Rehabilitation of Knee Injuries: Robert C. Manske and Mark V. Paterno
Rehabilitation of Knee Injuries: Robert C. Manske and Mark V. Paterno
Knee Injuries
27
Robert C. Manske and Mark V. Paterno
Although as tennis players age the risk of osteoar- condylar notch or fossa, which is the attachment
thritis increases, an association with tennis has not site for the cruciate ligaments. Each of the
[9] been highly correlated, at least in Swedish condyles is cam shaped with a smaller curvature
male tennis players. The purpose of this chapter is posterior that of the anterior. The lateral femoral
to describe knee injuries in competitive and recre- condyle is wider both anterior-posterior and
ational tennis. The chapter will start with a review medial-lateral when compared to the medial fem-
of anatomy and biomechanics of the knee. This oral condyle. The medial condyle extends further
will be followed by a discussion of the various anterior than the lateral; however because the
injuries and how they will be managed by sports shaft of the femur angles in a medial direction,
medicine professionals. Finally a return to sports the two condyles sit relatively even in the hori-
program for a player with a tennis injury will be zontal plane. The proximal tibia articulates with
described. the distal femur. The proximal tibia is formed by
the medial and lateral tibial plateau which expand
its proximal end over the smaller shaft. The
27.2 Anatomy and Biomechanics medial tibial plateau is slightly concave to accept
of the Knee the convex medial femoral condyle. However, the
lateral tibial plateau is either flat or slightly con-
The anatomy and biomechanics section of the vex [10, 11], which may create a problem with a
knee is presented as a foundation to better under- convex distal lateral femoral condyle. An impor-
stand clinical decision-making regarding knee tant ridge runs down the center of the tibia. This
injuries. The knee joint proper consists of several ridge, the intercondylar eminence, is the attach-
joints and articulations including the tibiofemoral ment of the anterior cruciate and posterior cruci-
joint and the patellofemoral joint. The bones that ate ligaments. Several other important landmarks
are inherent to these joints include the femur, on the tibia are the tibial tubercle and the Gerdy’s
tibia, and patella. At first glance this seemingly tubercle. The tibial tubercle is situated on the
simple synovial structure looks relatively nonde- anterior surface of the tibia and is the attachment
script; however upon a closer look, one will see site of the patellar tendon. Gerdy’s tubercle is on
that the knee is one of the more complex diarthro- the anterior lateral tibial flare and is the attach-
dial joints in the human body. As the knee sits at ment site of the iliotibial band.
the confluence of the two longest bones in the
human body, tremendous forces are placed upon
this articulation. The knee is also expected to 27.4 Patellofemoral Joint
operate in both an open kinetic chain (OKC) and
closed kinetic chain (CKC) functions. The patellofemoral joint consists of the posterior
patella and the anterior femoral trochlea. The
patella is the largest sesamoid bone in the body.
27.3 Tibiofemoral Joint The patella is engulfed within the extensor mech-
anism which includes the quadriceps tendon and
The tibiofemoral joint is comprised of the distal the patellar tendon. The patella has both a base
femur and the proximal tibia. Each of these bones (proximal) and an apex (distal). The anterior sur-
has unique characteristics. The distal femur face of the patella is very palpable due to its
includes the femoral condyles and the intercon- superficial location on the anterior knee. The
dylar notch. This portion of the femur is covered patella is convex anteriorly in both superior-infe-
with hyaline articular cartilage which, when rior and medial-lateral direction. The thickest
healthy, can tolerate large shear and compressive cartilage in the body (up to 6 mm) is found on the
forces that are placed upon the knee. Two con- posterior patella and is thought to distribute very
dyles, one lateral and one medial, are rounded large compressive and shear forces that occur at
protuberances that are centrally divided the inter- the patellofemoral joint during dynamic a ctivities.
27 Rehabilitation of Knee Injuries 417
A vertical ridge runs down the center of the the femur to the fibular head. Between the LCL
patella dividing it into almost equal medial and and the bony structures runs the popliteus tendon.
lateral halves. However, there is a second smaller This ligament restrains a varus stress placed on
vertical ridge that runs along the medial facet that the knee. The MCL is a large, broad, flatter liga-
separates the medial facet from the odd facet. ment that runs from the medial epicondyle of the
Most of the posterior patella, except the distal femur to the tibia below the joint line. The MCL
inferior pole, is articular. The patellofemoral is divided into a deep and superficial portion. The
joint is a relatively unstable joint as the sulcus is deep portion attaches to medial meniscus and
shallow and patella does not fit deeply into the includes a meniscofemoral and meniscotibial
sulcus. As the intercondylar notch continues portion. The superficial band inserts at the femo-
anteriorly, it becomes the trochlear grove also ral epicondyle and the tibial plateau. (Fig. 27.1).
known as the femoral sulcus. This sulcus is bor-
dered both medially and laterally by the patellar
facets of the distal femur. 27.6 Meniscus
Anterior
cruciate
ligament
Posterior
cruciate
Lateral ligament
Posterior
collateral
cruciate
ligament
ligament
Medial
collateral
ligament
Fig. 27.1 Lateral and medial collateral ligaments. (Image taken from Loudon, Manske and Reiman. Clinical Mechanics
and Kinesiology. Human Kinetics, 2013. Page 286, Figure 14.7)
Medial meniscus
Posterior cruciate ligament
ligament of Humphrey is known as the anterior ular arteries. This blood supply reaches approxi-
meniscofemoral ligament and runs from the PCL mately 25% and 10–30% of the thicker periphery
to the lateral meniscus. of the lateral and medial meniscus, respectively
Both menisci in the cross section are pie [13]. This is problematic for adequate healing if
shaped or wedged. The outer periphery is thicker, an injury to the meniscus occurs in the inner thin-
while the inner portion is thinner. The vascular ner portion of the meniscus. Due to the
supply to the meniscus is from the superior and arrangement of the blood supply to the menisci,
inferior branches of the medial and lateral genic- an injury to the periphery has a chance to heal,
27 Rehabilitation of Knee Injuries 419
while injury to the inner 1/3 to 2/3 has minimal cutting activity. Classically, ACL injury was
chance to heal intrinsically if at all. described as a hyperextension injury [15], but
more recent evidence suggests that if the knee is
positioned with excessive valgus and femoral/
27.7 Articular Cartilage tibial rotation, it becomes vulnerable to injury as
well [16]. Athletes who present with ligament
Hyaline articular cartilage is the material that dominance (reliance on ligamentous structures
covers the ends of long bones in synovial joints. rather than neuromuscular contributions to con-
Articular cartilage is primarily composed of trol dynamic knee movement), quadriceps domi-
water contributing up to 80% of its weight. It is nance (high quadriceps-to-hamstring strength
water that gives the cartilage its ability to absorb ratio), limb dominance (tendency to favor one
stress and compressive forces that occur during limb with dynamic activity) [17], and trunk dom-
normal activities of daily living such as walking, inance (excessive trunk movement) [16] often
running, and jumping. The remaining compo- demonstrate high-risk movements during athletic
nents of cartilage include proteoglycans and non- activity and are, subsequently, at increased risk
collagenous proteins and collagen. Because for ACL injury. Injury to the ACL results in
cartilage covers the ends of long bones, it is espe- mechanical instability of the knee as there is an
cially important in knee function. This is espe- increase in anterior tibial translation of the knee
cially true since the area of cartilage that is as well as excessive tibial rotations. If the ACL
injured in the knee makes contact with the patella injury is coupled with other ligamentous injuries,
or femur around 30–70° of knee flexion [14]. this mechanical instability may be even greater.
This is even further problematic that following In addition to mechanical instability, the athlete
injury to articular cartilage, healing is often com- may present with functional instability or a sen-
promised due to cell apoptosis and the presence sation that the knee is “giving way” after ACL
of catabolic enzymes. Due to these issues, articu- injury. This sensation of giving way may be
lar cartilage cannot form a fibrin scaffold or reported only with higher-level pivoting and cut-
mobilize cells to repair the defect. ting activities, such as tennis, or it may be
reported with lower-level activities of daily living
[18]. The level of activity, at which time the
27.8 Ligament Injuries patient reports functional instability, often factors
into the decision to undergo surgical manage-
Ligament injuries may occur as the result of a ment of the ACL injury.
non-contact mechanism during tennis. Frequent Injury to the ACL can be medically treated both
pivoting and cutting place the knee ligamentous non-operatively and operatively. Non-operative
structure at risk. Epidemiologic data suggests the treatment following ACL injury requires an imme-
knee ligaments at greatest risk while playing ten- diate focus on the management of acute impair-
nis are the anterior cruciate ligament, represent- ments as well as a systematic assessment of ability
ing 11–13% of all knee injuries in tennis [2–4], to safely participate in pivoting and cutting activi-
the medial collateral ligament, and lateral collat- ties without the athlete reporting a sensation of
eral ligament [2]. “giving way.” Repeated giving way at the knee
results in high vulnerability to sustaining further
meniscal and articular cartilage injury and neces-
27.9 A
nterior Cruciate Ligament sitates surgical management to restore knee stabil-
Injury ity. Once the acute impairments of knee joint
effusion and loss of motion and strength are man-
The ACL provides stability to the knee during aged, the athlete can be assessed to determine if
pivoting, cutting, and rotational activities. Injury they are a candidate to pursue non-operative man-
may occur when landing from a jump or planting/ agement of ACL injury. In a body of work by
420 R. C. Manske and M. V. Paterno
Fitzgerald, Snyder-Mackler, and colleagues from provide mechanical and functional stability in the
the University of Delaware [19, 20], a screening knee and allow for an attempt to return to pre-
tool was developed to determine if a patient is a injury level of activity. Variation in surgical
“coper” indicating potential to function in the reconstruction technique as well as graft-type
absence of an ACL or a “non-coper” indicating an selection may result in necessary modification to
individual who likely would not function well with the rehabilitation process. Despite these vari-
ACL deficiency. The screening tool includes ables, rehabilitation after surgical reconstruction
assessment on four single-leg hop tests, reported is guided by a criteria-based progression from
number of giving way episodes, the Knee Outcome immediate postoperative management to func-
Survey, and a global rating of knee function [20]. tional transition back to sport. Table 27.1 will
Patients who are classified as “non-copers” are outline this rehabilitation.
often recommended for surgical intervention. If
the patient is determined to be a “coper,” they par-
ticipate in rehabilitation designed to enhance 27.10.1 Phase I: Preoperative Phase
strength and mobility as well as a specialized “per-
turbation” rehabilitation program which focuses The preoperative phase is seen in Table 27.1 and
on balance and reactive neuromuscular control is followed prior to surgery. Goals of this phase
designed to maximally challenge and train the pro- are to restore motility, increase quadriceps activa-
prioceptive system as a means to enhance dynamic tion and decrease pain and effusion. Ambulation
functional stability of the knee. Once rehabilita- at this time is weight bearing as tolerated with
tion is complete, the patient is able to successfully crutches and a brace locked in full extension.
pass all return to sports assessments, and a func- Gentle range of motion (ROM) as tolerated
tional progression back to tennis is complete; these and a progression of exercises as patient is able
athletes may attempt a return to sport. Although to tolerate is utilized in this early preoperative
some athletes are successful with non-operative period. Exercise progression should not
management of ACL injury, a 10-year outcome increase symptoms, pain, or effusion.
study of patients with ACL injury suggests a rela-
tively low percentage of athletes are able to resume
prior levels of function in the presence of ACL 27.10.2 Phase II: Immediate PO Phase
deficiency [21]. Further, a case report specific to
tennis players with ACL deficiency noted that in a Acute phase rehabilitation after ACL reconstruc-
cohort that was able to return to recreational ten- tion is focused on managing acute, postoperative
nis, they continued to report lower level of tennis swelling, range of motion (ROM), and initiation
function as well as difficulty with higher-level of quadriceps activation. Postoperative effusion
movements [22]. Collectively, these data suggest is prevalent after ACL reconstruction and inhibits
return to high-level tennis with an ACL-deficient quadriceps activation [23] and mobility. Acute
knee may be a challenge for many athletes, and a phase rehabilitation includes use of modalities
systematic evaluation of potential ability to suc- such as cryotherapy and compression dressings
ceed with this treatment course is required prior to to assist in swelling reduction. In addition, the
attempting a non-operative course. patient is advised in frequent elevation and home
use of compression and cryotherapy to assist in
reduction of effusion. Early resolution of postop-
27.10 ACL Reconstruction erative effusion assists in restoring the patient’s
Rehabilitation ability to actively contract the quadriceps and
slows postoperative disuse atrophy.
If the athlete’s goal is to return to high-level ten- Weight bearing after ACL reconstruction is
nis, which requires fast-paced pivoting and cut- typically progressed over 3–6 weeks. Patients
ting, surgical reconstruction may be necessary. may initiate touch-down weight bearing immedi-
The goal of the ACL reconstruction would be to ately after ACL reconstruction and progress as
27 Rehabilitation of Knee Injuries 421
Table 27.1 (continued)
Days–
Phase weeks Goals Restrictions Treatment Clinical milestones
Phase V: Post- Restoration of full None Previous Previous
Return to operative motion strengthening milestones
Activity Wks 12+ No swelling Unilateral calf raises Full motion
Phase No pain Progress CKC Full confidence in
Return of full exercises knee
activities Advance hamstring Function testing
exercises >90% of
Agility drills uninvolved
Advanced balance Isokinetic testing
drills >90% of
Sports specific drills uninvolved
CKC closed kinetic chain, CPM continuous passive motion, PO postoperative, RICE rest, ice, compression, elevation,
ROM range of motion, SLR straight leg raise, WBAT weight bearing as tolerated, Wks weeks
Rehabilitation following anterior cruciate ligament reconstruction. (Taken from: From Manske RC, Lehecka BJ, DeCarlo
M, McDivitt R. Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal
Interventions: Techniques for Therapeutic Exercise, 3rd ed. Table 24-1 page 751: McGraw Hill Education, New York, 2014
effusion resolves and motion and quadriceps acti- impairments are resolved and focus turns to the
vation improve. The use of a postoperative brace advancement of foundational strength and neuro-
such as an immobilizer or a postoperative ROM muscular control. While the return of quadriceps
brace can provide additional support in the acute strength remains the primary focus after ACL
phase and may allow a more rapid progression of reconstruction, progressive resistive exercises to
weight bearing but will require gait retraining to address hamstring strength deficits, as well as hip
insure a normal gait pattern once the brace is dis- and core strength, are critical.
continued. Patients are permitted to discontinue Quadriceps strength training requires a
crutch use once they have resolution of postopera- dynamic incorporation of both open kinetic chain
tive effusion, full extension, and sufficient knee strengthening to address isolated quadriceps
flexion to demonstrate a normal gait pattern and weakness often seen after ACL surgery and
adequate quadriceps control to demonstrate a sin- closed kinetic chain strengthening to encourage
gle-leg squat to 30° of knee flexion. Once these dynamic incorporation of quad activity while
criteria are met, they can progress off of crutches. executing functional tasks. Open kinetic chain
Early exercise in the acute phase of ACL knee extension should be executed in protected
reconstruction rehabilitation is focused on mus- ranges initially, avoiding full extension, to limit
cle activation and ROM. Prior to progression to anterior translation stress on the healing graft.
the subacute phase of rehabilitation, the patients Hamstring contraction provides dynamic
must demonstrate full knee extension, flexion to resistance to anterior tibial translation. Return of
120–135°, sufficient quad activation to execute a hamstring strength after ACL reconstruction
straight leg raise without an extensor lag, and helps protect the healing graft as it reduces the
normal patellar mobility. Once these criteria are underlying risk factor of quad dominance.
met, the patient is prepared to progress to the sub- Initiation of hamstring strengthening early after
acute phase of rehabilitation. ACL reconstruction with a hamstring graft is
contraindicated; however as the patient pro-
gresses to the neuromuscular reeducation phase
27.10.3 Phase III: Intermediate of rehabilitation, hamstring strengthening can be
PO Phase progressed.
Proximal hip and core strengthening is critical
The intermediate PO phase of rehabilitation is after ACL reconstruction. Evidence has demon-
focused and initiated when the initial acute strated the importance in hip strength and muscle
27 Rehabilitation of Knee Injuries 423
activation [24], in reducing the risk of future tact or non-contact mechanisms, can result in
injury as well as normalizing movement patterns MCL injury. Injury to the MCL is diagnosed
postoperatively. Further, the ability to control along a continuum with Grade I injuries repre-
trunk movement and maintain trunk position over senting the least structural damage to the ligament
the base of support during dynamic movement while Grade III injuries representing complete
can help to reduce stress on the knee joint. Trunk disruption of the MCL. Injuries can occur either at
strengthening as well as dynamic proprioception the attachment site or in the mid-substance of the
activities are critical during this phase of rehabili- ligament. As the MCL is an extra-articular liga-
tation to prepare the athlete to participate in the ment structure, there is potential for healing, and,
final phase of rehabilitation. as a result, the majority of these injuries are suc-
cessfully managed nonoperatively.
Initial management of an acute MCL injury will
27.10.4 Phase IV: Strengthening Phase be dependent on the extent of tissue injury and the
expected time needed to allow tissue healing to
The final phase before release to return to tennis occur. The focus of acute rehabilitation of MCL
is the Strengthening and Return to sport phase. injury is pain and effusion management coupled
This phase is focused on introducing and reinte- with progression of ROM and strength. Grade I
grating the athlete back into dynamic activity injuries may be permitted to initiate weight bearing
which will be experienced on the court. Prior to and ROM activity without restriction in the early
entering this phase of rehabilitation, the patient phases of rehabilitation if stability is good and pain
must demonstrate sufficient lower extremity is minimal. Grade III injuries may require a period
strength and functional performance. The athlete of restricted ROM with a brace, which can protect
who is ready to initiate the Return to Activity against valgus stress, while limiting full extension
phase must demonstrate a solid foundation of as the MCL is at greatest tension in full extension.
strength as well as a baseline proficiency with the With respect to strengthening exercises, activity to
initiation of dynamic movement. Isokinetic quad- focus on core, hip, and lower extremity strength
riceps and hamstring strength deficits of less than can be initiated as tolerated by the patient as long as
15% of the contralateral limb are necessary to all valgus stress to the knee is avoided. Due to the
enter this phase of rehabilitation. Similarly, func- wide continuum in the extent of MCL injuries, the
tional hop test performance should be less than a length of time spent in the acute phase of rehabili-
15% deficit, and patient-reported function on the tation after MCL injury is highly variable.
IKDC should be a minimum of 85 prior to entry Once sufficient healing has occurred and the
to this phase [25]. The focus of this phase should patient has regained full ROM, focus turns to
be on integration back to tennis-specific activity, advancing strength and neuromuscular control.
beginning with activities at sub-max speed, Strengthening continues to be advanced with a
followed by a progression to higher-level activity continued focus on core, hip, quadriceps, and ham-
at max effort and full speed. Prior to full release string strengthening. Prior limitations with lateral
to tennis activity, the patient should pass a return movements and valgus stress may start to be slowly
to sports assessment as outlined at the end of this initiated at sub-max speeds and intensities and
chapter. slowly progressed over time as tolerated. In addi-
tion to strengthening, balance and proprioception
exercises should be progressed at this time.
27.11 M
edial Collateral Ligament Advancement from double-leg to single-leg tasks
Injury and progression for sagittal plane to more tri-planer
movement is indicated at this time. Once sufficient
Medial collateral ligament (MCL) injury occurs strength and neuromuscular control are gained, the
less frequently in tennis; however the pivoting and patient must successfully progress through a transi-
cutting stress of the sport do place the MCL at tion to function phase, similar to the end of ACL
risk. Valgus stress to the knee, either through con- reconstruction rehabilitation prior to progression
424 R. C. Manske and M. V. Paterno
back to sport. If residual laxity is a concern, the use extensor mechanism, increasing susceptibility to
of a brace may be considered prior to return to anterior knee pain in the presence of overuse.
sport, but this is not typical in tennis. Interventions may focus on orthotic stabilization
to improve lower extremity alignment and reduce
stress on the extensor mechanism.
27.12 Patellofemoral Pain Local interventions at the knee joint in patients
with PFPS are utilized when the patient presents
Patellofemoral pain syndrome (PFPS) is the most with knee-specific impairments contributing to
prevalent disorder involving the knee [26] and is anterior knee pain. This may include strength def-
the second most common musculoskeletal symp- icits, altered proprioception, or patellofemoral
tom presenting to physical therapists [26]. instability to name a few. Attempts have been
Despite this high prevalence, the potential etiol- made to classify types of anterior knee pain, in the
ogy of and risk factors for developing PFPS are hopes of guiding interventions [28]. In the tennis
widespread and remain unclear [27], and a vari- player, the most typical forms of local impair-
ety of theories about its etiology and appropriate ments contributing to anterior knee pain result
rehabilitation exist. The presence of impaired from repetitive microtrauma and/or malalignment
anatomic morphology and/or altered dynamic at the knee joint. These types of patellofemoral
neuromuscular function can result in an increased pain mechanisms are best managed with flexibil-
potential to experience anterior knee pain with ity intervention in the presence of tightness and
overuse. Frequent participation in tennis has the strengthening interventions in the presence of iso-
potential to place repetitive stress on the anterior lated weakness or weakness through the kinetic
knee resulting in pain. chain. The key in successful management of ante-
Once an accurate diagnosis highlights the rior knee pain in this population is proper identifi-
underlying mechanism contributing to the over- cation of the underlying mechanism and an
use syndrome, appropriate rehabilitation can be appropriate intervention plan to target these inter-
initiated to target the underlying mechanisms. ventions. This should then be followed by a pro-
Rehabilitative and etiologic investigations have gressive return to tennis activity.
focused on three areas of dynamic neuromuscu-
lar function and their associated effect on PFPS:
the proximal area at the trunk and pelvis, the dis- 27.13 Meniscus
tal area at the foot and ankle, and the local area at
the quadriceps and the patellofemoral joint (PFJ) In any sports that requires running, twisting, and
itself. pivoting, meniscus and articular cartilage injuries
Proximal interventions for PFPS focus on are common. Meniscal and cartilage injuries can
enhancing proximal stability to serve as a stable be treated both conservatively and surgically. The
base for distal extremity movements. Excessive goal of treatment that is followed will depend on
trunk and pelvis movements as a result of core and the athlete’s ability to play without pain or symp-
hip weakness can translate into inefficient move- toms. It is not uncommon to first attempt conser-
ment patterns and potentially placement of the vative treatment before jumping into surgical
lower extremity in at risk positions. Proximal inter- considerations.
ventions should be initiated when these deficits are
identified in the presence of anterior knee pain.
Distal interventions at the foot and ankle in 27.14 Meniscus Tears
patients with patellofemoral pain are initiated
when the patient presents with abnormal foot and Meniscal tear types are numerous and include
ankle alignment which may alter stress on the oblique, vertical longitudinal, radial (or trans-
knee joint. Typically, a more pronated or supi- verse), horizontal cleavage, or complex
nated foot may result in dynamic changes at the (Fig. 27.3). The majority of meniscal tears are
27 Rehabilitation of Knee Injuries 425
Fig. 27.3 Various types of meniscus tears. (Image taken from Magee D, Zachazewski JE, Quillen WS, Manske
RC. Pathology and Intervention in Musculoskeletal Rehabilitation. Elsevier, 2016. Figure 21-6; page 779)
Therefore, total meniscectomy should be a last necessary. The leg should be elevated as much as
resort, while meniscal repair or partial meniscec- possible to allow gravity to help decrease swell-
tomy with preservation of as much tissue as pos- ing in the first few days following surgery. The
sible should be the treatment goal. Meniscus patient should restrict the amount of time stand-
repair is an option if the tear is in the peripheral ing with the lower leg in a dependent position
area where the meniscus still has an adequate which will also help decreased edema.
blood supply. This blood supply is imperative for The ability to regain full knee extension is criti-
biologic healing of the torn meniscus. Surgical cal for almost all knee surgeries. Immediate exten-
repairs historically have been repaired via an sion should be the priority with flexion as tolerated.
open procedure; however presently these repairs Towel extensions, prone hangs, and heel props all
are done through a small incision or totally help to gain passive extension, while wall slides
arthroscopically. help with knee flexion range of motion. Extension
can also be facilitated by weight shifting and lock-
ing out the knee in weight bearing.
27.15 Meniscectomy Weight bearing following meniscectomy is as
Rehabilitation full as tolerated. Ambulation should be with
bilateral axillary crutches, and these should be
Rehabilitation following meniscectomy is based discontinued once the athlete is able to ambulate
on symptoms. Because there is nothing repaired with normal gait. By 2 weeks the athlete should
or sutured together that requires soft tissue heal- be independently weight bearing with no antalgia
ing constraints, progression is fairly smooth. Most or limp.
patients following meniscectomy respond well Quadriceps, hamstring, and total leg strength-
without problems. Evidence exists that demon- ening exercises can begin and progress as toler-
strate in some instances a home exercise program ated. Straight leg raises (Fig. 27.4), quadriceps
or medication following meniscectomy is equal to and hamstring sets, and calf raises can begin as
supervised therapy [35–37]. These studies are in tolerated.
contrast with those that have shown supervised Phase II: (Weeks 1–3) Goals of this phase are
therapy demonstrates increased strength deficit in a complete return to full ROM equal to the unin-
the training group [38], significant extensor volved side, normalization of gait and improve-
strength deficits for up to 6 months in those fol- ment of strength and control, and return to
lowing meniscectomy [39], and both knee flexor controlled agility and sports-specific activities.
and extensor strength deficits that would indicate Cryotherapy can be continued as needed, espe-
a need for supervised therapy [40]. cially following exercises and activities. If ROM
Table 27.2 from Manske RC, Lehecka BJ, is not yet symmetrical to the uninvolved side,
DeCarlo M, McDivitt R. Rehabilitation of the exercises to facilitate it should continue. This may
Knee. In: Hoogenboom BJ, Voight ML, Prentice include manual therapy and joint mobilization
WE, (eds). Musculoskeletal Interventions: techniques to continue progression until full.
Techniques for Therapeutic Exercise, 3rd ed. out- Weight-bearing exercises such as squats, lunges,
lines rehabilitation following a partial meniscec- and step-downs can all begin as long as pain and
tomy. Goals of phase I are to control swelling and swelling do not return, sure signs of too fast of
edema, increase range of motion, normalize gait, progression. Cardiovascular exercises such as sta-
and improve quadriceps control. tionary bike and elliptical or stair climber can
Phase I: (Days 1–7) Cryotherapy will be per- begin at easy levels of 10–15 min progressing to
formed early either constantly or 6–8 times per moderate to high for 30 min or more.
day to control pain and swelling. Use of com- Balance and proprioceptive exercises can
pressive garments is also beneficial to decrease begin to improve neuromuscular limb control.
edema control in the lower leg. Usually with a These forms of exercise should be performed
meniscectomy, a postoperative knee brace is not bilaterally initially with simple weight shifting
27 Rehabilitation of Knee Injuries 427
progressing to unilateral as tolerated. All exer- string curls can begin bilaterally and progress too
cises should start out simple progressing to more unilaterally.
complex as the athlete has demonstrated mastery Phase II: (Weeks 3–6+) The focus of the final
of the easier exercise. phase is on functional return. More detail on a func-
As strength and control start to return in these tional return to sports will be presented near the end
weeks, more traditional exercises can be included of this chapter. Suffice it to say that the athlete should
to try to incorporate the principle of muscle have full ROM and strength at minimum. A gradual
overload to allow gaining quadriceps and ham- implementation of sports-specific activities includes
string strength. Squats, leg presses, and ham- running, agility, hopping, and jumping activities.
428 R. C. Manske and M. V. Paterno
p ainful at end range into full hyperflexion. Also 90°, cycling is added to the exercise routine. No
even though ROM is increased, cutting and pivot- loading exercises should be performed in ranges
ing are still restricted. Because ROM is now past past 60–80° before 12 weeks postoperatively [42].
430 R. C. Manske and M. V. Paterno
At this time advanced balance and propriocep- understand the biomechanics of cartilage and its
tion drills can begin. These include single-leg response to injury and surgery to allow healing
balance and perturbation-type exercises. If the comes better understanding of how to handle
athlete’s balance is improved enough, they can these injuries postoperatively. Like many other
perform balance drills also with eyes closed. knee procedures, early motion and a gradual pro-
Weight bearing and loaded exercises can con- gression to full weight bearing are important.
tinue to progress by adding weight or resistance. However, exact time frames for when these
Phase IV: (Weeks 11–16+) Goals for phase IV should occur vary on pending surgeons and their
are increased strength, power, and endurance and particular preference or philosophies of cartilage
sports-specific drills to return the athlete back to healing. Until more specific guidelines can be
full activity. Restrictions of agility and pivoting agreed upon, communication between therapist
are lifted at this time but should begin in a safe and surgeon is paramount to achieving a success-
and controlled manner. ful rehabilitation. It is important to have a full
Exercises in this phase include advanced understanding of the extent of damage, durability
strengthening drills and initiation of sports-spe- of the surgical procedure, size and location of the
cific exercises that mimic or simulate sports defect, and specific restrictions placed upon the
activity. Agility drills are very important for ten- athlete [44]. When possible a diagram of the
nis-specific training. Plyometric exercises can lesion site is also helpful as it will enable the
begin at this time starting bilaterally progressing treating therapist to know where ROM limita-
to unilateral. Usually jogging can commence at tions are and to ensure that the lesion is not
12–16 weeks if strength deficits of the quadriceps engaged during exercises.
are less than 20%. For general purposes of this chapter we will
describe postoperative rehabilitation for both
microfracture and ACI procedures that can be
27.17 Articular Cartilage seen in Table 27.5.
In general there are two broad methods of sur- The early postoperative phase is also known as
gery of articular cartilage defects: bone marrow the proliferation phase. Goals for this phase
stimulating procedures and replacement tech- include independent ambulation, quadriceps
niques. Bone marrow stimulation procedures activation, limiting effusion, wound healing,
include abrasion arthroplasty, drilling, and micro- and pain reduction. During this phase there is a
fracture. These techniques utilize the athletes significant amount of constraint placed upon
own pluripotent marrow stem cells to create the athlete in an effort to protect the repair [45,
reparative tissue consisting of fibrocartilage, pri- 46]. In most instances weight bearing at this
marily type I which has different wear character- point is non-weight bearing or a controlled par-
istics of normal type II cartilage [43]. Replacement tial weight bearing. Communication is impor-
techniques include osteochondral autologous or tant at this time to ensure appropriate
allograft transplant surgery (OATS) and autolo- weight-bearing status. If you are unsure, it is
gous chondrocyte implantation (ACI). Each of better to error on the conservative side and
these procedures has their own specific rehabili- begin non-weight bearing until status is
tation guidelines with most including some confirmed.
degree of limited weight bearing and restricted Passive range of motion (PROM) of the tibio-
controlled early ROM (Table 27.4). femoral joint is performed by the therapist and
Rehabilitation following articular cartilage the patient themselves (Fig. 27.5) or with assis-
surgery continues to evolve. As we begin to tance of a continuous passive motion (CPM)
27 Rehabilitation of Knee Injuries 431
device. PROM is done to create movement or dif- intra-articular scar tissue formation. Movement
fusion of synovial fluid to stimulate reparative should not only occur at the tibiofemoral joint but
cell production [47, 48]. Gentle movement of the also at the patellofemoral joint. Patellar mobiliza-
knee is started immediately following surgery to tion and passive movement in all planes should
help nourish articular cartilage. It also provides occur, as limitations of patellar mobility can be
the additional benefit of preventing deleterious disastrous for knee function.
432 R. C. Manske and M. V. Paterno
Table 27.5 Post-operative rehabilitation for articular cartilage surgery (microfracture and autologous chondral
implantation)
Weeks/
Phase months Goals Restrictions Treatment Clinical milestones
Phase I: Early PO 0–6 Independent NWB or RICE Full extension × 1
PO phase weeks ambulation with TTWB with Gluteal sets week
assistive devices SLR × 4
assistive device Full flexion × 6
Quadriceps activation Quad sets in range weeks
Decreased effusion that does not engage Independent use of
Wound healing lesion ambulatory device
Pain reduction PROM and AAROM No increased pain
Patellar mobilization No increased
Scar tissue effusion
mobilization
No CKC exercises
Phase II: PO 6–12 Quadriceps control DC assistive Exercises as previous Previous milestones
Intermediate/ weeks Normal patellar device as Begin CKC exercise Full ROM extension
transition mobility tolerated by 8 Restrict ROM that and flexion
phase Increase ROM weeks does not engage lesion Good quadriceps
Begin CKC activities My use pool or Mini-squats control
Proximal strengthening unweighting Step-ups Normal patellar
Begin balance and device to Flexibility exercises mobility
proprioception transition to Balance and FWB without
Pain reduction FWB proprioception symptoms
Phase III: PO 3–6 Normalize quadriceps No cutting Exercise as previous Previous milestones
Remodeling months recruitment No deep Progressive balance Good balance and
phase Normal patellar squatting exercise challenging proprioception
mobility No running or proprioceptive system Ability to jump and
Full AROM/PROM jogging Leg press land bilaterally
No pain Lunges without symptoms
No effusion Agility drills at 50%
effort progressing to
full after 6 months
Phase IV: PO 6–9 Same as previous No restrictions Agility exercise Previous milestones
Maturation months Return to full activity Strength and power Full confidence in
and Return to exercises knee
activity phase Jumping progressing Excellent clinical
Hopping progression exam
Running progression Pass functional
testing measures
CKC closed kinetic chain, FWB full weight bearing, NWB non weight bearing, PO post-operative, RICE rest, ice, com-
pression, elevation, ROM range of motion, SLR straight leg raises
Rehabilitation following microfracture and autologous chondral implantation. (Taken from: Manske RC, Lehecka BJ,
DeCarlo M, McDivitt R. Rehabilitation of the Knee. In: Hoogenboom BJ, Voight ML, Prentice WE, (eds). Musculoskeletal
Interventions: Techniques for Therapeutic Exercise, 3rd ed. Table 24-5 page 767: McGraw Hill Education, New York,
2014)
Fig. 27.5 Active assistive knee flexion range of motion Fig. 27.6 Lateral stepping with bands
begun to fill with immature cartilage cells and is movements or perturbation devices, which place
now able to tolerate some degree of progressive greater stress to the articular surface due to
weight bearing. Controversy exists as too aggres- increased shear forces (Fig. 27.7). Balance exer-
sive of weight bearing may risk cartilage delami- cises are initiated bilaterally on level ground then
nation, while too conservative of approach may progressing to single leg and on labile surfaces as
not provide adequate cartilage tissue stimulation the athlete improves (Fig. 27.8). Using this
[49, 50]. Weight bearing is usually progressed approach will ensure a gradual progression of
from non-weight bearing to partial and then to applied loads and increased demands that will
full. Increased knee pain, increased swelling, or decrease the risk of damaging the healing articu-
decreased quadriceps volitional recruitment and lar cartilage.
motor control are indications that the weight-
bearing progression is too fast. These signs and
symptoms should be watched for closely during 27.17.4 Phase III: Months 3–6
weight-bearing progressions and if seen may
require alteration of normal progression to one Goals of the remodeling phase are to continue to
more slowly in nature. work on quadriceps control, maintain ROM,
Exercise stresses can be gradually increased progress weight-bearing ability, and increase bal-
through increased loads and reps. Stresses should ance. These goals are achieved through increas-
always begin bilaterally and in cardinal planes ing difficulty of exercise in the progression.
and progressing unilaterally and in multiple Due to the ongoing remodeling during phase
planes. Squats, lunges, and step-ups should begin III, exercises are able to be applied with gradual
in the cardinal planes moving anterior to poste- increased load and intensity without harming
rior and medial and lateral (Fig. 27.6) directions the cartilage tissue that is becoming increas-
before addition multiple plane rotational type ingly tolerant. Light functional activities can
434 R. C. Manske and M. V. Paterno
program. Specifically, the athlete should dem- translates into the return to sports phase.
onstrate a minimum of 85% limb symmetry Plyometric activities are ideal interventions at
with quadriceps and hamstring strength as well this phase as they provide an opportunity to
as performance on functional hop testing. enhance functional strength and power while
Further, the athlete should present with a introducing sports-specific movements. Sub-
patient-reported outcome score on the IKDC of maximum effort and plyometrics in a single plane
85/100. Once these criteria are met, the patient of movement represent an ideal starting point.
is ready to initiate a return to sports program. Plyometrics such as wall jumps and broad jumps
The goal of this program is to integrate the ath- helps to introduce the movement patterns while
lete back to the prior intensity and magnitude of providing an opportunity to evaluate technique.
participation in tennis. Once technique is mastered, progression of plyo-
Initiation of a tennis-specific return to sports metric activity can continue to more explosive
program begins with an understanding of the nec- movements, single-leg activities, and triplanar
essary movements to successfully resume activ- movement. Activities such as 180° jumps, single-
ity. Tennis requires quick pivoting and cutting, limb maximum effort jumps, and single-limb
reactionary activities, jumping and landing on a lateral jumping are appropriate progressions.
single limb, and rapid acceleration and decelera- Tennis athletes should follow a continual pro-
tion. A successful return to sports program will gression of plyometric activities that align with
include a dynamic progression to a point of profi- sports-specific movements. Participation in ten-
ciency at full speed for all these activities. The nis activities requires single-leg pivoting and cut-
return to sports phase of rehabilitation should ting in all planes, single-limb jumping, and quick
include a focus on advancement of residual reactions. End-stage plyometrics for tennis play-
strength and power deficits, transition to high- ers should mimic these movement patterns.
speed pivoting and cutting activities, and integra- The final aspect of the return to sports phase
tion into sports-specific activities. is a reintegration to sports-specific movements.
Maintenance of foundational strength and Agility drills, on the tennis court, which repli-
power or resolution of mild residual deficits in cate tennis activities such as approaching the net,
this area is a key component of the end phase of lateral movement, and diagonal cutting may
rehabilitation. Necessary strength criteria to enter begin at sub-maximal speed, in a planned pattern
this final phase of rehabilitation are sufficient to of movement, and progress toward full-speed,
participate in these activities, but not sufficient to unanticipated movements. These activities may
return to sport. Strengthening interventions at begin without a tennis racquet and the progress
this phase are focused on a progression of closed toward replicating these movements with ball
kinetic chain and functional strengthening activi- and request involvement. Once the patient has
ties. Often, activities such as double-limb and demonstrated ability to successfully execute all
single-limb squatting exercises initially on a sta- necessary activities to participate in tennis, a
ble surface but then progressing to unstable sur- return to play progression should begin. Based
faces are examples of opportunities to advance on the injury, the length of time in this phase
functional strength. During all of these exercises, may vary but should begin with an abbreviated
attention should be on maintaining good trunk time and intensity of participation and sequen-
and lower extremity alignment to insure normal tially progress as indicated. At the culmination
movement patterns are engrained in the patients of the return to sports phase of rehabilitation, the
as they return to sport [16, 51]. athlete should present with a strength and func-
Beyond the resolution of residual strength tional performance deficit of less than 10% on
deficits, the return to sports phase must initiate the involved limb, as well as a successful com-
and progress dynamic, sports-specific move- pletion of a progressive return to high-level piv-
ments. The initiation of this process often begins oting and cutting as well as integration back to
in the end stages of traditional rehabilitation and sport.
436 R. C. Manske and M. V. Paterno
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