Gabrielle Herman, SPT Clinical Problem Solving II September 22, 2016

 Outline of presentation ◦  Patient demographics ◦  Patient Evaluation, Assessment, Goals ◦  Clinical question ◦  2 Studies ◦  Conclusions ◦  Clinical Application   Interventions   Outcomes ◦  Future Research

  To investigate effectiveness/safety of early mobilization protocol following quadriceps tendon repair

  OP orthopedic clinic 2 weeks post op quadriceps tendon repair

  HPI ◦  MOI: fell down stairs 4/3/2016 ◦  Surgical repair: 4/6/2016

  PMH ◦  Medical conditions: high cholesterol and HBP ◦  No previous PT

  Medications ◦  Percocet post-operatively ◦  Aspirin every 12 hr ◦  Cholesterol medication ◦  Supplements: Fish oil, magnesium, vitamin D

Chief complaints:   “Stiffness” in R knee   “Instability” during

showers without brace   Recent onset L LBP   Numbness above patella   Decreased sensation

over incision site

Pain: 0-1/10

Ease factors: ice 3x/day, elevation

Ambulation: no p! weight bearing

Occupation: advertising, desk job

Hobbies/fitness: stair climber or elliptical 3x/week, sometimes lifts weights, walking

  3% of all tendon ruptures (Kannus, et al)

  Men in 6th and 7th decade   Surgical repair preferred

method

Conventional approach 6 weeks immobilization with

PWB

◦  Persistent pain ◦  Difficulty regaining motion ◦  Muscle weakness ◦  bone mass ◦  Poor cartilage nutrition ◦  Patella baja

Early motion WBAT, PROM, isometrics day 1

•  adhesion formation •  Promotion of health cartilage •  tensile strength •  Gliding function •  Joint mechanics •  tendon vascularity •  Earlier organization/

remodeling of collagen •  number collagen filaments

Gait   Dial lock brace in full extension without crutches ◦  Early mobilization protocol

  WBAT immediately   Quad sets day 1   Allowed ROM to 60 ◦  Circumducting R LE with L lateral trunk lean

Joint mobility   Decreased patellar mobility; superior/inferior glides

Palpation   1/10 p! at lateral patellofemoral joint line   Tenderness noted Psoas and middle/distal IT band

Inflammation   L/R suprapatellar (49.5 cm/41.5 cm)   L/R infrapatellar (41.5 cm/38.5 cm)

ROM MMT

Knee flexion

in sitting (25°) in supine (35°) leg off table (40°) (p! 7/10)

HS 4-/5

Knee extension

in long sitting (5°) Quad 4/5

Ankle All planes WFL All planes 5/5

Quadriceps tendon rupture/repair

Activity Limitations - Normal gait pattern

- Stair climbing - Standing - Sitting

- Squatting

Body Function/Structure

- Quadriceps atrophy - Decreased patellar mobility - Increased muscle guarding - Decreased knee flexion

ROM

Participation restrictions

- Sitting at work - Stair climber/elliptical

trainer - Recreational running

- Golfing

Environmental Factors - Works in an office setting - Sitting at desk most of day

- Some help at home

Personal Factors - Overweight

- 58 year old Caucasian male - Intrinsically motivated

  POC ◦ Neuromuscular re-education ◦  AROM ◦  Stretching/Flexibility ◦  Electrical stimulation ◦  Therapeutic exercise ◦  Balance/proprioception training ◦  Soft tissue mobilization

  Frequency/Duration ◦  2x/week for 4 weeks

  PROM ◦  In four weeks, patient will display PROM to 90 degrees

to perform functional gait patterns and LE mobility   Strength ◦  In four weeks, patient will demonstrate increased

ability to perform active quad set in isolation per post-op protocol without increase in p!

  HEP ◦  In 1 week, patient will verbalize adherence and understanding

of HEP to begin increasing ROM and strength for LE function for ADLs

  Function ◦  In 1 week, patient will demonstrate heel-to-toe gait pattern in

extension brace to facilitate quadriceps contraction and functional gait pattern without deviations

  Is an early mobilization protocol safe and effective for improving knee flexion ROM, quadriceps strength and functional outcome in a 58 year old male patient post-op quadriceps tendon rupture/repair?

 Title: Early motion after quadriceps and patellar tendon repairs: outcomes with single-suture augmentation

◦  West, J. L., Keene, J. S., & Kaplan, L. D. (2008). Early Motion After Quadriceps and Patellar Tendon Repairs Outcomes With Single-Suture Augmentation. The American journal of sports medicine, 36(2), 316-323.

Purpose: Present results of 20 quadriceps and 30 patellar tendon repairs that were augmented with a single No. 5 non-absorbable “relaxing suture” and treated with an accelerated rehab protocol of early motion, full weight bearing and brace free ambulation

Study design: Case series; Level IV

Data collection:   2 senior authors’ surgical database June 1994-July 2005   N=50 (20 quad and 30 patellar)   No exclusion criteria   Age, MOI, ROM, strength, length of follow up, post op

complications

Patient population   Age: mean 55 years

(quadriceps)

  MOI: 14 slipped/tripped and fell, 10 fell down flight of stairs, 12 during sport

  Time to operation: mean 7 days from injury

Surgical Technique   End-to-end repair   No. 5 Ethibond “relaxing

suture”

Post operative protocol   24-48 hours: ◦ Operative leg elevated ◦  Braced locked 5-7 days

  Wound healing postoperative week 6: ◦  0-55° knee AROM ◦  SLR ◦  Full weight bearing

with locked extension brace

  After 6 weeks: ◦  Ambulate brace free ◦  Full active flexion

Clinical follow up   2 week intervals first 6

weeks   At 3, 6, 9, 12 mo after

surgery ◦  Status of wound ◦  ROM ◦  Gait ◦ Quadriceps strength

 The Lysholm knee rating scale ◦  1 or more years after surgery ◦  Excellent (91-100), good (84-90), fair (65-83),

poor (<64)

ROM:   6 week goal: 120° flexion and brace free ambulation achieved by both groups (mean 7.2 weeks)

  12 weeks: all 50 patients active flexion equal or within 10° of uninjured knee

  6 months: 40 full extension, 10 lacked 3-10°

Strength:   MMT all 50 patients 5+ HS and Quad at 6 mo-1 yr   Isokinetic12 mo: quads 35-38% HS 4-5% strength

deficits

Patellar position: No evidence of patella baja or alta

Lysholm Scores and Activity Levels:   All patients reached pre injury levels of

activity within 6 months  Mean follow up of 4 years (1-12 year range)

on Lysholm scores ◦ Average 92 (“excellent”)  35 excellent, 15 good, no fair or poor

*No postoperative complications *No re-ruptures

 Tension produced by the relaxing suture used in this study protects suture line during early mobilization

 Active physical therapy safe and effective when initiated in first week

 Excellent functional results  Although strength deficits still present,

results very similar to those reported by other studies

 Controlled stress and early joint motion shown to accelerate and enhance soft tissue healing

Strengths   1 surgical technique   1 rehab protocol   Sample size relative to other studies

Limitations   Retrospective study   No radiographs on follow up   No details of physical therapy included

  Title: Postoperative functional rehabilitation after repair of quadriceps tendon rupture: a comparison of two different protocols

◦  Langenhan, R., Baumann, M., Ricart, P., Hak, D., Probst, A., Badke, A., & Trobisch, P. (2012). Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols. Knee Surgery, Sports Traumatology, Arthroscopy, 20(11), 2275-2278.

 Purpose: to compare outcome of two different postoperative protocols after primary repair of unilateral quadriceps tendon rupture ◦  Full body weight bearing and early knee flexion

compared to conventional restricted knee motion and non-weight bearing

 Level III Evidence: “Therapeutic” retrospective comparative study

•  Data collection • All patients treated since 2001 for isolated

unilateral quadriceps tendon rupture at two trauma centers • Minimum follow-up 24 months •  Exclusion criteria bilateral rupture, re-rupture

after primary repair, non-operative •  Same surgical technique •  End-to-end suture •  Patellar drill holes •  Intra operative stress test to 40-60° knee flexion

•  Patient groups (N=66, 59 men, 7 women) •  Group A – traditional/conservative rehab (N=28) •  Passive and active knee flexion limited to 40° with hinged

brace •  Weight bearing restricted to floor contact not exceeding

50% body weight until 6 weeks

•  Group B – functional rehab (N=38) •  Passive and active knee flexion 30°: first two weeks, 60°:

week 2-4, 90° week 4-6 •  Allowed immediate full body WBAT

•  Outcomes of interest •  Primary: Patient’s clinical outcome measured by subjective

International Knee Documentation Committee form (IKDC)

•  Secondary: rate of complications and time of returning to work

 No significant differences for clinical outcome as measured with the IKDC score

 Average return to work time ◦  90 days for group A (conservative) ◦  74 days for group B (aggressive) ◦ Not significant

 2 re-ruptures in both groups ◦  8% for A ◦  5% for B

  Supports hypothesis that early functional mobilization in combination with full weight bearing is safe and clinically equivalent

 Limitations ◦ Multiple different surgeons ◦ Underpowered study for means of

determining difference in IKDC score ◦  Strength and joint mechanics were not analyzed

“Prospective multicentre study of the clinical and functional outcomes following quadriceps tendon repair with suture anchors” Mille, et al (2016)

Results: •  ROM: 124.5° knee flexion (90% after 3 mo) •  Strength: 20% quadriceps deficit assessed with

dynamometer •  MRI: tendon in contact with bone, thickened/

irregular with signs of remodeling activity •  The Tegner, Lysholm, Cincinnati: 82%

patients “satisfied” or very satisfied with the outcome

 Age  Gender  Unilateral rupture  MOI  Early surgical intervention  Early mobilization protocol

  Is an early mobilization protocol safe and effective for increasing knee flexion ROM and quadriceps strength in a 58 year old male patient post-op quadriceps tendon rupture/repair?

◦  YES definitely safe and equally effective, if not superior

Clinical application •  Positive benefits of early mobilization for

tendon healing vs. complications to prolonged immobilization *Facilitates healing process *Increases tensile strength *Improving joint biomechanics

•  Pick early mobilization! Educate

PHASE I (0-2 weeks) PHASE II (2-6 weeks)

Rehab Goals Protect Normalize gait Discontinue crutches

Precautions WBAT with crutches with brace locked in

extension

Brace locked at all times; besides during rehab, Avoid active knee extension

ROM 0-30° passive flexion 0-90°flexion; avoid knee hyperextension

Ther ex Isometric quad sets 4 way SLR Knee extension ROM Seated HS/calf stretches M/L & A/P patellar mobs Weight shifts: BAPS/tilt board, tramp march Fwrd/lat step ups Sit to stand Gait Training

Manual Therapy

N/A IASTM, patellar mobs, scar massage, contract relax stretching, active release hip flexors, end range

flexion overpressure

Modalities Ice MH & Russian Stim, TENS with LLPS

PHASE III (6-12 weeks) PHASE IV (12 weeks)

Rehab Goals Normalize gait on level surfaces with brace opened to 30-40

Initiate active quad contraction in weight bearing

- Normalize gait on all surfaces

- SLS 10 sec - Full knee ROM

- Controlled squat to 70°

Precautions Avoid knee flexion past 70 in WBing - Avoid forceful eccentric cxn - Avoid impact activites

- Avoid exercise that creates movmnt compensations

ROM PROM: 115° weeks 7-8, 130° weeks 9-10 (active knee extension permitted)

AROM: at least 0°-110°

Full PROM/AROM flexion and extension

Ther ex CKC posterolateral hip strengthening: squats, shallow lunge steps Stationary bike OKC hip strengthening Eccentric quad strengthening

Balance/proprioception Return to gym/sport Hip/core strengthening Functional movements Stairmaster

Strength   Knee ext (5/5)   Improved quad set   Controlled eccentric quad

contraction

Function   Decreased gait

deviations   No p!

0

20

40

60

80

100

120

140

0 2 4 6 8 10 12

Deg

rees

Weeks

R knee flexion ROM

 Prospective RCT: compare early mobilization therapy protocol vs. immobilization

 Physical therapy interventions to address impairments specific to quadriceps tendon repair ◦ Tissue healing ◦ ROM ◦  Joint mechanics

  Mille, F., Adam, A., Aubry, S., Leclerc, G., Ghislandi, X., Sergent, P., & Garbuio, P. (2016). Prospective multicentre study of the clinical and functional outcomes following quadriceps tendon repair with suture anchors. European Journal of Orthopaedic Surgery & Traumatology, 26(1), 85-92.

  Ciriello, V., Gudipati, S., Tosounidis, T., Soucacos, P. N., & Giannoudis, P. V. (2012). Clinical outcomes after repair of quadriceps tendon rupture: a systematic review. Injury, 43(11), 1931-1938.

  West, J. L., Keene, J. S., & Kaplan, L. D. (2008). Early Motion After Quadriceps and Patellar Tendon Repairs Outcomes With Single-Suture Augmentation. The American journal of sportsmedicine, 36(2), 316-323.

  Langenhan, R., Baumann, M., Ricart, P., Hak, D., Probst, A., Badke, A., & Trobisch, P. (2012). Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols. Knee Surgery, Sports Traumatology, Arthroscopy, 20(11), 2275-2278.

  Kannus, P. E. K. K. A., & Jozsa, L. (1991). Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am, 73(10), 1507-1525.