1. Hospitalization step
Objective: The recovery of mobility, muscle toning, achieving active blocking, and learning how to walk with help
Medical massage and patellar mobilization, prevention of phlebitis.
Active mobilization – aided flexion/extension – Artromot.
– Quadriceps reviving
– Co-contraction of the quadriceps and hamstring muscle: Press a pillow or the hand of the physical therapist on the knee.
– Closed kinetic chain work: pushing the foot and triple withdrawal
Overall maintenance of the lower limb: hip and leg (outstretched leg beatings and ankle circumduction).
Learn how to walk with a splint and English cane.
2. Step of readjustment to everyday life (up to week 6)
This step will allow the recovery of daily life activities (walking, climbing – descending stairs, driving ….) and the resumption of less active or sedentary work.
The objectives are therefore focused on the resumption of unaided walking, recoveryof a bent knee, a full extension and active flexion > 120°.
The sessions are carried out in the first 3 weeks at home, 2 to 3 times a week according to the patient’s progress. Each session lasts 40 minutes and is primarily active.
It should not produce pain and be progressive. The main objective is the recovery of unaided walking.
1. Massage, patellar mobilization:
Session always starts with a gentle periarticular and scar massage. Transverse and vertical patellar mobilization is associated here.
2. Extension recovery:
Extension recovery is made according to the technique of the active stretching of the popliteal space.
No posture weight.
No stretching of the hamstring muscles.
3. Flexion readjustment:
This is done actively in laying position – helped by the physical therapist using the joint guiding technique using the ankle, seated at the foot of the bed.
You should not force yourself or induce pain during or after exercise. Flexion must “come” gradually. On average flexion is 90° after 3 weeks.
Do not pull the quadriceps in prone position (it is a joint stiffness not muscle stiffness).
4. Closed kinetic chain muscle work:
Quadriceps and hamstring muscles will only be worked in closed kinetic chain (CKC) not to overload the transplantation and patella.
The exercise consists of calf thrusts and triple withdrawals in the axle, controlled by the physical therapist.
• – Medical massage and patellar mobilization, prevention of phlebitis.
• – Active mobilization – aided flexion/extension – Artromot.
There is no constraint that requires keeping the splint and English canes for 3 weeks; everything depends on progress. The objective is the ability to walk unaided after 2 to 4 weeks. The physical therapist must therefore improve walking since the hospital discharge for the recovery of the patient’s natural walking ability. This walking trainingis first performed with English walking sticks (CA), without the splint, then gradually without the CA.
6. Physical therapy:
Ice shall be used systematically.
Pain management physical therapy can be used as adjunct therapy.
Electro-myo-stimulation shall never be used as a method to strengthen the muscles, but only as adjunct therapy and in particular to remove muscle inflexibility.
3. Self-rehabilitation phase (week 6 – month 4)
Kinesiotherapy is usually stopped at this phase, at the physician’s discretion (acc. to “General Protocol »).
The kinesiotherapy interruption criteria are resuming walking unaided with one knee bent, full extension and active flexion > 120°.
Then, self-rehabilitation exercises are proposed for completing recovery (acc. to sheet “Exercises in the self-rehabilitation step”)
4. Intensive rehabilitation step (month 4 – month 6)
At this stage, kinesiotherapy is resumed, which will allow a maximum rehabilitation of amplitudes, strength and stability of the knee, in order to resume athletic activity.
Criterion to resume kinesiotherapy and to have a painless and non-swollen knee.
Objectives: Recovering force, amplitude and maximum stability of the knee, insisting on the following points:
• – Maximum recovery of quadriceps force in closed chain and of hamstring muscles in open and closed chain.
• Proprioceptive rehabilitation.
1. Maximum recovery of joint amplitude
At this stage, all amplitudes are worked (flexion/extension and rotation). All amplitude gaining techniques can be used, of course respecting the basic rules: progressive and painless.
• – Hyperextension is not worked.
• – Techniques of contraction – relaxation in the maximum flexion position while in prone position are particularly harmful to the knee,more so as joint or periarticular stiffness is involved more often than muscular or tendinous stiffness. These techniques are not justified unless there is an actual muscle stiffness (measured by goniometer as the difference between flexionin supine position and ventral position, normally<10 °) and they should be used with extreme gentleness. 2. Maximum strength readjustment Various components of strengthwill be worked: strength – endurance first, then strength – speed and maximum strength. For quadriceps, work in closed chain only;OKC causes significant constraints on the transplant (even if the load is proximal) and patella. Hamstring muscles can be worked in OKC or CKC. Do not forget to work on their flexion and rotation functions. Here are some possible examples: • – Calf press: Work is carried out on a press between 0° and 45 to 60° flexion. – Semi squat: Muscle work with weights and demi-flexion (0-40 °) • – Plyometry: Jumps (jumping skips?, jumping with step to the front, rear and sides. If progress is difficult or insufficient, it will work with CYBEX: Isokinetic flexion/extension exercises at low and high speeds. Techniques to avoid: • – While not prohibited, OKC techniques are not advised because they cause significant stress to the transplant (even if the load is proximal). • – Isometric techniques with significant working time (> 10-20 s), especially chairpose technique (seating along the wall).
• – Contraction – relaxation techniques in maximum flexion position are particularly harmful to the knee.
3. Proprioceptive rehabilitation.
There are many exercises to develop proprioceptivity with or without equipment. Here are some classic examples:
• Standing on a Freeman step possibly holding a wall bars.
• Standing on a trampoline, the patient should hold balance on one foot without jumping.
• Standing on a trampoline, the patient must perform jumping, juggling…
• Jumping rope on 2 feet, then on 1 foot with movement forward, backward and sideways.
• Proprioceptive pathways by jumping on the trampoline, then on unstable steps.
5. Sports rehabilitation step (month 6 – month 12)
After 6 months, kinesiotherapy is replaced by sports resumption in the gym and out. The focus is on progressive preparation for the resumption of sports according to knee recovery. Endurance sports are resumed first, then more complex, sports, but without physical contact; sports called “pivot-contact” » are resumedafter between nine months and one year with the doctor’s agreement.