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Curs 11:

RECUPERAREA POST- TRAUMATICA


A GENUNCHIULUI- APLICATII IN
TRAUMATOLOGIA SPORTIVA
Dr. Florin Filip
ffilip_99@yahoo.com
FEFS/ DSDU
An universitar 2016/ 2017
Epidemiologie
Anatomie functionala (1)
- Genunchiul este o articulatie majora expusa la multiple
traumatisme directe/ indirecte
- Slaba acoperire cu tesuturi moi (plagi!)
- Implicata in biomecanica statica/ dinamica a membrului
inferior:
- asigurarea statica in momentul de sprijin
- asigurarea pozitiei piciorului in momentul balansului  adaptarea la
denivelarile terenului
- Poate suferi in caz de imobilizare pentru alte afectiuni
ortopedice
- Functia articulara si integritatea muscularturii prorpii sunt
strans legate
Anatomia genunchiului (1)
Anatomia genunchiului (2)
Anatomia genunchiului (3)
Anatomia genunchiului (4)
Anatomia genunchiului (5)
Anatomia genunchiului (6)
Anatomia genunchiului (7)
Biomecanica genunchiului (1)

- Flexia genunchiului :
- ROM normal intre 130-1400
– ADL necesita flexie de 115°
– Poate creste pana la 160° in ‘squatting’

- Extensia: 5-100 , hiperextensia este considerata normala


- Articulatia patelo- femurala (PFJ):
- Creste performanata mecanica a grupului qvadriceps (Q)
- Diminua frecarea la nivelului Q si al condililor femurali
- Ditribuie uniform presiunile de la nivel femural
Biomecanica genunchiului (2)

Activities Knee Flexion


• normal gait/level 60°
surfaces
• stair climbing 80°
• sitting/rising from 90°
most chairs
• sitting/rising from 115º
toilet seat
• advanced function > 115°
Biomecanica genunchiului (3)
Etiopatogenia traumatismelor genunchiului
- Leziunile traumatice sunt relativ frecvente (articulatie
superficiala, expusa agentilor din mediu)
- Slaba acoperire cutanata explica incidenta mare a fracturilor
deschise
- Stabilitatea genunchiului depinde de numerosi factori
musculo- ligamentari, astfel incat se intalnesc leziuni
particulare (menisc, LIA, etc.)
- Forme clinice: fracturi, entorse, luxatii, leziuni vasculo-
nervoase
- Forme particulare:
- fracturi de platou tibial sau diafiza femurala
- rupturi de ligamente incrucisate sau colateraler
- fracturi de rotula sau rupturi de tendon rotulian
Clinica traumatismelor genunchiului (1)
Clinica traumatismelor genunchiului (2)
Clinica traumatismelor genunchiului (3)
Clinica traumatismelor genunchiului (4)
Clinica traumatismelor genunchiului (5)
Clinica traumatismelor genunchiului (6)
Principii de tratament KT
- Sechelele traumatice sunt reprezentate de:
- Durere
- Deficit de stabilitate
- Deficit de mobilitate
- Combaterea durerii este primordiala deoarece:
- Determina atitudini vicioase (flexum)
- Impiedica ortostatismul si mersul
- Dupa obtinerea unui genunchi indolor se vor recupera
stabilitatea si mobilitatea (!se va evita mobilizarea precoce)
- Se vor utiliza si tehnici preliminare kinetoterapiei propriu-
zise (posturare, combaterea edemului, troficitate, etc.)
- Reluarea mersului este etapa finala a programului de
recuperare
Tratamentul durerii
• PRICE (Protection, Rest, Ice, Compression, Elevation)

• Caldura locala umeda (in absenta leziunilor


inflamatorii)

• Agenti fizici– ionto, e- stim, TENS

• Mobilizare articulara precoce cu sprijin (leziuni


gradul I si II)
Tehnici de recuperare
• Faza I:
– Controlul durerii si al tumefierii locale
– Favorizarea vindecarii locale
– P.R.I.C.E.
– Imobilizare sau bracing pentru unele leziuni
– Mentinerea functionalitatii cardio- respiratorii
si a mobilizarii trunchiului
Rehabilitation Techniques

• Phase II: ROM


– Early ROM can minimize harmful changes
in ligaments due to immobilization
• AROM: Heel slides, active hamstring stretch,
squats, quad sets
• PROM: Prone/supine leg extensions with or
w/o assistance. Static quad, hip, groin, glut,
ITB, seated calf and hamstring stretching
• AAROM: Wall Slides, heel slides with
contralateral limb assistance
• PNF
Rehabilitation Techniques
• Phase III: Strengthening.
– Overload principle, but not too early or too
aggressive
• can harm healing tissue
• Gently progressive: isometric to isotonic to
isokinetic to plyometric to functional activity
• Closed chain exercises proven to be more
effective for knee rehabilitation
– Can implement early on in most knee rehabs
– OKC can increase anterior tibial shear
Rehabilitation Techniques

• Isometrics: Quad Sets, Glut Sets, Hamstring


Sets. Co-contraction
• Isotonic: SLR-hip flex, ext. abduction and
adduction. Squats; DL & SL, lunges; single,
multiplane, step ups forward and lateral.
Deadlifts; double leg and single leg. Clams
• Proprioception: Progressive balance
exercises
• Can add unstable surfaces, perturbations, ball
toss and/or rotation to exercises as they progress
Rehabilitation Techniques
• Phase IV: Functional progressions return
to sport activity
– Running progression: straight ahead at ½
speed to ¾ speed to full sprint to change of
direction lateral movement @ ½ speed to ¾
speed to full speed.
– Sport specific movements and activity
Rehabilitation Techniques

• Phase V: Maintenance and monitoring


of return to sport

• All phases should include core and


cardiorespiratory exercises
• Athlete should be comfortable and
confident in their progression
• Use pain and swelling as guide for
progression.
ANTERIOR CRUCIATE INJURIES
Initial Treatment
• Surgery NOT INDICATED
– Immediate surgery leads to an unacceptable incidence of
arthrofibrosis (loss of ROM)
• RICE
– Rest
– Ice
– Compression
– Elevation
• Range of Motion exercises
• Gait reeducation
– quickly eliminates the need for crutches
• Cold/compression CryoCuff®
• Strengthening and flexibility program for hamstrings and
quadriceps
• Emphasize extension equal to the other leg
• Cycling
Options?
• Non-surgical
– Must be willing to give up sports with exception of
cycling and activities in a health club
• Strength and conditioning program
• Surgical
– For people that want to return to sports and need
the stability (athletes)
Allografts
• Advantages
– Technically easy
• Biological Considerations
– Greater than one year for revascularization
– Rejection
– Infectious transmission
• Technically easy
• Economic considerations
– Very expensive
• Success Rate 80% stable knees
• Return to sports not before one year
• Indications
– Non-athletic patients over 40
Hamstring Tendon
• Advantages
– Technically easy
• Disadvantages
– Lack of bone to bone healing
– Maturation takes one year
– Sacrifice of a major muscle group that provides major
posterior translation of the tibia (the hamstring tendons
are the allies of the ACL)
• Success rate 90% stable knees
• Return to sports 9 months to one year
• Long term hamstring weakness present
Bone-Patellar Ligament-Bone
• GOLD Standard
• Advantages
– Bone to bone healing
– Strongest graft
– Maturation occurs rapidly
• Return to sports 6 months
• Disadvantage
– Requires attention to detail at surgery and rehab
Contra lateral patella tendon
• (PLATINUM standard)
• Less postop pain
• Faster rehab
– Divide the problem into two parts
– ACL leg concentrates on ROM
– Graft leg concentrates on Strength
• No braces or crutches
• Return to sports 3 months
– Improvement continues over first year
INDICATIONS FOR SURGERY:
Complete tear; associated meniscal pathology
Well motivated person who will do the rehab program; physiologically young
Unwilling to change lifestyle; job and sports require twisting, cutting
Minimal evidence of DJD
PATELLOFEMORAL PAIN
SYNDROME
The patella must have balanced
muscular forces around it to ride
properly in the femoral groove.

The VMO should fire before the VL.

The VMO/VL ratio should be 1:1

Tight ITB, hamstrings and calf can


disrupt muscular balance.
OTHER FACTORS
CAUSING PFPS:
1. Overpronation
2. Anteversion
3. Weak Hip ER & ABD
4. Tibial Varum
5. Increased Q angle
ILIOTIBIAL BAND SYNDROME
Complains of pain on knee flexion
May complain of snapping
Pain gets worse on ROM from full
flexion to full extension.

Often result of: genu varum; over


pronation; femoral anteversion;
spinal problems.
SHIN SPLINTS
Most common area affected is
antereomedial shin.

Starts out as muscle/tendon injury

Can progress to periosteal injury

Can end up as a stress fracture


Recognition and Management of
Specific Injuries
• Medial Collateral Ligament Sprain
– Cause of Injury
• Result of severe blow or outward twist – valgus
force
– Signs of Injury - Grade I
• Little fiber tearing or stretching
• Stable valgus test
• Little or no joint effusion
• Some joint stiffness and point tenderness on lateral
aspect
• Relatively normal ROM
• MCL
– Grade 1
• Can begin early ROM and isometric exercise 1-
2 days after injury
• May return to activity fairly quickly
– Grade 2
• May require 4-5 days of rest to allow
inflammation to subside before starting rehab
ex.
• 4-6 week recovery period

– Exercise bike and closed chain exercises can begin


for grade 1 & 2 sprains as early as it is tolerated
• MCL
– Grade 3 sprains
• May take up to 3 months to return
• Brace for 4-6 weeks, non-weight bearing for 3
weeks.
– Can remove brace for treatment and rehab
– Rehab limited to isometrics and straight leg
exercises
– After the brace is discontinued can progress rehab
similar to Grade 1 & 2 sprains
• Functional and
Prophylactic Knee
Braces
– Used to prevent and
reduce severity of knee
injuries
– Provide degree of
support to unstable knee
– Can be custom molded
and designed to control
rotational forces and
tibial translation
Motion
• PROM
– Patellar mobs
– Tibialfemoral Joint mobilization (accessory and physiologic
motions)
• Grade III-V
• Flex/Ext (some IR and ER)
– Stationary bike
– Fibular mobs
• AAROM
• AROM
– Heel slides
Strengthening
• Isometric
– Quad sets
– Hamstring sets
– Glut Sets
– ABD ISO
• Dynamic
– Open chain
– Closed chain
Strengthening

• Open Chain
– SLR
– Steamboats
– Short arc quads
– Knee extensions (avoid last 30 deg)
– Hamstring curls
Strengthening
• Closed Chain
– Terminal knee extension
– Squat progression (wall, mini, full)
– Lunges / Split squats
– Step-ups/Step-downs
– Hamstring stool scoots
– Eccentric HS in kneeling (difficult can be painful)
– Calf raises
Strengthening
• Do not forget the Hip
• Prior emphasis on quad/VMO activation and
deficits missed weakness and imbalance of hip
ER, ABD and EXT
Proprioception
• SLS
– Eyes open / closed
• Foam
• BOSU Ball
• Rebounder
• BAPS Board
• Body Blade
• Clock Drills
• Perturbations
Endurance
• Bike
• Treadmill
– Walk, Jog, Run
• Elliptical
• Stair stepper
• Pool
– Swim, Jog, Aerobics
Power
• Advanced weight lifting
– Leg press
– Hamstring curl
– Squats
– Lunges
– Dead lifts
– Calf raises
Skilled Activity
• Figure 8s
• Kariokas
• Single leg hop
• Lateral shuffles
• Ladder drills
• Form drills
• Box jumps/plyometrics
Full Activity
• Walk to run progression
• Return to sport drills
• Return to full practice
• Return to competition
Summary
• Effective interventions:
– Eccentric exercise
– General quad strengthening
– Hip, trunk, ankle strengthening: emphasize form
– Plyometrics
• Consider:
– Taping during exercise if reduces pain
– Foot orthoses if rearfoot varus
– SI joint manipulation if fits hypothesized criteria
Therapy and Rehabilitation
• Immediate!
• ROM key on ACL leg!
• Strengthening key on graft leg
• Gait training
• Jogging in 1 month
• Sports specific drills 6 weeks
• Criteria for returning to sports
– Full and equal motion in both knees
– Strength equal to 80% of preop graft leg both knees
– Swelling absent
– Plyometrics
– Neuromuscular reeducation
• Average return to sports 3 months
– Confidence and performance continue to improve for one year
Mobilitate- stretching
Mobilitate- strengthening
Proprioceptia
Terapia ocupationala
Terapia ocupationala
ANKLE SPRAINS
Ottawa ankle rules
JOBST
INTERMITTENT
COMPRESSION
DEVICE
ROM exercises

Strengthening

Proprioception

Agility

Running/jumping
Syndesmotic
Injury
ACHILLES TENDONITIS
ACHILLES TENDON RUPTURE
LONG REHAB: Average 6-9 months
PLANTAR FASCITIS
Over pronation
Pes cavus foot
Tight calf muscles
Tibial varum
Anteversion
Weak ER of hip