Ligamys – Self-healing of the anterior cruciate ligament® – Self-healing of the anterior cruciate ligament Rehabilitation Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box

Ligamys® – Self-healing of the anterior cruciate ligamentRehabilitation

3Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com 3

Table of contents

1. Introduction 5

2. Rehabilitation protocol for patients with isolated ACL rupture 6

3. Rehabilitation protocol for patients with ACL rupture and meniscus suture 10

4. Possible summary for operative report 13

Note The rehab scheme on the following pages has been specifically developed for the after-treatment of a liga-menation. The exercises and time indications are sug-gestions, the time and weight declarations may vary from patient to patient depending on antecedents and accompanying injuries. The individual situation needs to be considered in any case.

4 Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com

In coordination with

Thorsten Müller PT MScBettina Bertschy PT MSc

Inselspital BerneInstitute for Physiotherapy 3010 Berne, SwitzerlandTel. +41 32 632 24 26www.physio.insel.ch

5Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com

1. Introduction

Until now, cruciate ligament reconstruction in case of a rupture has been regarded as the gold stand-ard in the field of sports medicine. However, with the growing importance of physical activity and sports in our daily lives, an intact cruciate ligament has become an essential prerequisite for maintain-ing long-lasting stability and proprioception.

When a cruciate ligament is ruptured, patients wish to be treated with state-of-the-art medical technol-ogy. Against this backdrop, Swiss orthopaedists have further developed the range of treatment op-tions with the primary objective of preserving the ruptured cruciate ligament.

The so-called “ligamentation” method makes it possible to dynamically stabilise the ruptured cruci-ate ligament using a Ligamys implant if operated on within 21 days after the injury. With this medical technology, the ruptured cruciate ligament can heal and grow back together. As a result, propriocep-tion of the knee joint is preserved and patients can return to their previous levels of activity.

With the Ligamys implant, rehabilitation is clearly faster compared to conventional cruciate ligament reconstruction. Immediate intraligamentary stabili-sation enables the patient to load the knee joint sooner, as exemplified by the rehabilitation proto-cols described below. Rehabilitation after dynamic intraligamentary stabilisation with Ligamys may take up to seven months depending on the pa-tient’s starting level and performance target.

For rehabilitation, a distinction should be made be-tween isolated cruciate ligament ruptures and in-juries that additionally involve the meniscus. In the second case, because there is a sutured meniscus lesion in addition to the implant, the rehabilitation period will be prolonged by about three weeks.

Resuming the previous type of sports activity should be possible within 18-20 weeks after sur-gery. Clearance for such activity is given if the re-spective test battery is successfully completed af-ter 16 or 20 weeks.

6 Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com6

The following principles apply:• weight bearing depending on the level of discomfort• no training of the M. quadriceps (extensor) in the open muscle chain • activation of the musculature from day 5 in order to preserve the protective function

• The indications below should be regarded as guidelines; time frames may vary depend-ing on the case history and/or the presence of concomitant injuries

• Patients should inform the surgeon and the physiotherapist about their preferred types of sports so that the course of rehabilitation can be adjusted accordingly

Phase 1 from day 1

Priorities: reduction of swelling,

pain control, learning independent

mobilisation

Goals:

• reduction of activities to a minimum

in order to ensure adhesion of the

cruciate ligament stumps

• control of swelling

• fixed orthesis in an extended posi-

tion • physiotherapy for independent mo-

bilisation

• learning the safety precautions

(avoiding anterior drawer move-

ment, quadriceps/hamstring tension,

co-contraction)

• walking and climbing stairs on

crutches with weight bearing de-

pending on level of discomfort

–

2. Rehabilitation protocol for patients with isolated ACL rupture


Phase 2 from day 5

Priorities: start of active physiotherapy

without orthesis

Goals:

• knee joint mobility, free flexion,

extension up to 0° (caution: avoid

overextension!)

• neuromuscular coordination

• innervation training of extensors in a

long-sitting position

• prevention of major muscle atrophy,

start of strength-endurance train-

ing for neural facilitation (complex

method) • improvement of muscular elasticity

Phase 3 from week 3

Priorities: muscle growth,

sensorimotor control

Goals:

• mobility by end of week 6, free flex-

ion/extension, at least 90°/0°/0°

• muscle growth training (hypertro-

phy) of the entire leg musculature,

especially the quadriceps (in closed

muscle chain) in an initially near-

extended position, as well as the

hamstrings and the calf and hip

musculature –

• active in-line axial stabilisation in a

single-leg stance on a stable and

later on an unstable surface


Phase 4 from week 6

Priorities: unlimited control of move-

ment, bilaterally equal strength

Goals:

• continued rehabilitation until ca-

pacity of unlimited movement is

attained, including critical situations

during normal everyday movements

• maximal strength

• optimal coordination and stabilisa-

tion, including when in motion

(running)

Phase 5 from week 10

Priorities: jumps, sports-specific training

Goals:

• jumping ABC –

• optimal stabilisation when changing

direction and making quick move-

ments

• muscle growth for sports-specific

training –

• vibration training now permitted

(recommended: Zeptor)


Test battery Weeks 16 and 24

Goal: return to sport

Tests:

• Lysholm score (for subjective assessment)

• hop tests*

• range-of-motion measurement

• pain measurement (visual analogue scale VAS)

• strength test (on leg press: at least 90 % of the healthy leg)

* Hop tests: single limb hop test, timed 6 m hop test, triple hop for distance, crossover hop for distance.

Calculation of lower limb symmetry:

Distance measurement = affected side/healthy side x 100 % è min. score 85 %

Time measurement = affected side/healthy side x 100 % è min. score 85 %

Sporting activities

With optimal rehabilitation and good muscular stabilisation of the knee, sporting activities may be

started as follows:

Cycling (on roads) from week 6

Jogging (with good quality footwear) from week 10

Skiing/snowboarding from month 6

Stop-and-go sports such as tennis, squash etc. from month 6

Contact sports such as soccer, handball, martial arts etc. from month 6


The following principles apply:• 6 weeks with partial weight bearing at 15 kg • no training of the M. quadriceps (extensor) in the open muscle chain • orthesis to limit movements during the first 6 weeks• 60° knee flexion for 3 weeks, followed by 90° knee flexion for an additional 3 weeks

• The indications below should be regarded as guidelines; time frames may vary depend-ing on the case history and/or the presence of concomitant injuries

• Patients should inform the surgeon and the physiotherapist about their preferred types of sports so that the course of rehabilitation can be adjusted accordingly

Phase 1 from day 1

Priorities: reduction of swelling,

pain control, learning independent

mobilisation

Goals:

• reducing activity to a minimum

to ensure adhesion of the cruciate

ligament stumps

• control of swelling

• fixed orthesis in an extended

position • physiotherapy for independent

mobilisation

• learning the safety precautions

(avoiding anterior drawer move-

ment, quadriceps/hamstring tension,

co-contraction)

• walking on crutches with 15 kg par-

tial weight bearing –

3. Rehabilitation protocol for patients with ACL rupture and meniscus suture


Phase 2a from day 5

Priorities: removal of orthesis, mobility, neural facilitation, hypotro-

phy prevention

Goals:

• knee joint mobility up to 60°, extension up to 0°; orthesis set to

60° (caution: avoid overextension!)

• innervation training of extensors in a long-sitting position

• neuromuscular coordination

• improvement of muscular elasticity

• prevention of major muscle atrophy, start of strength-endurance

training for neural facilitation (complex method), leg press with

15 kg up to 60° knee flexion, for calf in knee joint extension, leg

curl up to 60° knee flexion

Phase 2b from week 3 to week 6

Priorities: mobility, neural facilitation, hypotrophy prevention

Goals:

As in phase 2a but with the following progression:

• knee joint mobility up to 90°, extension up to 0°, orthesis set to

90° (caution: avoid overextension!)

• continued strength-endurance training for neural facilitation

(complex method), leg press with 15 kg up to 90° knee flexion,

for calf in knee joint extension, leg curl up to 90° knee flexion

When the goals of phases 2a and 2b have been attained,

phase 3 may be started in consultation with the surgeon.


Phase 3a from week 6 to week 8

Priorities: transition to full weight bearing without orthesis,

neural facilitation, sensorimotor control

Goals:

• free mobility without limitations

• continued strength-endurance training for neural facilitation

(complex method) without weight-bearing or mobility limitations

–

• build-up of a two-leg stance, single-leg stance with in-line axial

stabilisation on a stable surface

Phase 3b from week 9 to week 12

Priorities: transition to full weight bearing, neural facilitation,

sensorimotor control

Goals:

As in phase 2a but with the following progression:

• growth training (hypertrophy) of the entire leg musculature, espe-

cially the quadriceps (in closed muscle chain) in an initially near-

extended position, as well as the hamstrings and the calf and hip

musculature –

• active in-line axial stabilisation in a single-leg stance on an unsta-

ble surface


see page 8


see page 8

Test battery weeks 20 and 28

see page 9

Sporting activities

With optimal rehabilitation and good muscular stabilisation of the

knee, sporting activities may be started as indicated on page 9 but

with a delay of 4 weeks.


Ligamentation – isolated ACL rupture

Level of exercise Exercise depending on level of discomfortDays 1 – 5 Reduction of activities to a minimumDay 5 – week 3 Start of active physiotherapy, free flexion, extension up to 0°Weeks 3 – 6 Mobility up to end of week 6: free flexion/extension, at least 90°/0°/0°Weeks 6 – 10 Unlimited control of movement From week 10 Sports-specific training, jumps

OrthesisDays 1 – 4 Fixed orthesis in an extended positionFrom day 5 Physiotherapy without orthesis

Weight bearing / walking aidsDays 1 – 5 Weight bearing depending on level of discomfort

Return to sportFrom week 6 Cycling (on roads)From week 10 Jogging (with good quality footwear)From month 6 Skiing, snowboarding, stop-and-go sports (tennis, squash etc.), contact sports (soccer, handball, martial arts etc.)

Ligamentation – ACL rupture with additional meniscus suture

Level of exercise Exercise depending on level of discomfortDays 1 – 5 Reduction of activities to a minimumDay 5 – week 3 Start of active physiotherapy, mobility: flexion 60°, extension up to 0°Weeks 3 – 6 Mobility: flexion 90°, extension up to 0°From week 6 Mobility: free, unlimited From week 12 Unlimited control of movementFrom week 16 Sports-specific training, jumps

OrthesisDays 1 – 4 Fixed orthesis in an extended positionDay 5 – week 3 Orthesis set to 60° flexion, 0° extensionWeeks 3 – 6 Orthesis set to 90° flexion, 0° extension

Weight bearing / walking aidsDay 1 – week 6 Partial weight bearing with 15 kgFrom week 6 Transition to full weight bearing, without orthesis

Return to sportFrom week 10 Cycling (on roads)From week 14 Jogging (with good quality footwear)From month 7 Skiing, snowboarding, stop-and-go sports (tennis, squash etc.), contact sports (soccer, handball, martial arts etc.)

4. Possible summary for operative report


Notes

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Documents

Ligamys – Self-healing of the anterior cruciate ligament® – Self-healing of the anterior cruciate ligament Rehabilitation Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box