Download Non-operative Treatment for Type 1 Tibial Plateau Fracture

Non-operative Treatment for
Type 1 Tibial Plateau
Fracture
By: Britt Dickman
Rehabilitation of Athletic Injuries
Dr. Valerie Moody
Spring 2014
1
Introduction:
The knee has a medial and lateral tibial plateau, on which the menisci sit and articulate
with the femoral condyles. These types of fractures only account for one percent of all fractures
and up to 70% of isolated tibial plateau fractures occur to the lateral plateau, whereas 25% are
isolated medial tibial plateau fractures.1, 2 The mechanism of injury to cause a tibial plateau
fracture is produced by an axial load with either a valgus or varus force.1, 2 According to the
Brigham and Women’s Hospital, motor vehicle accidents account for the majority of tibial
plateau fractures due to impact on collision, followed by falls and sport injuries. A fracture to the
proximal tibia results from low-energy trauma or high-energy trauma.3 With both types of
trauma, soft tissue injury also needs to be assessed.
When a fracture to the proximal tibia occurs, the articulating anatomical structures to the
area are at risk for being damaged. The medial and lateral condyles are separated by the
intercondylar eminence, which is the attachment site for the cruciate ligaments. The lateral and
medial collateral ligaments are taken into account as well because they surround the knee joint.
The attachment of the muscles in the area are evaluated for damage due to the attachment sites
above and below the tibial plateau. Each of these structures are inspected to help determine the
severity of the injury.
The Schatzker system is used to classify the severity of tibial plateau fractures. The
system has six groups: a type I fracture is a split of the lateral plateau; a type II involves a split
and depression of the lateral plateau; type III is a pure depression of the lateral plateau; type IV
fractures involve only the medial plateau; type V are bicondylar fractures; and type VI are
bicondylar with separation of the metaphysis and diaphysis of the tibia.1 Management of tibial
plateau fractures vary from conservative non-operative to operative. If the soft tissue in the knee
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is damaged or the fracture is displaced and not stable, operative treatment is required. A nondisplaced to partially displaced, stable fractures are treated with a brace and non-weight bearing.3
A published article on outcomes of patients 20-years after non-operative treatment revealed the
majority of the patients had excellent outcomes.4 A similar study followed patients for 10 years
that had displaced fractures and were treated non-operatively. The majority of the patients had
moderate to severe arthritic changes. Decoster et al. recommends surgical forms of treatment
when the tibial plateau fracture is displaced.5
The purpose of surgery in tibial plateau fractures is to repair the ligamentous structures,
realign the bones, and stabilize the knee. Fracture fixation includes plates, screws, or external
fixations. In some severe cases, bone grafts are used. The degree and severity of the injury
indicates what type of surgery is performed.2 The longevity of knee joints are analyzed after
suffering a high-energy tibial plateau fracture and repaired with external fixation.1 All reports
were good to excellent outcomes. The technique of external fixation helps minimize disruption to
the soft tissues, while allowing for realignment and proper healing to be restored in the joint.4
What was common among all of these surgical techniques was that all patients were required to
wear hinge brace and were non-weight bearing for 12 weeks.1
Applying the knowledge of the knee’s anatomy and peer-reviewed studies on clinical
findings for tibial plateau fracture rehabilitation, this plan of care focuses on rehabilitating the
knee back to pre-injury function and strength. This is accomplished with a method that is slow
enough to prevent stiffness and malunion.1 To avoid these issues from happening,
communication between the patient and clinician is necessary. Most importantly, patient
compliance is stressed throughout the rehabilitation process, as it is very beneficial for a positive
rehabilitation outcome.
3
Clinical Findings:
The patient, a 17-year-old male pole-vaulter, missed the landing on his jump and landed
on the track. The team physician evaluated the athlete and determined from the way he landed on
the track caused a type I tibial plateau fracture. After the evaluation, the team physician
established there was minimal displacement but the knee was stable. The athlete has been put
into a hinge brace for the next 12 weeks and to be non-weight bearing for 6 weeks.
Rehabilitation has been instructed to start immediately.
The physician’s examination showed the athlete is lacking 25 degrees of extension and he
only has 55 degrees of flexion due to pain. Normal range of motion (ROM) for flexion of the
knee is 0-145 degrees and normal extension is 0-10 degrees, though slight hyperextension is
common at the knee.6 Knee flexion and extension is essential for activities of daily living (ADL)
and for sport specific activities. Loss of ROM affects the function of the entire lower extremity.
If knee flexion is not regain to normal ranges, alterations to gait occur, and a person has
difficulty going up stairs and sitting.7 Limited knee extension also affects gait patterns along with
running and jumping because of the failure to attain the proper closed-packed position of the
knee.7 In order to pole-vault, an athlete needs to sprint down the track, which requires them to
have full ROM of the knee. Sprinting requires at least 125 degrees of flexion and full extension.6
If these ROM problems are not resolved, it is impossible for the athlete to perform at the
previous level of competition, not to mention perform activities of daily living such as walking
and sitting properly. To complete ADL’s, a flexion of 70 degrees and extension of 30 degrees is
required at the knee.6
4
In addition to ROM, patellar mobility was assessed to be about 50% of normal. As the
knee goes from flexion to extension, the patella should track medially within the 45-18 degree
range and then track laterally in the last 18 degrees of extension.6 Tracking of the patella depends
on the relationship between the femur and tibia, the Q-angle, the integrity of the patella’s soft
tissue restraints, foot mechanics, and the flexibility of the muscles surrounding the knee joint.6, 7
If the patella is not moving properly, the function of the lower extremity is altered. Alterations to
the lower extremity affect activities of daily living and inhibit athletic performance.7 Referring
back to having adequate range of motion at the knee, the knee needs to move within the full
ROM in order for the athlete to pole-vault. When the patella has only half of its mobility, the
knee does not have the proper biomechanics to have normal function. Little evidence is found to
support or refute patellar mobility prediction of how the lower extremity functions.6
The team physician’s examination of the patient notes a large effusion around the knee.
Effusion is fluid accumulating around the joint, also known as swelling. Many signs and
symptoms of swelling include pain, stiffness, and bruising.6 Joint effusion induces quadriceps
joint inhibition and knee joint mechanics.7 Each of these signs all need to be addressed early in
rehabilitation to help regain ROM and mobility.
The information from the physician’s exam highlights the importance of applying
exercise to regain ROM early in the rehabilitation program. The athlete first needs to get to the
point where he performs activities of daily living. Once he accomplishes this, regaining full
ROM needs to occur in order for the athlete to have a chance to return to his sport. Assisting the
athlete to return to the ROM and mobility that he had pre-injury helps stabilize the knee and
helps the athlete return to play without fear of re-injury.
5
Long Term Goals:
The primary goal of the rehabilitation program is to control the effusion of the affected
knee and regain full ROM. While increasing the ROM of the knee through exercise, the next
goal of the rehabilitation plan is to improve patellar mobility. Most importantly, the long term
goal of the rehabilitation plan is to return the athlete to play with full range of motion and proper
strength and endurance of the muscles of the affected knee needed to compete and train in his
sport. After 18 weeks the affected knee should be strong enough to practice pole-vaulting
without the brace. The athlete only progresses towards the long-term goal only if he completes
the short-term goals as outlined in this plan of care.
Phase I (0-6 weeks post-injury):8
The main focus in the first phase of this plan of care is to control to reduce pain and to
inflammation and to increase range of motion on the affected knee. Treating inflammation early
is important to prevent secondary metabolic injury.9 Increasing range of motion early with
exercises is to prevent the formation of joint stiffness and deep vein thrombosis, which can result
secondary to prolonged immobilization.10 Both effect the athlete’s ability to perform at the
previous level of competition. All ROM exercises are done actively in this phase. Modalities are
used accordingly to help treat pain.
To assess the goal of decreasing edema in the joint, the circumference of the affected
knee and unaffected knee is measured daily, prior to each session. Three measurements are
recorded on each knee, one at midpatella, one 7 cm above the superior border of the patella, and
one 15 cm above the superior border of the patella.11 The goal is to have the measurements of the
affected knee equal the measurements of the unaffected knee by week 4. To obtain these results
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modalities are used in conjunction with a compression wrap on the affected knee. Most
importantly, the athlete compliance determines if the goal is met or not, because utilizing the
RICE (rest, ice, compression and elevation) method is required at home.
The second goal of this phase, increase ROM, is observed using goniometric
measurements. The affected knee’s ROM is measured at the beginning of each session just like
the circumference measurement. The axis of the goniometer is placed on the lateral epicondyle,
the stationary arm lines up with the greater trochanter, and the movement arm lines up with the
lateral malleolus.6 By week 6, the knee is able to flex to 90 degrees. This goal is achieved by
active ROM exercises and joint mobilization techniques for the knee.
Along with increasing ROM and decreasing edema, rebuilding the strength of the hip
flexors and extensors, hip internal and external rotators, knee flexors and extensors, knee internal
and external rotators, ankle dorsiflexors and plantarflexors is important. All strengthening is
done isometrically moving to isotonic exercises towards the end of the phase. The upper and
lower leg are strengthened with quadricep sets and hamstring sets.12 Core strength is essential for
pole-vaulters to compete at all levels. Throughout this phase, core strengthening is incorporated
with addition to exercises to help maintain the athlete’s cardiovascular endurance.
Cardiovascular endurance is maintained with an upper extremity bicycle. Pool exercises are used
towards the end of this phase.
Core strengthening and stabilization is important in helping with dynamic functional
strength and neuromuscular efficiency through the whole kinetic chain.12 The first part of core
strength teaches the athlete to actively contract the transversus abdominis (TA) and its force
couple, the multifidus. Verbal cues help the athlete visualize how to contract their TA and
multifidus. The athlete utilizes the prone and supine position to activate the TA due to the
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inability to weight bear and lack of ROM.12 In order to move onto the second phase of
rehabilitation, these exercises are important.
Knee ROM
Exercise
Sets and Repetitions
Wall Slides to 90 Degrees
2 sets, 10 reps
Hamstrings
Hold-Relax Technique for 1
minute (within pain free
ROM)
Static Assisted for 1 minute
Piriformis Stretch
Sidelying IT Band Stretch
Quadriceps
Patella Mobility
Gastroc/Soleus Stretching
Hold-Relax Techniques- hold
for 1 minute
Hold for 1 minute (within
pain free ROM)
3-5 minutes
Strength Exercises
Quadricep Sets
Hold for 30 seconds repeat 3
times
2 sets, 10 reps
(Week 1-2)
Hamstring Sets
2 sets, 10 reps
Straight Leg Raise (MultiPlane)
3 sets, 10 reps
4 Way Hip
(Prone and Side lying with
resistance inferior to knee)
4 Way Ankle
(With Resistance Band)
PNF Knee Pattern (through
pain free ROM)
Star Toe Touches (Standing
on unaffected, affected leg
doesn’t touch ground)
Hip Adduction with Cuff
Weight
Hip Abduction with Cuff
Weight
Clam Shells
3 sets, 8 reps
Strength Exercises
(Week 2-4)
Strength Exercises
(Week 4-6)
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3 sets, 8 reps
2 sets, 10 reps
5 reps
3 sets, 10 reps
3 sets, 10 reps
2 sets, 10 reps
Core Exercises
TA Isometrics
2 set, 10 reps, hold for 10 sec
(Week 1-3)
Multifidus Isometrics
2 set, 10 reps, hold for 10 sec
Press Ups
2 set, 15 reps, hold for 5 sec
Abdominal Rolls
2 set, 10 rolls on each side
Prone Cobra
2 set, 15 reps
Core Exercises
Superman’s
2 set, 20 reps, hold for 3 sec
(Week 4-6)
Toe Taps
3 sets, 10 reps
Heel Slides
3 sets, 10 reps
Abdominal Crunches
3 sets, 20 reps
Russian Twists
3 sets, 25 reps
Cardiovascular Exercises
(Week 1-4)
Upper Extremity Bicycle
Interval Workout
10 seconds of high intensity
and 20 seconds of low
intensity (25 minutes)
Cardiovascular Exercise
(Week 4-6)
Upper Extremity Bicycle
Interval Workout
15 seconds of high intensity
and 20 seconds of low
intensity (25 minutes)
Pool Workout
Walking Forward and
Backward (20 minutes)
Stationary Bike
20 minutes at a moderate
intensity as tolerated
Rationale:
Through phase I, all ROM exercises are done actively. Using active motions helps
prevent the joint from moving in the painful arc of motion, which passive stretching of the
musculature around the knee is used in the beginning weeks.12 The damaged structures are given
time to heal when ROM is kept in the pain free arc, which helps prevent instability around the
knee.8,12 Patellar glides are utilized during this phase to help increase knee extension and flexion
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and to help stretch the lateral retinaculum and tight medial structure.12 By the end of this phase,
patellar mobility is back within normal limits. The gastrocnemius and soleus stretch help with
knee extension.12
As ROM in functional patterns is important, it is also important to strengthen the muscle
of the affect knee. This includes muscles of the hip, knee, and ankle. Initially, the muscles that
act upon the knee are trained isometrically.12 The isometric exercises include the quadriceps sets
and hamstring sets. Additionally, all exercises that strengthen the hip, ankle, and lower leg are
completed while the athlete is out of the hinge brace.8 The athlete is in a controlled environment
and monitored for safety and stability of the knee while out of the brace.
As ROM is increasing, proprioceptive neuromuscular facilitation (PNF) patterns are
utilized to help increase ROM, strength, and neuromuscular control. PNF exercises utilize
sensory, motor and psychological feedback.12 The patterns of PNF are through functional
patterns and assist muscles on re-education of individual motor elements through neuromuscular
control, joint stability, and coordination.12 During phase I, the athlete only moves through the
ranges that are pain free. PNF exercises are performed without the brace to increase the
cutaneous feedback to the athlete.
Using resistance bands for the ankle helps build initial strength in these muscles without
stressing the knee. The four way knee is performed prone and side lying with the resistance band
inferior to the knee to help prevent torque of the knee. During these exercises, the clinician
instructs the athlete on proper form and pace of the exercises. The straight leg raise through the
multi-plane patterns initiate functional movements the lower extremity works in and also starts
preparing the muscle to start strengthening.8 The athlete has a light cuff weight around the
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inferior portion of the knee decreasing the stresses on the knee. These exercises help regain
muscular control and minimize atrophy.12
Cardiovascular fitness need to be maintained to prevent deconditioning of the athlete
while they are out of practice.12 Since the athlete is non-weight bearing and restricted to 90
degrees during the first six weeks, the upper extremity arm bicycle is utilized. It allows the
athlete to keep up his cardiovascular fitness and work his upper extremity. Towards the last three
weeks of the phase, the athlete starts walking in the pool with assistance. The pool eliminates
gravitational stresses on the knee. This is a gait way into partial weight-bearing exercises during
phase II.12 The stationary bike is during the last week of phase I. The seat is lowered to the angle
of knee flexion the patient has. The stationary bike is used to facilitate cardiovascular training,
and it is used to help regain active range of motion in the knee. The athlete goes at an intensity
that causes no pain.
In order for the athlete to progress to phase II of the plan of care, he must exhibit active
knee extension to 90 degrees and full knee extension. All ranges are pain free. Also, the athlete is
able to complete sets and repetitions for each strengthening exercise. Making sure the athlete is
able to do the strengthening exercises in this phase is important because phase II strengthening
exercise become more rigorous. Progressing the athlete without an adequate foundation of
strength has a negative effect on the stability of the knee. Imbalances in strength between the
affected leg and the non-affected leg result in an increase of re-injury and favoring of the nonaffected leg.13
11
Phase II (7-12 weeks):8
The second phase of this plan of care focuses on regaining full ROM of the knee joint. By
week 12, the athlete has knee flexion equal to the unaffected knee.3 This phase focuses on
progressing the athlete from non-weight bearing to partial weight bearing to full-weight bearing.
Closed-kinetic-chain exercises are added to the strengthening exercises. These exercises help reestablish neuromuscular control around the knee, which facilitate dynamic stability of the knee.12
By week 12, the athlete will no longer needs the hinge brace to help stabilize the knee.
At the beginning of this phase, bone healing is in the remodeling process. Wolff’s law is
utilized to ensure bone tissue is being laid in the direction in which forces are placed on the
bone.9 The forces that are placed along the bone causes the bone to realign along the lines of
tensile force. It is important for forces to gradually increase throughout the rehabilitation process
in order for bone to heal properly.9
Knee ROM
(Week 7-12)
Exercise
Sets and Repetitions
Thomas Stretch
Hold for 30 seconds repeat 3
times
Hold for 30 seconds repeat 3
times
Hold for 30 seconds repeat 3
times
3-5 minutes
Adductor Stretch
Quadriceps
Patellar Glides
Calf Stretches
Strength Exercises
(Week 7-9)
Posterior Tibial Glides
Hold for 30 seconds repeat 3
times
3-5 minutes
IT Band Stretch
Hold-Relax repeated 3 times
Hamstring
Hold-Relax repeated 3 times
Calf Raises
(Body Weight)
3 sets, 10 reps
12
Mini Squats-use stick
(0-40 degrees)
PNF Knee Pattern
(Through a greater range)
Monster Walks
(Light Resistance Band)
4 Way Hip
(Increase resistance, move
resistance placement to ankle
and now performed weight
bearing)
Step Ups
Strength Exercises
(Week 10-12)
Core Exercises
3 sets, 10 reps
3 sets, 8 reps
3 sets, 5 yards back and forth
3 sets, 8 reps
2 sets, 10 steps each leg
Lunges
(Bodyweight)
Gluteus Maximus Lift with
cuff weight
Wall Slides
3 sets, 10 reps on each leg
Terminal Knee Extensions
2 sets, 15 reps
Leg Press
(Light Weight)
Hamstring Curls
2 sets, 20 reps
Squats
(Resistance Tubing working
to weights)
Lateral Step Ups (hold
bar/stick)
Quadruped Opposite
Arm/Leg
Supine Twist
3 sets, 8 reps
3 sets, 15 reps
3 sets, 10 reps
3 sets, 10 reps
2 sets, 1 minute
2 sets, 10 reps on each side
2 sets, 10 reps on each side
Abdominal Draw on a
Bosuball
Crunches
2 sets, 10 reps, hold for 5
seconds
2 sets, 50 reps
Plank
3 sets, 45 seconds
Plank with hand on Swiss
Ball
Oblique Crunch with Swiss
Ball between Legs
3 sets, 45 seconds
13
2 sets, 25 reps both sides
Neuromuscular Control
(Week 7-9)
All Exercises start with eyes
open and progress to eyes
closed
Neuromuscular Control
(Week 9-12)
All Exercises start with eyes
open and progress to eyes
closed
Plyometric Exercises
(Week 10-12)
Cardiovascular Exercises
Supine Bridge
2 sets, 25 reps
Single Leg Stance
(On stable surface)
Double Leg Stance
(On stable surface)
Tandem Stance
(On stable surface)
Single Leg Stance
(On airex pad)
Double Leg Stance
(On airex pad)
Tandem Stance
(On airex pad)
Squats on BOSU Ball (hold a
stick/bar)
Ankle Jumps
3 set, 20 seconds
3 sets, 20 seconds
3 sets, 20 seconds
3 set, 15 seconds
3 sets, 15 seconds
3 sets, 15 seconds
3 sets, 10 reps
3 sets, 20 seconds
Lateral Sliding
3 sets, 30 seconds
Front Back Hops
3 sets, 30 seconds
Side-to-Side Hops
3 sets, 30 seconds
Single Leg Jumps
2 sets, 10 jumps
Double Leg Jumps
2 sets, 10 jumps
Stationary Bike
(Interval Training)
10 sec high intensity, 20
seconds low intensity (20-25
min)
Speed of 3.0-3.5 mph at a 2%
grade (20 minutes)
Jogging with Light resistance
(20 minutes)
Moderate Intensity
(25 minutes)
Walking/Jogging on
Treadmill/Outside
Pool Exercise
Elliptical
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Rationale:
Utilizing the knowledge of the bone healing process dictates the use of passive
movements to increase ROM. After 6 weeks, the bones is healed to the point where more
stresses are put on the knee to increase the range of motion.12 To gain even greater ranges of
motion in the knee, joint mobilization of the patella continues, along with adding posterior tibial
glides to increase flexion of the knee. Throughout the phase, interval training on a stationary bike
is utilized to help maintain cardiovascular fitness, as well as move the knee through more of a
functional ROM.8,12
In addition to focusing on restoring full ROM, the open-kinetic-chain exercises must
progress to closed-kinetic-chain exercises. The athlete begins to perform minisquats to about 40
degree to get the lower extremity accustomed to holding his body weight. Performing calf raises
with body weight, lunges, and step ups start to increase forces along the bone, helping the bone
tissue lay down in appropriate patterns.9 Monster walks, four way hip, and gluteus maximus lifts
are essential in making sure the muscle of the lower leg are strengthening to support the function
of the kinetic chain.
PNF exercises perform through more range of motion helps provide the maximal
response for increasing strength and neuromuscular control. With diagonal 1 and 2 patterns, the
clinician provides resistance while the athlete performs the PNF patterns.12 Having the clinician
provide resistance, the intensity of exercises increases, helping the athlete become stronger
throughout larger functional ROM than linear strengthening provides.
In addition to PNF exercises, single leg, double leg, and tandem stances on static
surfaces and on airex pads help reestablish neuromuscular control, while the athlete is weight
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bearing. Performing these exercises without the hinge brace helps with dynamic stability of the
knee. The athlete starts of on a static surface to begin establishing proprioception.12
To provide a thorough rehabilitation to the athlete and to make the transition back to
participation easier, core strengthening is trained during this phase. Now that the athlete is full
weight bearing, he performs a variety of core exercises. Doing the core exercises on a Swiss ball
provides a challenge to the athlete. The challenge is creating an unstable environment for the
athlete to strengthen abdominals. Side crunches on the Swiss ball between the legs provides the
challenge to the oblique muscles.12 To increase the difficulties of the isometric contraction
exercises of the TA and multifus, they are performed in the quadruped position. The supine
bridge also helps activate the TA and multifidus in a tougher position.12
Along with maintaining core strength, the cardiovascular fitness is also essential in
helping the athlete return to participation smoothly. With the athlete weight bearing, more
cardiovascular exercises are utilized. The athlete now progresses to a jog in the pool with
resistance. Stationary bike exercises use an interval training technique to allow for increased
work and increase intensity.12 The athlete now starts at a walking pace on a treadmill or outside
to get the athlete used to a proper gait pattern that may have been forgotten while non-weight
bearing.8 The elliptical provides an alternative method to the athlete for the cardiovascular
exercises.
As cardiovascular training is important during rehabilitation, plyometric training is also
important. The main purpose of plyometrics is to increase the excitability of the nervous system
for improved reactive ability of the neurovascular system. To utilize benefits of plyometric
training, the athlete needs to first start getting used to the movements required in the exercises.12
The athlete starts with ankle jumps, front and back hops, and side to side hops. These exercises
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begin towards the end of the phase when an adequate amount of strength has been established.12
Progressing into single leg and double leg prepares the athlete for increased loads of plyometrics
in phase III.
In order to progress the athlete into the final stage of this plan of care, the athlete must
have full range of motion at the knee (0 degrees extension and around 140 degrees of flexion).6,12
The athlete must have the sets and repetitions completed for each strength exercise outlined
within this phase. All exercises are pain free. The exercises must be done without the hinge brace
with no compensation.12
Phase III (13-18 weeks):8
At this point in rehabilitation, the athlete has full range of motion at the knee. The athlete
is also strong enough to sustain close-chain exercises such as squats and calf raises, movements
essential for pole-vaulting. Throughout this phase, the athlete increases plyometric exercises to
help build explosive power and dynamic stability needed to complete the athlete’s sport. All
exercises are performed without the athlete’s hinge brace. On the last day of week 18, the athlete
completes the Vail Sport Test and the Carolina Functional Performance Index (CFPI).12,13
The athlete does warm-ups with their teammates and complete functional activities. If he
passes both of the functional test, the athlete fully returns to practice 18 weeks after sustaining
the tibial plateau fracture. The main goal of this phase is to return the athlete to practice strong
enough to feel confident that the risk of re-injury of his knee without a brace is minimal.
Knee ROM
Exercise
Sets and Repetitions
Walking Hamstring Stretch
25 yards
17
(Dynamic Stretching)
Strength Exercises
Core Exercises
Knee to Chest Stretch
25 yards
Walking Adductor
25 yards
Walking Quad
25 yards
Butt Kicks
25 yards
Open and Close Gate
25 yards
High Knees
25 yards
Squats
(With bar and weight)
Calf Raises on Step
3 sets, 10 reps
Reverse Squats while holding
a bar/stick
Monster Walks
(Increase Resistance Band)
Dead Lift
5 sets, 10 reps
5 sets, 10 yards
Single-Leg Squat
2 reps, 1 min
Lateral Bounding (working
up to resistance bands
through the 6 weeks)
Forward Walking with
resistance (can holding
bar/stick)
Backward Walking with
Resistance (can holding
bar/stick)
Prone Walk-Out on Swiss
Ball
Prone Bride “Around the
World”
Russian Twist with Medicine
Ball
Quadruped Opposite
Leg/Arm on Half Foam
Rollers
Hanging Windshield Wipers
3 sets, 30 seconds
18
3 sets, 15 reps
3 sets, 10 reps
3 sets, 30 seconds
3 sets, 30 seconds
3 sets, 15 reps
3 sets, 10 reps
3 sets, 25 reps
3 sets, 15 reps
3 sets, 20 reps
Neuromuscular Control
Plyometric
Single Leg Squats on BOSU
Ball while holding a broom
stick in position of running
with a pole-vault
Throw Backs Standing on
airex pad single leg
Lateral Bounding over BOSU
Ball
Three Hurdle Jumps
3 sets, 15 squats each leg
3 sets, 20 throws on each leg
3 sets, 30 sec
2 sets, 10 jumps
Two Leg Lateral Hop Overs
with stick
Box Jumps
2 sets, 10 jumps
Alternate-leg Power Step-ups
while holding a stick/bar
Standing Long Jump
3 sets, 10 steps each leg
Single Leg Long Jump
10 jumps
Depth Jump to Vertical Jump
10 jumps
Cardiovascular Exercises
Jogging
(Week 13-14)
Pool Exercise
Cardiovascular Exercises
(Week 15-18)
Running
5 mph at 5% grade
(20 minutes)
Running with resistance
(20 minutes)
Moderate Intensity for 25
minutes
40 meters
Sprints (with/without pole)
Interval Training
2 sets, 15 jumps
10 jumps
10 second sprint, 30 second
jog (20 minutes with 2 min
rest every 5 minutes)
Rationale:
The first part of this phase focuses on dynamically stretching the lower extremity. A
dynamic stretch is when the muscle contracts and is moved through the ROM. It is important to
incorporate a dynamic stretch in a rehabilitation program to prevent re-injury. There are many
instances in sports when a muscle is forced beyond its active limits, and if there is not enough
19
elasticity, the muscle is injured.12 During pole-vaulting, the athlete needs to prepare for
appropriate flexibility in order to get down the track and over the beam with no injury.
As flexibility is important, increasing strength and endurance prepares the athlete for
competition. The strength and plyometric exercises focus on increasing the power and
coordination of the muscles needed during pole-vaulting. All of the exercises incorporated in
phase III are used to prepare the athlete for the stresses that are placed on the athlete’s body
during competition. Both sides of the body need to be equal in strength and conditioning to
reduce the risk of injury.13
As strength is increasing, neuromuscular control is also increasing. Neuromuscular
control is important to refocus the athlete’s awareness of peripheral sensation and process the
signals in coordinated motor strategies. Making the athlete stand on an airex pad while doing
throw backs causes the muscle to stiffen which heightens the stretch sensitivity of the receptor.12
The body processes multiple stimuli from balancing on the BOSU ball while standing on a
single-leg. This helps improve neuromuscular control.12 All exercises are done close-chained to
enhance the joint congruency and the neurosensory feedback and minimize shear forces.12
In addition to regaining full strength and power, it is also essential to regain full
cardiovascular endurance in order for the athlete to perform. This phase focuses on running and
sprinting to get the athlete ready to be quick down the track. Utilizing sprints in different patterns
helps the athlete with agility and speed.12
Throughout this phase the core needs to be trained. A pole-vaulter needs to have an
excellent, well-rounded strength in his core. The athlete needs to be able to control their core,
which in return controls forces along the extremities, to achieve proper biomechanics to perform
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at their best ability.13 When the team is doing any of their core exercises, the athlete may
participate.
When this phase is completed the athlete complete two functional tests to return to
competition: Vail Sports Test and Carolina Functional Performance Index (CFPI). Criteria of
passing these tests are further discussion in the “Return To Play Criteria” section. If criteria to
passing these functional tests met, then approval from the physician shows the athlete he is ready
to return to competition safely.
Contraindications/Precautions:
The main precaution with tibial plateau fractures is knee stiffness and joint contracture
that can occur if immobilization lasts too long. Both of these prevent the athlete from achieving
normal knee extension.1 With that being said, being over aggressive trying to obtain range of
motion too quickly can cause instability in the affected knee.12 Furthermore, beginning passive
range of motion stretching early in the rehabilitation is detrimental to obtaining an excellent
rehabilitation outcome.2 Malunion also results from inadequate initial treatment or late collapse
of fracture. To prevent malunion, the patient is non-weight bearing for 6-8 weeks.1,2,12
Return to Play Criteria:
The first requirement in order to return to play successfully is the athlete must be able to
progress through each phase of this plan of care. This includes regaining full range of motion and
completing all of the outlined sets and repetitions for all strength exercises. Second, he must pass
the Vail Sport Test and the CFPI. Finally, in order for the athlete to return to competition, the
physician must approve the athlete is healed and ready to compete.
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The Vail Sport Test is effective at evaluating the athlete’s power, neuromuscular control,
muscle endurance, and movement quality. The test is out of 54 point, and in order for the athlete
to pass, he must score a 46 or higher.14 There are four components to the test: single-leg squat for
3 minutes, lateral bounding for 90 seconds, and forward/backward jogging for 2 minutes. The
athlete is scored based upon the capability of them to establish strength and muscular endurance,
absorb and produce force, while maintaining appropriate movement at the trunk and lower
extremity.14
Utilizing the CFPI helps the athletic trainer evaluate the lower-extremity functional
performance. The test includes the co-contraction test, carioca test, shuttle run test, and onelegged timed hopping test.12 CFPI is best used pre-injury so the results are compared to current
testing to ensure the athlete is progressing in the rehabilitation. The CFPI has reliable criteria for
functional performance testing and return to play.12
Both of these functional assessments are highly reliable and have research behind them to
prove their value to determine whether an athlete is ready to return to play after a tibial plateau
fracture. With this plan of care being based entirely on evidence-based research, completing this
rehabilitation plan should put the athlete in a position to successfully pass the Vail Sport Test and
the CFPI. Utilizing these resources, the input of the physician, and the input of the athletic trainer
allows the athlete to return to competition with a low risk of re-injuring the knee.
Conclusion:
Tibial plateau fractures only account for a small percentage of fractures being more
relevant in the elderly. Since this injury is not a prevalent injury, it is important to have a strong
understanding of the injury and a quality based plan to provide the best outcome for injured
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athletes. This plan focuses on decreasing inflammation, begin active range of motion early in
rehabilitation, and providing strengthening exercises to strengthen all muscles that affect the
knee in a manner to allow the athlete to return to competition with enough strength to safely
pole-vault. Additionally, the plan of care includes an objective functional assessment tests in
returning the athlete to play when they have regained full function of the affected limb, thus
decreasing the risk of re-injury in the fracture knee.
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