Download Ligamys® – Self-healing of the anterior cruciate ligament

Ligamys® – Self-healing
of the anterior cruciate ligament
Rehabilitation
Table of contents
1.Introduction
5
2. Rehabilitation protocol for patients with isolated ACL rupture6
3. Rehabilitation protocol for patients with ACL rupture
and meniscus suture10
4. Possible summary for operative report13
Note
The rehab scheme on the following pages has been
specifically developed for the after-treatment of a ligamenation. The exercises and time indications are suggestions, the time and weight declarations may vary
from patient to patient depending on antecedents and
accompanying injuries. The individual situation needs
to be considered in any case.
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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In coordination with
Thorsten Müller PT MSc
Bettina Bertschy PT MSc
Inselspital Berne
Institute for Physiotherapy
3010 Berne, Switzerland
Tel. +41 32 632 24 26
www.physio.insel.ch
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Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
1. Introduction
Until now, cruciate ligament reconstruction in case
of a rupture has been regarded as the gold standard in the field of sports medicine. However, with
the growing importance of physical activity and
sports in our daily lives, an intact cruciate ligament
has become an essential prerequisite for maintaining long-lasting stability and proprioception.
When a cruciate ligament is ruptured, patients wish
to be treated with state-of-the-art medical technology. Against this backdrop, Swiss orthopaedists
have further developed the range of treatment options with the primary objective of preserving the
ruptured cruciate ligament.
The so-called “ligamentation” method makes it
possible to dynamically stabilise the ruptured cruciate ligament using a Ligamys implant if operated
on within 21 days after the injury. With this medical
technology, the ruptured cruciate ligament can heal
and grow back together. As a result, proprioception of the knee joint is preserved and patients can
return to their previous levels of activity.
With the Ligamys implant, rehabilitation is clearly
faster compared to conventional cruciate ligament
reconstruction. Immediate intraligamentary stabilisation enables the patient to load the knee joint
sooner, as exemplified by the rehabilitation protocols described below. Rehabilitation after dynamic
intraligamentary stabilisation with Ligamys may
take up to seven months depending on the patient’s starting level and performance target.
For rehabilitation, a distinction should be made between isolated cruciate ligament ruptures and injuries that additionally involve the meniscus. In the
second case, because there is a sutured meniscus
lesion in addition to the implant, the rehabilitation
period will be prolonged by about three weeks.
Resuming the previous type of sports activity
should be possible within 18-20 weeks after surgery. Clearance for such activity is given if the respective test battery is successfully completed after 16 or 20 weeks.
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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2. Rehabilitation protocol for patients
with isolated ACL rupture
The following principles apply:
• weight bearing depending on the level of discomfort
• no training of the M. quadriceps (extensor) in the open muscle chain • activation of the musculature from day 5 in order to preserve the protective function
• The indications below should be regarded as guidelines; time frames may vary depending on the case history and/or the presence of concomitant injuries
• Patients should inform the surgeon and the physiotherapist about their preferred types
of sports so that the course of rehabilitation can be adjusted accordingly
Phase 1 from day 1
Priorities: reduction of swelling,
pain control, learning independent
mobilisation
Goals:
• reduction of activities to a minimum
in order to ensure adhesion of the
cruciate ligament stumps
• control of swelling
• fixed orthesis in an extended position
• physiotherapy for independent mobilisation
• learning the safety precautions
(avoiding anterior drawer movement, quadriceps/hamstring tension,
co-contraction)
• walking and climbing stairs on
crutches with weight bearing depending on level of discomfort
– 6
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
Phase 2 from day 5
Priorities: start of active physiotherapy
without orthesis
Goals:
• knee joint mobility, free flexion,
extension up to 0° (caution: avoid
overextension!)
• neuromuscular coordination
• innervation training of extensors in a
long-sitting position
• prevention of major muscle atrophy,
start of strength-endurance training for neural facilitation (complex
method)
• improvement of muscular elasticity
Phase 3 from week 3
Priorities: muscle growth,
sensorimotor control
Goals:
• mobility by end of week 6, free flexion/extension, at least 90°/0°/0°
• muscle growth training (hypertrophy) of the entire leg musculature,
especially the quadriceps (in closed
muscle chain) in an initially nearextended position, as well as the
hamstrings and the calf and hip
musculature
– • active in-line axial stabilisation in a
single-leg stance on a stable and
later on an unstable surface
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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Phase 4 from week 6
Priorities: unlimited control of movement, bilaterally equal strength
Goals:
• continued rehabilitation until capacity of unlimited movement is
attained, including critical situations
during normal everyday movements
• maximal strength
• optimal coordination and stabilisation, including when in motion
(running)
Phase 5 from week 10
Priorities: jumps, sports-specific training
Goals:
• jumping ABC
– • optimal stabilisation when changing
direction and making quick movements
• muscle growth for sports-specific
training
– • vibration training now permitted
(recommended: Zeptor)
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Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
Test battery Weeks 16 and 24
Goal: return to sport
Tests:
• Lysholm score (for subjective assessment)
• hop tests*
• range-of-motion measurement
• pain measurement (visual analogue scale VAS)
• strength test (on leg press: at least 90 % of the healthy leg)
* Hop tests: single limb hop test, timed 6 m hop test, triple hop for distance, crossover hop for distance.
Calculation of lower limb symmetry:
Distance measurement = affected side/healthy side x 100 % è min. score 85 %
Time measurement = affected side/healthy side x 100 % è min. score 85 %
Sporting activities
With optimal rehabilitation and good muscular stabilisation of the knee, sporting activities may be
started as follows:
Cycling (on roads) from week 6
Jogging (with good quality footwear) from week 10
Skiing/snowboarding from month 6
Stop-and-go sports such as tennis, squash etc. from month 6
Contact sports such as soccer, handball, martial arts etc.
from month 6
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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3. Rehabilitation protocol for patients
with ACL rupture and meniscus suture
The following principles apply:
• 6 weeks with partial weight bearing at 15 kg
• no training of the M. quadriceps (extensor) in the open muscle chain • orthesis to limit movements during the first 6 weeks
• 60° knee flexion for 3 weeks, followed by 90° knee flexion for an additional 3 weeks
• The indications below should be regarded as guidelines; time frames may vary depending on the case history and/or the presence of concomitant injuries
• Patients should inform the surgeon and the physiotherapist about their preferred types
of sports so that the course of rehabilitation can be adjusted accordingly
Phase 1 from day 1
Priorities: reduction of swelling,
pain control, learning independent
mobilisation
Goals:
• reducing activity to a minimum
to ensure adhesion of the cruciate
ligament stumps
• control of swelling
• fixed orthesis in an extended
position
• physiotherapy for independent
mobilisation
• learning the safety precautions
(avoiding anterior drawer movement, quadriceps/hamstring tension,
co-contraction)
• walking on crutches with 15 kg partial weight bearing
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Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
– Phase 2a from day 5
Priorities: removal of orthesis, mobility, neural facilitation, hypotrophy prevention
Goals:
• knee joint mobility up to 60°, extension up to 0°; orthesis set to
60° (caution: avoid overextension!)
• innervation training of extensors in a long-sitting position
• neuromuscular coordination
• improvement of muscular elasticity
• prevention of major muscle atrophy, start of strength-endurance
training for neural facilitation (complex method), leg press with
15 kg up to 60° knee flexion, for calf in knee joint extension, leg
curl up to 60° knee flexion
Phase 2b from week 3 to week 6
Priorities: mobility, neural facilitation, hypotrophy prevention
Goals:
As in phase 2a but with the following progression:
• knee joint mobility up to 90°, extension up to 0°, orthesis set to
90° (caution: avoid overextension!)
• continued strength-endurance training for neural facilitation
(complex method), leg press with 15 kg up to 90° knee flexion,
for calf in knee joint extension, leg curl up to 90° knee flexion
When the goals of phases 2a and 2b have been attained,
phase 3 may be started in consultation with the surgeon.
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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Phase 3a from week 6 to week 8
Priorities: transition to full weight bearing without orthesis,
neural facilitation, sensorimotor control
Goals:
• free mobility without limitations
• continued strength-endurance training for neural facilitation
(complex method) without weight-bearing or mobility limitations
– • build-up of a two-leg stance, single-leg stance with in-line axial
stabilisation on a stable surface
Phase 3b from week 9 to week 12
Priorities: transition to full weight bearing, neural facilitation,
sensorimotor control
Goals:
As in phase 2a but with the following progression:
• growth training (hypertrophy) of the entire leg musculature, especially the quadriceps (in closed muscle chain) in an initially nearextended position, as well as the hamstrings and the calf and hip
musculature
– • active in-line axial stabilisation in a single-leg stance on an unstable surface
Phase 4 from week 12
Test battery weeks 20 and 28
see page 8
see page 9
Phase 5 from week 16
Sporting activities
see page 8
With optimal rehabilitation and good muscular stabilisation of the
knee, sporting activities may be started as indicated on page 9 but
with a delay of 4 weeks.
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Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
4. Possible summary
for operative report
Ligamentation – isolated ACL rupture
Level of exercise
Days 1 – 5 Day 5 – week 3 Weeks 3 – 6 Weeks 6 – 10 From week 10 Exercise depending on level of discomfort
Reduction of activities to a minimum
Start of active physiotherapy, free flexion, extension up to 0°
Mobility up to end of week 6: free flexion/extension,
at least 90°/0°/0°
Unlimited control of movement
Sports-specific training, jumps
Orthesis
Days 1 – 4 From day 5 Fixed orthesis in an extended position
Physiotherapy without orthesis
Weight bearing / walking aids
Days 1 – 5
Weight bearing depending on level of discomfort
Return to sport
From week 6 From week 10 From month 6 Cycling (on roads)
Jogging (with good quality footwear)
Skiing, snowboarding, stop-and-go sports (tennis, squash etc.),
contact sports (soccer, handball, martial arts etc.)
Ligamentation – ACL rupture with additional meniscus suture
Level of exercise
Days 1 – 5
Day 5 – week 3
Weeks 3 – 6
From week 6 From week 12 From week 16 Exercise depending on level of discomfort
Reduction of activities to a minimum
Start of active physiotherapy, mobility: flexion 60°, extension up to 0°
Mobility: flexion 90°, extension up to 0°
Mobility: free, unlimited
Unlimited control of movement
Sports-specific training, jumps
Orthesis
Days 1 – 4 Day 5 – week 3 Weeks 3 – 6 Fixed orthesis in an extended position
Orthesis set to 60° flexion, 0° extension
Orthesis set to 90° flexion, 0° extension
Weight bearing / walking aids
Day 1 – week 6 Partial weight bearing with 15 kg
From week 6 Transition to full weight bearing, without orthesis
Return to sport
From week 10 From week 14 From month 7 Cycling (on roads)
Jogging (with good quality footwear)
Skiing, snowboarding, stop-and-go sports (tennis, squash etc.),
contact sports (soccer, handball, martial arts etc.)
Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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Notes
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Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com
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