Penanganan

cedera olahraga
pada sendi lutut
Disampaikan oleh :
Dr. Maria Eva Dana, SpKFR
pada Simposium Ilmiah RS Mitra Kemayoran
Sabtu, 19 November 2011

2012-3-8

Rehabilitation after reconstruction

of Anterior Cruciate Ligament (ACL)
The goal of rehabilitation:
to return the patient to a preinjury level of activity.
This involved:
restoration of normal Range of Motion (ROM),
strength & stability of the knee
to return to functional activities.
2012-3-8

In athletes,
the rehabilitation program must also strive
to restore agility, skill & speed
as well as a functionally stable knee
that can withstand all rigors of sports-related
activities.

2012-3-8

Proper balance between

protection of the reconstructed ligament &
prevention of disuse sequelae
maybe difficult.
The reconstructed ligament
must be properly protected to allow healing &
to prevent excessive strain on the graft
however

2012-3-8

Prolonged immobilization is not desirable

because of the numerous detrimental effects associated
with this form of treatment, including
- disuse atrophy of muscle tissue
- severe changes in articular cartilage & ligament
- loss of joint ROM
from the formation of intraarticular adhesions.

2012-3-8

Accelerated rehabilitation based on the observation

that patients who did not comply with restrictions
imposed by a traditional protocol,
had better ROM, strength & function
without compromising joint stability
than did those who complied.

2012-3-8

The protocols stress the following principles:

- Initiation of early ROM & weight bearing.
- Early edema control techniques.
- Avoidance of excessive stress to the graft (avoiding
excessive early open-chain exercises).
- Early hamstring strengthening to provide dynamic joint
stability & to decrease strain on the graft.
- Proprioceptive retraining & neuromuscular reeducation.

2012-3-8

The protocols.
Muscle strengthening & conditioning.
Incorporation of closed kinetic chain exercises.
Sports-specific agility training.
A bracing algorithm.
Criteria-based progression from one level to the next.
Criteria-based return to athletic activity.

2012-3-8

Erikson & Haggmark demonstrated 40% quadriceps

atrophy after just 5 weeks of immobilization.
In addition, the rate of atrophy was increased with
immobilization in a shortened position (such as joint
flexion).
Clancy et al. reported a decrease in knee flexion
contractures from more than 10 at 8 weeks after surgery
with traditional rehabilitation, to an incidence of 1,7%
using an accelerated protocol.

2012-3-8

Shelbourne & Nitz also reported a decreased incidence of

arthrofibrosis from 12% with traditional ACL
rehabilitation to 4% using the accelerated protocol.
The goals for ROM in an accelerated protocol, according
to Fu et al., are full knee extension (equal to the
uninvolved knee) within 2-3 weeks after surgery & full
flexion wihtin 8 weeks.

2012-3-8

Closed Kinetic Chain (CKC) Exercises versus Open Kinetic

Chain (OKC) Exercises.
- Knee exercises for rehabilitation after ACL reconstruction

are divided into 2 broaded categories: CKC & OKC.

2012-3-8

CKC exercises are those in which motion at the knee is

accompanied by motion at tha hip & ankle.
The distal segment of the extremity (foot) is in contact with
a pedal, platform, or ground surface.
Examples: - minisquats
- cycling
- leg presses

2012-3-8

OKC exercises are those in which motion at the knee is

dependent of motion at the hip & ankle.
The distal segment of the extremity (foot) is free of move.
Examples: - leg extensions
- leg curls.

2012-3-8

Timing of Rehabilitation Progression

The exact time constraints for healing & maturation of ACL grafts, as
well as the loads that they can withstand at specific points of time,
are not entirely understood.
After carefully studying ACL stresses & elongation involved in
functional & rehabilitative activities, Henningnet al. concluded that
the proper order of rehabilitation program, with regard to ACL
stress, should be the following :
1. Crutch walking
2. Stationary cycling
3. Walking
4. Slow running on level surface
5. Faster running on level surface.

2012-3-8

They caution patients to avoid downhill running, because

running down a 4.5-degree decline at 5 mph produces
ACL elongation 2x as great as running on a level treadmill.
Rubenstein & Shelbourne believe that common
postoperative complications are largerly avoided if the
following goals are attained by 2 weeks after surgery:
- Full knee extension
- Minimal swelling
- Leg control ( active control by quadriceps)
- 90 degrees of flexion.
2012-3-8

Neuromuscular Retraining
The intact ACL has been demonstrated to have an
important sensory function in the normal knee. Studies
indicate that the normal ACL has mechanoreceptors that
may be able to detect joint position, as well as sudden or
slow joint position changes.
Disruption of the ACL destroys the mechanoreceptors,
thus eliminating normal joint propioception.

2012-3-8

Early, controlled weight bearing & CKC exercises help to

reeducate proprioceptors in the lower extremity.
Passive cycling is an example of proprioceptive retraining
that can be initiated relatively early.
More complex proprioceptive activities, such as agility
training, are typically introduced later in the
rehabilitation progression.

2012-3-8

Joint Effusion
Joint effusion is a secondary effect of any operative
procedure.
Patients with joint effusions typically experience
significant quadriceps atrophy because of neuromuscular
inhibition.
Because of its inhibitory effect, it is important to diminish
joint effusion as early as possible after ACL reconstruction.
Typically, the patient is instructed in edema control
techniques, such as ice, compression, limb elevation, &
active quadriceps setting & ankle pumps.
2012-3-8

Loss of Motion
Loss of motion (LOM) is one of the most common
complications after ACL reconstruction.
Fu et al. define LOM as knee flexion contracture of more
than 10 degrees &/ knee flexion ROM of less than 125
degrees.
Functionally, loss of knee extension appears to be more
serious than loss of knee flexion.
Loss of knee extension after ACL surgery may lead to an
abnormal gait, quadriceps weakness, & patellofemoral
pain.
2012-3-8

Arthrofibrosis
Several studies report an increased incidence of
arthrofibrosis after reconstruction of an acutely injured
ACL.
Shelbourne et al. noted a decreased incidence of
arthrofibrosis by delaying surgery at least 3 weeks.
We delay ACL reconstruction until the patient has
regained full ROM with minimal to no pain.
This avoids the risk of loss of motion associated with
attempting to rehabilitate a swollen knee with an acutely
inflamed, painful synovium.
2012-3-8

Cross-Over Effect
The cross-over effect is a neurophysiologic concept in
which exercise in one extremity causes strengthening in
the opposite extremity.
This concept can be used early in the rehabilitation
program with isometric quadriceps setting bilaterally to
induce a stronger quadriceps contraction in the involved
extremity.
It has been reported that strength in the involved
extremity may be increased as much as 30% through this
effect.
2012-3-8

ACL Bracing
Many surgeons opt to use a functional knee brace during
the rehabilitative period & with sporting activity for up to
1 year after reconstruction.

2012-3-8

Functional Testing
Functional testing after ACL rehabilitation attempts to
evaluate the functional stability of the knee joint.
Functional testing attempts to simulate, in a controlled
environment, the forces experienced during common
activities such as running, hopping, or cutting.
Risberg & Ekeland suggest that functional tests can be
categorized into 2 different functions: daily life function &
strength/stability function.

2012-3-8

Their studies indicates that after 3 months the figure

eight test & the stair-running test (two-legged tests)
provive a quantitative assessment of daily life function.
After 6 months the patient should be able to perform the
triple-jump test (one-legged test) to assess
strength/stability function.

2012-3-8

Criteria for Return to Sports

Return to sports activity is the usual goal after ACL
reconstruction.
Campbell Clinic guidelines
- Full ROM
- No joint effusion
- Isokinetic test indicates quadriceps strength is 80% or
more than uninvolved leg
- Isokinetic test indicates hamstring strength is 85% or
more than uninvolved leg
- One-legged hop for distance test is 85% compared with
uninvolved leg
2012-3-8

- Successful completion of running program

- Successful completion of sports-specific agility program
- Satisfactory clinical exam

Return to sport varies between 6-12 months, depending on

surgeons preference.

2012-3-8

Medial & Lateral Collateral

Ligament Injury of the Knee
Medial collateral ligament (MCL) injuries usually are
caused by a valgus stress.
The most common mechanism is a blow to the lateral
aspect of the knee.
The classic ODonoghue triad of injury is MCL, ACL, &
peripheral medial meniscus, but more recent reports
indicate that the most common triad is MCL, ACL, &
lateral meniscal tear.
The incidence of significant knee effusion with isolated
MCL tears is significantly lower.
2012-3-8

Instability in full extension indicates that secondary

restraints are disrupted in addition to the MCL.
Isolated MCL tests are treated nonoperatively with
protective bracing, early ROM, & physical therapy.
Gbr
Grade 1 & 2 injuries are treated with immediate ROM.
Grade 3 injuries are kept non-weight bearing & the brace
is locked for 2-3 weeks.
Chronic instability may require reconstruction.
2012-3-8

LCL injuries usually are caused by a varus stress.

Rehabilitation after LCL injury is similar to that after
injury of the MCL, but slower healing of LCL usually
requires a longer period of brace protection.
Complete LCL tears often are managed by operative
repair.

2012-3-8

Iliotibial Band Friction Syndrome of the Knee in

Runners
Iliotibial band friction syndrome is the most common
cause of the lateral knee pain in runners.
Gbr
Clancy reports that most runners with iliotibial band
friction syndrome must rest from running for 6 weeks.
For recalcitrant symptoms, Noble recommends surgical
release of the posterior fibers of the iliotibial band where
they over-lie the femoral condyle.

2012-3-8

Patellofemoral Disorders
Patellofemoral dysfunction, or disorder, may be defined
as pain, imbalance, inflamation, & /or instability of any
component of the extensor mechanism of the knee.
These conditions may result from congenital, traumatic,
or mechanical stresses (Shelton & Thigpen).
An individual with patellofemoral pain experiences
increased pain when the knee is flexed because the
patellofemoral joint reaction force (PFJRF) increases with
flexion of the knee fron 0,5 x body weight during level
walking to 3-4 x body weight during stair climbing & 7-8 x
body weight during squatting.
2012-3-8

Summary
The classic O Donoghue triad of injury is MCL, ACL, & peripheral
medial meniscus, but more recent reports indicate that the most
common triad is MCL, ACL, & lateral meniscal tear.
The goal of rehabilitation is to return the patient to a preinjury level
of activity.
This involved restoration of normal Range of Motion (ROM),
strength & stability of the knee to return to functional activities.
Accelerated rehabilitation based on the observation that patients
who did not comply with restrictions imposed by a traditional
protocol, had better ROM, strength & function
without
compromising joint stability than did those who complied.

2012-3-8