a number of reps. When you
feel or see the correct movement, continue to the next level.
Slide 96
Components of an effective Exercise program: Get the buy-in
from the patient Detailed documentation Quality of the movement
Speed Cues given/needed Strength Shaky/Tremorous Coordination
Sensation Intensity Activity it is related to improve
Slide 97
Progression/Regression of exercise Establish base point or
midline Points of contact: Progress from larger base of support to
smaller base of support Open chain vs. Closed chain # of
repetitions or sets Speed of the reps Cues: tactile& Verbal
Level of resistance Point of reference eccentric Isometric
concentric Stabilize vs. destabilize Weight shifting weight bearing
Sequence: Instruct correct movement repeat challenge add complexity
put into a functional activity Method of observation: visual,
tactile, bio feed back
Slide 98
Total Hip Arthroplasty Brief description of procedure: Hip
replacement is a surgical procedure in which the hip joint is
replaced by a prosthetic implant. Hip replacement surgery can be
performed as a total replacement or a hemi (half) replacement. A
total hip replacement (total hip arthroplasty) consists of
replacing both the acetabulum and the femoral head while
hemiarthroplasty generally only replaces the femoral head
Slide 99
Variations: Hemi Arthroplasty, Revision, Hip, Resurfacing,
ORIF. Muscles involved: Anterior approach: No muscles are cut other
than the Piriformis which is transected 50% of the time Posterior
approach:The piriformis muscle and the short external rotators
(tendons) are taken off the femur Lateral approach: The hip
abductors (gluteus medius and gluteus minimus) are elevated not cut
to provide access to the joint
Slide 100
When does Rehab start? For most elective orthopedic procedures,
the patient can start strengthening prior to the surgery, as
allowed by their pain and functional level. Unfortunately, this is
typically not reimbursed by insurance companies, or it may take
away from their post-op rehab visits. Precautions and time frames
Total hip precautions; restricted Hip Adduction, ER and Flexion as
per the surgeon. Avoid SIMULTANEOUS/COMBINATION movements of the
operative hip. Patients are allowed to flex, extend, abduct,
adduct, or rotate their operative hip in cardinal planes of motion
with NO restriction to movement. Any combination of motion during
the initial three (3) months, post operative period should be
avoided.
Slide 101
Weight bearing: Typically WBAT unless there was a surgical
complication, so ALWAYS read the operative report. ALWAYS FOLLOW WB
INSTRUCTIONS Surgical Hip Precautions
Slide 102
Acute Care Protocol: Hip DOS: Patient should get up with PT on
the DOS, unless the patient had surgical complications, or had
Total Anasthesia Patient can get up on the surgical or non-surgical
site and will use a walker to ambulate with the appropriate WB and
may sit in a chair, maintaining the 90 degrees hip angle. Patient
should also start Muscle Setting Exercises in bed. Day 1-4:Patient
should get up with nursing as well for BRP and for short
ambulation. Physical Therapy and Occupational Therapy will focus
safe transfers, following WB directions, using a walker, focusing
on posture as well. AAROM will be started today in all cardinal
planes as well. Walking distance will steadily increase and
precautions will be reviewed with the patient and their
family.
Slide 103
Ambulation Guidelines: Cemented Prosthesis: Weight bearing as
tolerated (WBAT) ambulation. Patients are required to initially use
a walker/crutches for a period of time, then are progressed to cane
ambulation. The cane is discontinued when the patient is ambulating
without a positive Trendelenberg test. Uncemented Prosthesis:
Patients are required to ambulate using a walker/crutches and
partial weight bearing for 6 post-operative weeks. Patients are
progressed to WBAT over the following 2 weeks. When patients are
able to ambulate without a positive Tredelenberg test, they may
ambulate without any assistive devices. No running or involvement
in sporting activities requiring running and/or jumpingfor 12
weeks.
Slide 104
POD #0: Begin isometric exercises and ankle pumps to leg.
Encourage the patient to perform these exercises every two hours
while awake. Begin assisted bed-to-chair transfers using an
assistive device to a chair of appropriate height. Weight bearing
status is dependent upon the type of prosthesis implanted. Patients
may sit in an upright position if comfortable. Discuss
post-operative dislocation precautions/restrictions. Acute Care
Protocol: Hip
Slide 105
Post-Operative Day 1: Continue lower extremity isometrics and
ankle pumps. Initiate upper extremity and contralateral limb
strengthening exercises. Begin assisted ambulation on level
surfaces using an assistive device, weight bearing status dependent
upon prosthesis used. Begin discharge planning and home needs
assessment. Review dislocation precautions/restrictions.
Slide 106
Post Operative Day 2: Review lower extremity isometric and
ankle pumping exercises. Begin supine lower extremity active
assisted range of motion exercises to the operative extremity.
Motions are to the patients tolerance and in cardinal planes.
Continue assisted ambulation on level surfaces. Reinforce hip
dislocation precautions/restrictions.
Slide 107
Post Operative Day 3: Continue comprehensive exercise program
with emphasis on increasing hip ROM and general muscle strength in
the operative extremity. Begin sitting exercises. Refine gait
pattern and instruct in stair climbing. Review home
instructions/exercise program with emphasis on
hipdislocation/precautions. Finalize discharge plans. All patients
require an assistive device for ambulation, an elevated toilet
seat, and follow-up physical therapy.
Slide 108
Hip Surgery: Phase II: Days 3-10 Goals: Achieve functional hip
range of motion, within cardinal planes of movement. Muscle
strengthening of the entire hip girdle of the operative extremity
with emphasis on hip abductor and extensor muscle groups. Attention
should also be directed toward any weakness present in the
operative extremity as well as any generalized weakness in the
upper extremities, trunk or contralateral lower extremity.
Proprioceptive training to improve body/spatial awareness of the
operative extremity in functional activities. Functional training
to promote independence in activities of daily living and
mobility.
Slide 109
Hip Surgery: Phase II: Days 3-10 Modalities for Pain Control
and Edema Reduction: Moist Heat, Ice Therapeutic Exercise: Gentle
Passive, Active-Assisted, and active lower extremity range of
motion Stationary Biking - No resistance to motion
Balance/Proprioception Training: Tandem Walking (line walking) Gait
Training: Level Surface Forward Walking Functional Training:
Standing Activities Transfer Activities
Slide 110
Hip Surgery: Phase III 10 days to 6 weeks: Goals: Muscle
strengthening of the entire hip girdle of the operative extremity
with emphasis on hip abductor and extensor muscle groups. Attention
should also be directed toward any weakness present in the
operative extremity as well as any generalized weakness in the
upper extremities, trunk or contralateral lower extremity.
Proprioceptive training to improve body/spatial awareness of the
operative extremity in functional activities. Endurance training to
increase cardiovascular fitness. Functional training to promote
independence in activities of daily living and mobility. Gait
training: Assistive devices are discontinued when the patient is
able to ambulate without a positive Trendelendberg test based upon
the ambulation guidelines (usually 4-6 weeks).
Slide 111
Hip: Phase III 10 days to 6 weeks: Modalities for Pain Control
and Edema Reduction: Moist Heat, Ice Exercises Continue previous
exercises Lower Extremity Strengthening Exercises using Theraband
Aquatic Therapy/Activities Iliotibial Band Stretches-Supine Scar
Massage/Mobility-May be instituted after suture removal when the
incision is clean and dry. Advance Passive, Active-Assisted, and
active lower extremity range of motion Closed Kinetic Chain
Activities Continue stationary bike, progress resistance
Slide 112
Hip: Phase III 10 days to 6 weeks: Balance/Proprioception
Training: Weight-Shifting Activities Closed Kinetic Chain
Activities Lateral Stepping over/around objects Gait Training:
Level Surface Forward Walking Sidestepping Retro Walking Uneven
Surfaces Functional Training Lifting, Carrying Pushing or Pulling,
Squatting or Crouching Return-To-Work Tasks
Slide 113
Phase IV 6-12 weeks: Exercises: Continue previous exercises
Advance Passive, Active-Assisted, and active lower extremity range
of motion Nordic Track Stair-Step Machine Iliotibial Band
Stretches- standing at twelve (12) weeks post-operatively Develop
walking program Continue pool and bike work Endurance Training: UBE
Ambulation Activities
Slide 114
Phase IV 6-12 weeks: Balance/Proprioception Training: Obstacle
Course Functional Training Lifting Carrying Pushing or Pulling
Squatting or Crouching Return to sport tasks
Slide 115
Total Knee Arthroplasty Brief description of procedure The
normal knee joint functions as a complex hinge allowing primarily
flexion and extension, but also rotation and gliding. The knee
joint is made up of three compartments, the lateral, medial and
patellofemoral. Damage to the cartilage of one or more compartments
may be the result of osteoarthritis (idiopathic or post-traumatic),
inflammatory arthritis (rheumatoid, psoriatic, etc.), avascular
necrosis, tumors, or congenital deformities. Osteoarthritis and
rheumatoid arthritis are the causes of the overwhelming majority of
total joint arthroplasties
Slide 116
Total Knee Arthroplasty Brief description of procedure Modern
total knee arthroplasty consists of resection of the diseased
articular surfaces of the knee, followed by resurfacing with metal
and polyethylene prosthetic components. For the properly selected
patient, the procedure results in significant pain relief, improved
function and quality of life
Slide 117
Variations: Partial Knee Arthroplasty, Fixed Bearing device or
Rotating Platform Device. Cemented or Compressed Fit; ACL/PCL
sparing, Patella preserving When does Rehab start? For most
elective orthopedic procedures, the patient can start strengthening
prior to the surgery, as allowed by their pain and functional
level. Unfortunately, this is typically not reimbursed by insurance
companies, or it may take away from their post-op rehab
visits.
Slide 118
Precautions and time frames Follow WB directions Kneeling onto
knee is typically not allowed/not recommended. Screen for blood
clots Screen for infection Acute Care Phase: Knee Phase I Immediate
Postoperative Phase (Day 0 10) Goals: Active quad contraction Safe
independent ambulation with walker or crutches as needed Passive
knee extension to 0 degrees Knee flexion to 90 degrees or greater
Control of swelling, inflammation, bleeding
Slide 119
Total Knee Surgery Protocol Day 0-2: Weight bearing as
tolerated with walker/2 crutches as needed starting on Day 0-1
Cryotherapy immediately and continuously unless ambulating ROM of
knee to begin immediately post op Exercises, Ankle pumps,
PROM/extension to 0 degrees SLR Quad sets Knee flexion to at least
90 degrees Knee extension to 0 degrees Instruct in gait training -
safe transfers
Slide 120
Total Knee Surgery Protocol Day 3-10: Weight bearing as
tolerated with walker/2 crutches as needed Cryotherapy Exercises:
Ankle pumps, PROM knee extension to 0 degrees, SLR, Quad sets AAROM
- Knee flexion to at least 90 degrees Hip adduction/abduction
Instruct in gait training safe transfers Start stationary bike, low
resistance
Slide 121
Total Knee Surgery Protocol Phase II: Motion Phase (Week 2-6)
Goals: Improve ROM Enhance muscular strength, endurance Dynamic
joint stability Diminish swelling/inflammation Establish return to
functional activities Criteria to enter Phase II: Leg control, able
to perform SLR AROM 0-90 degrees Minimal pain/swelling Independent
ambulation/transfers
Slide 122
Total Knee Surgery Protocol Weeks 2 -4: WBAT with assistive
device as needed. Wean from walker to cane or from 2 crutches to 1
by 2 weeks. Wean off all assistive devices by no later than 4
weeks. Exercises: Quad sets, SLR, VMO recruitment during quad sets
and SLR Knee extension 90-0 degrees Terminal knee extension 45-0
degrees Hip abduction/adduction Hamstring curls Knee flexion to at
least 115 degrees
Slide 123
Total Knee Surgery Protocol Stretching: Hamstrings
Gastroc/soleus Quads Passive knee extension stretch Continue
stationary bike and advance resistance as tolerated Continue
cryotherapy Patellofemoral mobilization Incision mobilization
Patients may begin to drive if they are no longer using assistive
devices for ambulation (about 2 weeks post op)
Slide 124
Total Knee Surgery Protocol Weeks 4-6: Exercises: Continue
previous exercises Initiate front and lateral step ups Advance
resistance on stationary bike Initiate progressive walking program
Initiate endurance pool program, swimming with flutter kick Return
to functional activities Continue compression, ice, elevation as
needed for swelling Patients should be walking and driving
independently at this point
Slide 125
Total Knee Surgery Protocol Phase III: Intermediate Phase
(Weeks 7-12) Goals: Progression of ROM to greater than 115 degrees
Enhancement of strength and endurance Eccentric/concentric control
of limb Cardiovascular fitness Functional activity performance
Criteria to enter Phase III: ROM 0-115 degrees Voluntary quad
control Independent ambulation Minimal pain
Slide 126
Total Knee Surgery Protocol Weeks 7-12: Exercises: Continue
previous exercises Continue pool activities Continue walking
Continue stationary bike Aggressive AROM 0-115 degrees Strengthen
quad/hamstrings
Slide 127
Total Knee Surgery Protocol Phase IV: Advanced Activity Phase
(Weeks 12 and beyond) Goals: Allow patients to return to advanced
level of function such as recreational sports Maintain/improve
strength and endurance of lower extremity Return to normal life and
routine Criteria to enter Phase IV: Full non painful ROM 0-115
Strength 90% of contralateral limb (if contralateral limb is
normal) Minimal pain and swelling Satisfactory clinical
examination
Slide 128
Total Knee Surgery Protocol Exercises: Quad sets, SLR, Hip
abduction/adduction, Step ups, Knee extension Stationary bike
Swimming Walking Stretching 0-115 degrees Return to pre op
activities and develop HEP to maintain function of leg. NO SQUATS
OR LUNGES AT ANY TIME!
Slide 129
Partial Knee Surgery: Brief Description of the procedure.
Unicompartmental knee replacement is an option for a small
percentage of patients with osteoarthritis of the knee In a
unicompartmental knee replacement, only the damaged compartment is
replaced with metal and plastic Partial Knee Replacement can only
be revised with a Total Knee Replacement
Slide 130
Partial Knee Surgery Protocol General Considerations: All times
are to be considered approximate, with actual progression based
upon clinical presentation. Patients are full weight bearing with
the use of crutches, a walker, or a cane to assist walking until
they are able to demonstrate good walking mechanics. Early emphasis
is on achieving full extension equal to the opposite leg as soon as
able. No passive or active flexion range of motion greater than 90
for the first two weeks. No two-legged biking or flexion exercises
for at least two weeks. Well-leg biking is fine. Regular manual
treatment should be conducted to the patella and all incisions so
they remain mobile. Early exercises should focus on recruitment of
the vastus medialis obliquus (VMO). No resisted leg extension
machines (isotonic or isokinetic) at any point in the
rehabilitation process.
Slide 131
Partial Knee Surgery Protocol Hospital Stay is typically 24
hours and as soon as the sensation and motor control is back in the
surgical leg and as soon as the patient is able to void, the
patient will go home and start OP PT. Initial focus is on
transfers, ambulation and AROM. 90 % are done on the medial aspect
of the knee May become OP procedure surgery soon
Slide 132
Partial Knee Surgery Protocol Week 1: Goal is to allow the
medial arthrotomy to heal and decrease swelling. MD visit on
post-op Day 1 to change dressing and review home exercise program.
Icing, elevation, and aggressive edema control (i.e.
circumferential massage, compression wraps). Straight leg raise
exercises (standing and seated), and passive and active ROM
exercises. OK to gently bend knee < 90 1 - 2x per day. Initiate
quadricep/adduction/gluteal sets, gait training,
balance/proprioception exercises. Well-leg cycling and upper body
conditioning. Soft tissue treatments and gentle mobilization to the
posterior musculature, patella, and incisions to avoid flexion or
patella contracture.
Slide 133
Partial Knee Surgery Protocol Weeks 2 - 4: Clinic visit at 14
days for suture removal and check-up. Continue with home program,
progress flexion range of motion, gait training, soft tissue
treatments, and balance/proprioception exercises. Incorporate
functional exercises as able (i.e. seated/standing marching,
hamstring carpet drags, hip/gluteal exercises, and core
stabilization exercises). Aerobic exercise as tolerated (i.e.
bilateral stationary cycling as able, UBE, pool workouts once
incisions are healed.)
Slide 134
Partial Knee Surgery Protocol Weeks 4 - 6: MD visit at 4 weeks
post-op. Increase the intensity of functional exercises (i.e.
progress to walking outside, introducing weight machines as able).
Continue balance/proprioception exercises (i.e. heel- to-toe
walking, assisted single leg balance). Slow-to- normal walking
without a limp.
Slide 135
Partial Knee Surgery Protocol Weeks 6 - 8: Add lateral training
exercises (i.e. lateral steps, lateral step-ups, step overs) as
able. Incorporate single leg exercises as able (eccentric focus
early on). Patients should be walking without a limp and range of
motion should be 110 flexion.
Slide 136
Partial Knee Surgery Protocol Weeks 8 - 12: Begin to
incorporate activity-specific training (i.e. household chores,
gardening, sporting activities). Low-impact activities until after
Week 12. Patients should be weaned into a home/gym program with
emphasis on their particular activity/sport. NOTE: All progressions
are approximations and should be used as a guideline only.
Progression will be based on individual patient presentation, which
is assessed throughout the treatment process.
Slide 137
Plyometrics (also known as "plyos" and "jumping") is a type of
exercise training designed to produce fast, powerful movements, and
improve the functions of the nervous system, generally for the
purpose of improving performance in sports. Plyometric exercises
may also be referred to as explosive exercises. Plyometric
movements, in which a muscle is loaded and then contracted in rapid
sequence, use the strength, elasticity and innervation of muscle
and surrounding tissues to jump higher, run faster, throw farther,
or hit harder, depending on the desired training goal.
Slide 138
Plyometrics is used to increase the speed or force of muscular
contractions, providing explosiveness for a variety of
sport-specific activities. Plyometrics has been shown across the
literature to be beneficial to a variety of athletes. Benefits
range from injury prevention, power development and sprint
performance amongst others
Slide 139
Plyometric training involves and uses practicing plyometric
movements to enhance tissues abilities and train nerve cells to
stimulate a specific pattern of [muscle contraction] so the muscle
generates as strong a contraction as possible in the shortest
amount of time. A plyometric contraction involves first a rapid
muscle lengthening movement (eccentric phase), followed by a short
resting phase (amortization phase), then an explosive muscle
shortening movement (concentric phase), which enables muscles to
work together in doing the particular motion. Plyometric training
engages the myotatic reflex, which is the automatic contraction of
muscles when their stretch sensory receptors are stimulated
(PNF).
Slide 140
Knee Surgery Protocol : Meniscopy The intent of this protocol
is to provide the clinician with a guideline of the post-operative
rehabilitation course of a patient that has undergone a meniscal
repair. It is no means intended to be a substitute for ones
clinical decision making regarding the progression of a patients
post-operative course based on their physical exam/findings,
individual progress, and/or the presence of post-operative
complications. If you require assistance in the progression of a
post- operative patient you should consult with the referring
Surgeon.
Slide 141
Knee Surgery Protocol : Meniscectomy Description of procedure:
Removal of a part of one of the menisci of the knee or part thereof
through an arthroscopic procedure, typically done at an ASC.
General Considerations: Weight-bearing as tolerated. Walk with
crutches. Surgical knee will be in a hinged rehab brace locked in
FULL EXTENSION for 4 weeks post-op. Regular assessment of gait to
avoid compensatory patterns. Regular manual mobilizations to
surgical wounds and associated soft tissue to decrease the
incidence of fibrosis. No resisted leg extension machines (isotonic
or isokinetic). No high impact or cutting/twisting activities for
at least 4 months post-op
Slide 142
Knee Surgery Protocol : Meniscectomy General Considerations:
Weight-bearing as tolerated. Walk with crutches. Surgical knee will
be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks
post-op. Regular assessment of gait to avoid compensatory patterns.
Regular manual mobilizations to surgical wounds and associated soft
tissue to decrease the incidence of fibrosis. No resisted leg
extension machines (isotonic or isokinetic). No high impact or
cutting/twisting activities for at least 4 months post-op
Slide 143
Knee Surgery Protocol : Meniscectomy Progression to the next
phase based on Clinical Criteria and/or Time Frames as Appropriate.
Key Factors in determining progression of rehabilitation after
Meniscal repair include: Anatomic site of tear Suture fixation
(failure can be caused by too vigorous rehabilitation) Location of
tear (anterior or posterior) Other pathology (ligamentous
injury)
Slide 144
Knee Surgery Protocol : Meniscectomy Phase I Maximum
Protection- Weeks 1-6: Goals: Diminish inflammation and swelling
Restore ROM Reestablish quadriceps muscle activity Stage 1:
Immediate Postoperative Day 1- Week 3 Ice, compression, elevation
Electrical muscle stimulation Brace locked at 0 degrees ROM
0-90
Slide 145
Knee Surgery Protocol : Meniscectomy Meniscal Repair Protocol
Motion is limited for the first 7-21 days, depending on the
development of scar tissue around the repair site. Gradual increase
in flexion ROM is based on assessment of pain and site of repair
(0-90 degrees). Patellar mobilization Scar tissue mobilization
Passive ROM
Slide 146
Knee Surgery Protocol : Meniscectomy Exercises Quadriceps
isometrics Hamstring isometrics (if posterior horn repair, no
hamstring exercises for 6 weeks) Hip abduction and adduction
Weight-bearing as tolerated with crutches and brace locked at 0
degrees Proprioception training with brace locked at 0 degrees
Slide 147
Knee Surgery Protocol : Meniscectomy Stage 2: Weeks 4-6
Progressive resistance exercises (PREs) 1-5 pounds. Limited range
knee extension (in range less likely to impinge or pull on repair)
Toe raises Mini-squats (less than 90 degrees flexion) Cycling (no
resistance) PNF with resistance Unloaded flexibility exercises
Slide 148
Knee Surgery Protocol : Meniscectomy Phase II: Moderate
Protection- Weeks 6-10 Criteria for progression to phase II: ROM
0-90 degrees No change in pain or effusion Quadriceps control (MMT
4/5) Goals: Increased strength, power, endurance Normalize ROM of
knee Prepare patients for advanced exercises
Slide 149
Knee Surgery Protocol : Meniscectomy Exercises: Strength-
progression Flexibility exercises Lateral step-ups Mini-squats
Endurance Program: Swimming (no frog kick), pool running- if
available Cycling Stair machine Coordination Program: Balance board
Pool sprinting- if pool available Backward walking Plyometrics
Slide 150
Knee Surgery Protocol : Meniscectomy Phase III: Advanced Phase-
Weeks 11-15 Criteria for progression to phase III: Full, pain free
ROM No pain or tenderness Satisfactory clinical examination SLR
without lag Gait without device, brace unlocked Goals: Increase
power and endurance Emphasize return to skill activities Prepare
for return to full unrestricted activities
Slide 151
Knee Surgery Protocol : Meniscectomy Exercises: Continue all
exercises Increase plyometrics, pool program Initiate running
program Return to Activity: Criteria Full, pain free ROM
Satisfactory clinical examination Criteria for discharge from
skilled therapy: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE
strength at least 4/5 4) Independent with home program 5) Normal
age appropriate balance and proprioception 6) Resolved palpable
edema
Slide 152
Knee Surgery Protocol : Partial Meniscectomy Rehabilitation
after a partial meniscectomy may progress aggressively because
there is no anatomic structure that requires protection.
Slide 153
Knee Surgery Protocol : Partial Meniscectomy Phase I Acute
Phase: Goals: Diminish pain, edema Restore knee range of motion
(goal 0-115, minimum of 0 degrees extension to 90 degrees of
flexion to progress to phase II)2 Reestablish quadriceps muscle
activity/re-education (goal of no quad lag during SLR Educate the
patient regarding Weight bearing as tolerated, use of crutches,
icing, elevation and the rehabilitation process Weight bearing:
Weight bearing as tolerated. Use two crutches initially progressing
to weaning crutches as swelling and quadriceps status
dictates.
Slide 154
Knee Surgery Protocol : Partial Meniscectomy Modalities:
Cryotherapy for 15 min 4 times a day 1 Electrical stimulation to
quadriceps for functional retraining as appropriate Electrical
stimulation for edema control- high volt galvanic or interferential
stimulation as needed
Slide 155
Knee Surgery Protocol : Partial Meniscectomy Therapeutic
Exercise: Quadriceps sets SLR Hip adduction, abduction and
extension Ankle pumps Gluteal sets Heel slides squats
Active-assisted ROM stretching, emphasizing full knee extension
(flexion to tolerance) Hamstring and gastroc/ soleus and quadriceps
stretches Use of compression wrap or brace Bicycle for ROM when
patient has sufficient knee ROM. May begin partial revolutions to
recover motion if the patient does not have sufficient knee
flexion
Slide 156
Knee Surgery Protocol : Partial Meniscectomy Phase II: Internal
Phase : Goals: Restore and improve muscular strength and endurance
Reestablish full pain free ROM Gradual return to functional
activities Restore normal gait without an assistive device Improve
balance and proprioception Weight bearing status: Patients may
progress to full weight bearing as tolerated without antalgia.
Patients may require one crutch or cane to normalize gait before
ambulating without assistive device.
Slide 157
Knee Surgery Protocol : Partial Meniscectomy Therapeutic
exercise: Continue all exercises as needed from phase one Toe
raises- calf raises Hamstring curls Continue bike for motion and
endurance Cardio equipment- stairmaster, elliptical trainer,
treadmill and bike as above. Lunges- lateral and front Leg press
Lateral step ups, step downs, and front step ups Knee extension
90-40 degrees Closed kinetic chain exercise terminal knee extension
Four way hip exercise in standing Proprioceptive and balance
training Stretching exercises- as above, may need to add ITB and/or
hip flexor stretches
Slide 158
Knee Surgery Protocol : Partial Meniscectomy Phase III Advanced
activity phase: Goals: Enhance muscular strength and endurance
Maintain full ROM Return to sport/functional activities/work tasks
Therapeutic Exercise: Continue to emphasize closed-kinetic chain
exercises May begin plyometrics/ vertical jumping Begin running
program and agility drills (walk-jog) progression, forward and
backward running, cutting, figure of eight and carioca program
Sport specific drills
Slide 159
Knee Surgery Protocol : Partial Meniscectomy Criteria for
discharge from skilled therapy: 1) Non-antalgic gait 2) Pain free
/full ROM 3) LE strength at least 4+/5 4) Independent with home
program 5) Normal age appropriate balance and proprioception 6)
Resolved palpable edema
Slide 160
Knee Surgery Protocol : ACL Reconstruction, Allograft (donor
tissue) Brief description: Allograft is most commonly used in lower
demand patients, or patients who are undergoing revision ACL
surgery (when an ACL reconstruction fails). Biomechanical studies
show that allograft (donor tissue from a cadaver) is not as strong
as a patient's own tissue (autograft). For many patients, however,
the strength of the reconstructed ACL using an allograft is
sufficient for their demands. Therefore this may be an excellent
option for patients not planning to participate in high-demand
sports (e.g. soccer, basketball, etc.).
Slide 161
Knee Surgery Protocol : AUTOGRAFT BONE-PATELLA TENDON-BONE and
ALLOGRAFT PROTOCOL Variation: Autograft, ACL repair, Patello Tendon
Autograft, Hamstring tendon Autograft. Phase I-Early Functional
(Weeks 1-2) Goals: 1. Educate re: the proper use of continuous
passive motion (CPM) machine a Home exercise program (HEP). 2.
Decrease pain and effusion. 3. Educate re: the importance of icing.
4. Independent donning,doffing, adjusting hinges, and use of knee
brace. 5. Safe ambulation with assistant device and knee brace
WEIGHT BEARING AS TOLERATED (WBAT) on the involved leg. 6. Promote
normal gait mechanics. 7. Early balance control. 8. Attain full
extension and functional flexion of the involved knee. 9. Obtain
baseline values for the uninvolved limb (isokinetic testing). 10.
Initiate early neuromotor control of all muscle groups.
Slide 162
Knee Surgery Protocol : ACL Reconstruction, Allograft Phase
I-Early Functional (Weeks 1-2) Goals: 1. Educate re: the proper use
of continuous passive motion (CPM) machine a Home exercise program
(HEP). 2. Decrease pain and effusion. 3. Educate re: the importance
of icing. 4. Independent donning,doffing, adjusting hinges, and use
of knee brace. 5. Safe ambulation with assistant device and knee
brace WEIGHT BEARING AS TOLERATED (WBAT) on the involved leg.
Slide 163
Knee Surgery Protocol : ACL Reconstruction, Allograft 6.
Promote normal gait mechanics. 7. Early balance control. 8. Attain
full extension and functional flexion of the involved knee. 9.
Obtain baseline values for the uninvolved limb (isokinetic
testing). 10. Initiate early neuromotor control of all muscle
groups.
Slide 164
Knee Surgery Protocol : ACL Reconstruction, Allograft Day of
Surgery: Ambulate WBAT with knee brace range from 0 to tolerated
active flexion (maximum 60) on level surfaces with axillary
crutches. The brace will initially be set by the physical
therapist. CPM will be set at 0 to 60 unless otherwise documented.
-Brace SHOULD NOT be worn while the operated limb is in the CPM.
-Brace is required only when ambulating and while performing
straight leg raise (SLR) exercises outlined below.
Slide 165
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-Operative Day #1: - Ambulate as above on level surfaces and
stairs. - CPM progression can be 10 20 daily but should not exceed
5 every 3 hours. - Review of patient ACL ( PATELLA TENDON-BONE
GRAFT) Home instructions. - KNEE BRACE MUST BE WORN WITH THE
STRAIGHT LEGRAISE (SLR) EXERCISES LOCKED AT 0. - ankle
strengthening for all planes with theraband. - quad set with towel
roll under the ankle to promote full extension. - heel slides. -
hamstring sets. - seated hip flexion. - seated active assisted knee
extension. - straight leg raises (SLR) in all 4 planes with BRACE
LOCKED AT 0.
Slide 166
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-operative Day #2-7: - Continue with above ambulation and
exercise guidelines. - Increase knee brace setting with active knee
motion. - Continue CPM until 90 active knee flexion is achieved.
CPM progression can be 10 20 daily but should not exceed 5 every 3
hours. - BAPS- in sitting. - Stationary bicycle- start with a low,
comfortable seat height to promote flexion, most force through
non-operated limb-increase seatheight in subsequent sessions. -
Supine wall slides- allow gravity to assist with knee flexion. DO
NOT perform wall slides in the upright or stance position. - Home
stretching for quadriceps, hamstrings, and gastrocnemius. - Balance
activities begin with bilateral stance activities and progress to
unilateral on the ground.
Slide 167
Knee Surgery Protocol : ACL Reconstruction, Allograft Bilateral
standing modified knee bends (0-30)-begin with body weight and then
add light extrinsic weight accordingly. - Marching in place- begin
in sitting and progress to standing. - Sidestepping - Multi hip to
involved lower limb. Be sure weight is applied proximal to the
knee. (flexion, extension, abduction, adduction, terminal knee
extension) - Retro walking Begin with body weight then progress to
pulling a weighted sled. Increase the load as tolerated. -
Quadriceps isometrics at varied degrees of knee flexion. - Active
knee extension of the involved knee (full) as tolerated. - Active
knee flexion full. - Rolling chair activity active hamstring/quad
activity by performing forward propulsion/retropulsion of rolling
chair using alternating lower extremities (90-0).
Slide 168
Knee Surgery Protocol : ACL Reconstruction, Allograft
Proprioceptive training: static stabilizing technique at various
degrees of knee flexion using therapeutic ball. Begin in supine
with legs on the ball then progress to sitting on the ball (90-0).
Heel raises begin with bilateral lower limbs then progress to
unilateral.
Slide 169
Knee Surgery Protocol : ACL Reconstruction, Allograft ** IN ALL
CLOSED CHAIN KNEE EXERCISES, DO NOT ALLOW THE ANTERIOR ASPECT OF
THE KNEE TO PASS THE TOES.** BY THE END OF WEEK 1: AROM: PROM: 0-80
0-90 0-105 0-120 0-120 0-125 **DO NOT PUSH >125 WITH PASSIVE
RANGE OF MOTION. CONTINUE TO CHECK RANGE OF MOTION PERIODICALLY TO
MAKE SURE RANGE IS MAINTAINED.**
Slide 170
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-operative Day #8-14: - Continue as above. - Straight leg
raises- without the brace if the patient demonstrates good quad
control, with resistance applied proximal to the knee. Use the
brace locked at 0 if an extension lag still exists. - Standing leg
curl- begin in standing with no added weight. The patient must
demonstrate easy effort prior to adding weight. - Multi hip- to
bilateral lower limbs. (Flexion, extension, abduction, adduction,
terminal knee extension). - Leg press- begin using bilateral lower
limbs (30 - 0). Begin with low extrinsic weight (10-50% maximum of
the patients body weight) and progress weight if the patient
demonstrates good quad control during terminal knee extension. The
patient at this time may begin unilateral leg press (10-30% maximum
of the patients body weight). - Balance activities progress to
bilateral activities on the disc the unilateral. - Discontinue
crutches at POD #14 if proper gait mechanics are obtained.
Slide 171
Knee Surgery Protocol : ACL Reconstruction, Allograft Phase
II-Progressive Functional (Weeks 3-11) Goals: 1. Decrease pain and
effusion. 2. Discontinue the postoperative brace when the patient
demonstrates good quad control. 3. Continue the development of
neuromotor control of all muscle groups. 4. Retrain for
proprioception and normalize responses to dynamic challenges.
Slide 172
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 3
through 4: Continue as above. Cable column- should be performed
once the patient is able to straight leg raise with resistance
distal to the knee with good quad control. Begin with flexion and
extension followed by abduction and adduction. Be more cautious
with those patients who have meniscal, medial or lateral collateral
involvement. Unilateral modified knee bends (0-30)- Stand erect.
Extend hip and flex the knee and place the dorsum of the foot on a
bench or box behind you. With support to the upper limb, lower the
torso, allowing your stance knee to flex to 45. **DO NOT ALLOW THE
ANTERIOR ASPECT OF THE KNEES TO PASS THE TOES.** Begin with body
weight and progress with light extrinsic weight. Step ups- begin
with body weight then add weights and step height gradually.
Discontinue if the patient has any complaints of pain. Balance
activities- incorporate multi task activities, i.e. unilateral
modified knee bend while performing arm curls while balancing on a
disc.
Slide 173
Knee Surgery Protocol : ACL Reconstruction, Allograft Closed
chain step machine (0-30)- begin with low resistance and maintain
short steps throughout. Swimming- the patient may perform side
stroke or flutter kick initiating motion from the hip. No
butterfly.
Slide 174
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 5
through 6: Continue as above. Progressive resisted knee extension-
perform activity with a slow controlled motion. Begin with cuff
weights for the involved leg and continue to do so until the
patient can comfortably lift 20 lbs. Do not allow the activity to
begin with >80 of knee flexion. Advanced hamstring activity with
the trunk flexed perform hip extension with upper extremity
support, with the hip extended to midrange perform a hamstring
curl, in the supine position perform bridging on the theraball with
hip flexion, and relaxed knee dead lifts if there is no history of
low back problems. Cross friction massage to scar.
Slide 175
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 7
through 8: Continue as above. Lateral activities begin by
increasing the speed with lateral stepping progressing to lateral
shuffles, ski simulator, modified slide board activities
(restricted distance slide board) to full range slide board. **WITH
ALL OF THESE EXERCISES BE AWARE OF VALGUS STRESSES** Cable column
simulated running once the patient exhibits good control with
single plane motion progress to multi joint motion. Crossover
stepping progress to cariocas as tolerated. BAPS in standing.
Beware of rotation occurring at the knee and valgus/varus
stresses.
Slide 176
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 8
through 11: Continue as above. Standing bicycle- with high
resistance, may progress to a bike spectrum. Plyometrics- begin
with mini jumps on the leg press at approximately 30% of body
weight.
Slide 177
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 8
through 11: Continue as above. Standing bicycle- with high
resistance, may progress to a bike spectrum. Plyometrics- begin
with mini jumps on the leg press at approximately 30% of body
weight. Phase III-Functional (Weeks 12-16) Goals: 1. Master
functional tasks of desired physical activity. 2. Optimize force
production and absorption with various activities.
Slide 178
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks
12-15: Continue as above. Lateral shuffles weighted, Stop and Go.
Slide board with the patient wearing a weighted vest (or holding a
hand dumbbell) incorporating a ball toss. Begin Dynamic skills
progression- (jumping, hopping, and leaping). Agility drill May
initiate light jogging program if the patient demonstrates good
force production (i.e. jumping) and absorption (i.e. landing),
especially when leaping from uninvolved to the involved limb. 10RM
testing as 12 weeks: begin heavy, moderate and light workout days
according to strength assessment guidelines.
Slide 179
Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks
16+: Continue as above. May initiate running of the patient
demonstrates good force production and absorption, especially when
leaping from uninvolved to involved. The patient may return to
activity without a derotation brace if: 1. Pain free with ADL and
rehab activities including agility and sport specific drills. 2. No
c/o stiffness during or after all above activities. 3. No c/o
giving way during all above activities. Objective: 1. Full AROM and
PROM (0-135).
Slide 180
Knee Surgery Protocol : PCL Reconstruction ISOLATED AND
COMBINED PCL RECONSTRUCTION POST- OP REHABILITATION PROTOCOL
GENERAL PRINCIPLES No open chain hamstring work Assume 8 weeks for
graft to bone healing time Caution against posterior tibial
translation (gravity, muscle action) CPM 0-60 to start PCL with
posterolateral corner or LCL repair follows different post-op care,
i.e., crutches x 3 months Supervised physical therapy takes place
for approximately 3-5 months post-op.
Slide 181
Knee Surgery Protocol : PCL Reconstruction GENERAL PROGRSSION
OF ACTIVITIES OF DAILY LIVING (ADLs) Patients may begin the
following activities at the post-op dates listed (unless otherwise
specified by the physician): Bathing/Showering without brace
(surgical incisions should be healed before immersion in water) 1
week post-op Sleep without brace 8 weeks post-op Driving 6-8 weeks
post-op Full weight bearing without assistive devices 8 weeks
post-op (with physician clearance)
Slide 182
Knee Surgery Protocol : PCL Reconstruction PHYSICAL THERAPY
ATTENDANCE The following is an approximate schedule for supervised
physical therapy visits: 0 to 1 month: 1 x week 1 to 3 months: 2-3
x week 3 to 9 months: 2 x month 9 to 12 months: 1 x month
Slide 183
Knee Surgery Protocol : PCL Reconstruction REHABILITATION
PROGRESSION 0-1 WEEK POST-OP Brace: Locked at 0-60 maximum Weight
bearing Status: WBAT with crutches, with brace locked Special
Considerations: Pillow under proximal posterior tibia at rest to
prevent posterior sag Therapy: Quad Sets Ankle Pumps SLR Hip
Alphabets Hip AB/AD
Slide 184
Knee Surgery Protocol : PCL Reconstruction 7-28 DAYS POST-OP
Brace: Locked except for protected range of motion performed by
physical therapist. WB Status: WBAT with crutches, with brace
locked Special Considerations: Continue use of pillow under tibia
at rest.
Slide 185
Knee Surgery Protocol : PCL Reconstruction Therapy: PT Assisted
knee flexion For PCL only patients: Maintain anterior pressure on
proximal tibia as knee is flexed. For combined PCL/ACL patients,
maintain neutral position of proximal tibia as knee is flexed. It
is important to prevent posterior tibial sagging at all times.
Hamstring and Calf stretching Calf press with Theraband Standing
calf raises with full knee extension Standing hip extension from
neutral
Slide 186
Knee Surgery Protocol : PCL Reconstruction 4-8 WEEKS Brace: 4-8
weeks: Brace is unlocked for supervised gait training only
(patients must be under the direct supervision of a PT) WB status:
WBAT with crutches Ther. Ex: - When patient exhibits independent
quad control, may begin open chain extension, if no flexion
contracture exists. Wall slides (0 to 45) Begin isometric, progress
to active against body weight. Ambulation in pool (only while in
physical therapy) Continue to maintain hamstring flexibility
Slide 187
Knee Surgery Protocol : PCL Reconstruction 8-12 WEEKS D/C Brace
8 weeks WB status: Wean off crutches at 8 weeks post- op May D/C
crutches if patient exhibits: No quad lag with SLR Full knee
extension Knee flexion 90-100 Normal gait pattern Therapy:
Stationary bike: Foot forward on pedal (no toe clips), seat high
Balance and proprioception, Seated calf raises Leg press (within
available range of motion)
Slide 188
Knee Surgery Protocol : PCL Reconstruction 12 WEEKS (3 MONTHS)
Progress functional and symptomatically Therapy: Treadmill walking
Jogging in pool with Swimm