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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 3 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 4 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 5 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 7 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) 8 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 9 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 10 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 11 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. 12 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 13 Notes 14 Mathys Ltd Bettlach • Güterstrasse 5 • P.O. Box • 2544 Bettlach • Switzerland • www.mathysmedical.com Mathys KK Tokyo 108-0075 Tel: +81 3 3474 6900 [email protected] Austria Mathys Orthopädie GmbH 2351 Wiener Neudorf Tel: +43 2236 860 999 [email protected] New Zealand Mathys Ltd. Auckland Tel: +64 9 478 39 00 [email protected] Belgium Mathys Orthopaedics Belux N.V.-S.A. 3001 Leuven Tel: +32 16 38 81 20 [email protected] Netherlands Mathys Orthopaedics B.V. 3905 PH Veenendaal Tel: +31 318 531 950 [email protected] France Mathys Orthopédie S.A.S 63360 Gerzat Tel: +33 4 73 23 95 95 [email protected] P. R. 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