MOUNTAIN ORTHOPAEDICS STANDARD REHABILITATION PROTOCOLS UPDATED JANUARY 2008

Transcription

1 MOUNTAIN ORTHOPAEDICS STANDARD REHABILITATION PROTOCOLS UPDATED JANUARY

2 TABLE OF CONTENTS Arthroscopic & Open Rotator Cuff Repair Accelerated Pages 3-4 Arthroscopic & Open Rotator Cuff Repair Pages 5-6 Arthroscopic Subacromial Decompression/Mumford Page 7 Arthroscopic Bankart Repair Pages 8-9 Total Shoulder Arthroplasty Pages Distal Bicep Tendon Repair Single Incision Endo-Button Technique Page 12 Total Hip Arthroplasty and Hip Resurfacing Pages Total Knee Arthroplasty Pages Lateral Retinacular Release Page 17 Isolated Meniscal Repair Page 18 Anterior Cruciate Ligament Reconstruction Bone Tendon Bone (BTB) Accelerated Hamstring Pages Anterior Cruciate Ligament Reconstruction: Hamstring Pages Distal Patellar Realignment Fulkerson/Elmslie-Trillat Page 23 Lateral Ankle Ligament Reconstruction Pages Ankle Fractures and Foot Fusion Pages Achilles Repair Page 28 Bunionectomy Page 29 Peroneal Tendon Repair Page 30 Syndesmosis Repair Page 31 Ankle & Foot Fusions Page 32 Posterior Tibial Tendon Reconstruction Page 33 Navicular Stress Fractures Page 34 2

3 Arthroscopic and Open Rotator Cuff Repair Accelerated Rehabilitation Protocol WEEKS 1-4 PASSIVE PENDULUM / CODMAN EXERCISE. Instruct in pendulum exercise twice daily for the first four weeks. Instruct patient in various alternative SLEEPING POSITIONS for early, painful stages (i.e. recliner, head elevated in bed, pillow under elbow and behind scapula). ACTIVE MOTIONS ALLOWED: (out of sling four times daily, ten minutes per session) Elbow flexion/extension Hand squeezes (can use Nerf ball, Theraputty, rolled wash cloth, etc.) Scapular protraction/retraction and elevation/depression (shrugs) Appropriate AEROBIC EXERCISE, as tolerated SLING/PILLOW/IMMOBILIZER full time, except as stated above. GOALS: Sleep without waking due to pain * Clinic visit frequency during this early stage should be limited as much as possible, depending on patient progress with PROM and pain. (Goal: 3-4 visits over the first 4 weeks). WEEKS 4-6 ACTIVE ASSISTED MOTIONS: VARIABLE POSITION ISOMETRICS in supine and/or sitting (should be comfortable and well controlled by P.T.) CLOSED CHAIN JOINT APPROXIMATION activities to elicit co-contraction around the GH joint (can be performed in standing and quadruped positions, as tolerated). TENDON RETRAINING (high repetition movements) GOALS: Full PASSIVE ROM in all planes (some patients may develop excessive tightness and may require more hands-on stretching and joint mobilization in combination with aggressive home stretches. If excessive pain or tightness is observed, contact MD) Discontinue sling and swathe at 6 weeks (unless MD instructs otherwise) WEEKS 6-8 Transition to ACTIVE ROM in controlled environment. (This is a very critical stage and patients will need close monitoring to avoid exacerbation of shoulder pain.) Continue with TENDON RETRAINING (from active assisted to active high repetition movements) Treatment must be individualized based on patient progress and motor control ability. 3

4 Continue with aggressive stretching and joint mobilization if full motion has not been obtained. (Consider posterior capsular, pectoralis major and internal rotation stretches, as well as thoracic mobility) Include multi-planar, low-load, long duration stretching as part of home program. GOALS: Able to reach overhead with minimal pain Good gleno-humeral rhythm with minimal scapular winging and shoulder hiking WEEKS 8-12 Initiation of PROGRESSIVE RESISTIVE EXERCISES as tolerated. High repetitions and low loads. Exercises include isolated rotator cuff and functional movement patterns Exercise progression and dosage should be carefully managed to avoid aggravation of the healing tissues. ADL LIFTING: 5 POUNDS MAXIMUM at waist level only (1/2 gallon of milk) GOALS: Able to perform most ADLs pain free Sleep without waking due to pain Able to lift, push and pull from 2-5 lbs. without pain and with good control WEEKS AVOID FULL STRESS OF THE ROTATOR CUFF FOR FOUR MONTHS ADL LIFTING: 10 POUNDS MAXIMUM at waist level only (one full gallon of milk) Progress to functional home program, including stretches and resistance training Home programs should be specific for demands of work and sports 1-2 visits may be saved for follow-up WEEKS ADL LIFTING: As tolerated. Let pain be their guide. If it hurts, back off. SPORTS: May golf unrestricted No throwing or racquet sports if operated shoulder is on dominant extremity. WEEK 24 No restrictions If still painful, return to see MD **Developed in conjunction with Joel Winters Sportsmed and Kim Reid Performance West P.T. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 4

5 Arthroscopic and Open Rotator Cuff Repair Standard Rehabilitation Protocol WEEK 1-4 (Day 0 28) PASSIVE RANGE OF MOTION: NO PROM, NO AAROM in elevation or external rotation. PENDULUM EXCERCISE: Twice daily / 5 10 minutes per session. Limit arcs of motion Instruct patient in various alternative SLEEPING POSITIONS for early, painful stages (i.e. Recliner, head elevated in bed, pillow under elbow and behind scapula) ACTIVE MOTIONS Allowed: (out of sling four times daily, ten minutes per session) Elbow flexion/extension Hand squeezes (can use Nerf ball, Theraputty, rolled wash cloth and etc. Scapular protraction / retraction and elevation / depression (shrugs) Appropriate AEROBIC EXERCISE, as tolerated. SLING / PILLOW / IMMOBILIZER: full time, except as above. WEEK 5 6 (Day 29 42) PASSIVE RANGE OF MOTION: Shoulder elevation in the plane of the scapula; external rotation as tolerated, unless otherwise specified by M.D. (Usually most comfortable in a seated position) If the shoulder becomes more painful DO NOT push through it or progress further until symptoms resolve. If HOME INSTRUCTION is given to spouse or other person living at home with patient, they should be able to demonstrate proper technique in any passive home exercises they will provide. CPM: If spouse or significant other cannot perform home program as noted above, CPM is a good alternative. Please call our office to request CPM and discuss with MD. Prescription will need to be provided via our office, and documentation of need is required in our charts. ACTIVE MOTIONS Allowed: (out of sling four times daily, ten minutes per session) Elbow flexion/extension Hand squeezes (can use Nerf ball, Theraputty, rolled wash cloth, etc.) Scapular protraction retraction and elevation depression (shrugs) Appropriate AEROBIC EXERCISE, as tolerated. SLING / PILLOW / IMMOBILIZER: full time, except as above. GOALS: Sleep without waking due to pain Passive Elevation 150 (progress to full elevation as tolerated) Passive External Rotation 40 (unless otherwise specified by M.D.) Discontinue sling and swathe at 6 weeks (unless M.D. instructs otherwise) 5

6 * Clinic visit frequency during this early stage should be limited as much as possible, depending on patient progress with PROM and pain. (Goal visits over the first 4 weeks) WEEK 7 8 ACTIVE ASSISTED MOTIONS: VARIABLE POSITION ISOMETRICS in supine and/or sitting (should be comfortable and well controlled by P.T.) CLOSED CHAIN JOINT APPROXIMATION activities to elicit co-contraction around the GH joint. (Can be performed in standing and quadriped positions, as tolerated). TENDON RETRAINING (high repetition movements). GOALS: Full PASSIVE ROM in all planes (some patients may develop excessive tightness and may require more hands-on stretching and joint mobilization in combination with aggressive home stretches. If excessive pain or tightness is observed contact M.D.) WEEK 9-10 Transition to ACTIVE ROM in controlled environment. (This is a very critical stage and patients will need close monitoring to avoid exacerbation of shoulder pain.) Continue with TENDON RETRAINING (from active assisted to active high repetition movements) Treatment must be individualized based on patient progress and motor control ability Continue with aggressive stretching and joint mobilization if full motion has not been obtained. (Consider posterior capsular, pectoralis major and internal rotation stretches, as well as thoracic mobility) Include multi-planar, low load, long duration stretching as part of home program. GOALS: Able to reach overhead with minimal pain Good gleno-humeral rhythm with minimal scapular winging and shoulder hiking WEEK Initiation of PROGRESSIVE RESISTANCE EXERCISES as tolerated. High repetitions and low loads. Exercises include isolated rotator cuff and functional movement patterns Exercise progression and dosage should be carefully managed to avoid aggravation of the healing tissues. ADL LIFTING: 5 POUNDS MAXIMUM at waist level only (1/2 gallon of milk). GOALS: Able to perform most ADLs pain free Sleep without waking due to pain Able to lift, push and pull from 2-5 lbs. without pain and with good control. WEEK ADL LIFTING: 10 POUNDS MAXIMUM at waist level only (One full gallon of milk). Progress to functional home program, including stretches and resistance retraining Home programs should be specific for demands of work and sports 1-2 visits may be saved for follow up. WEEK AVOID FULL STRESS OF THE ROTATOR CUFF FOR FOUR MONTHS ADL LIFTING: As tolerated. Let pain be their guide. If it hurts, back off. SPORTS: May golf unrestricted. No throwing or racquet sports if operated shoulder is on dominant extremity. WEEK 25 No restrictions If still painful, return to see MD *Developed in conjunction with Joel Winters Sportsmed and Kim Reid Performance West P.T. 6

7 Arthroscopic Subacromial Decompression/Mumford Rehabilitation Protocol WEEK 0-3 AAROM advance to AROM as tolerated when pain free with pulley and cane with emphasis on elevation in the plane of the scapula and external rotation. Home program, three times daily for fifteen minutes per session. Instruct patient in pulley use sitting or standing; cane use standing, sitting and supine. Clinic instruction and review during this time period usually limited to three to five visits. WEEK 4 AROM in all planes with terminal stretches advance to gentle PRE as tolerated. Goal of full, painless ROM by the end of week four. Home program twice daily. WEEK 5-6 Progressive PRE as tolerated. Free weights or Theraband within limits of pain. Home program daily. WEEK 7-12 PRE with free weights, sports cord, and/or upper extremity ergometer. Initiate and progress plyometrics. Increase endurance and strength. Goal: full recovery by 12 weeks postop. Week Home maintenance program. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 7

8 Arthroscopic Bankart Repair Rehabilitation Protocol MICAHEL M. HESS, MD Week 0-4! Shoulder sling and swathe full time day and night.! May have sling and swathe off four times daily for active hand, wrist, and elbow ROM.! May shower out of sling with surgeon s ok.! Isometrics all planes to maintain shoulder muscle tone (include scapular stabilization). Week 5-6! Initiate AROM in all planes as tolerated beginning week five.! Gentle progressive stretches in all planes except ABD / ER.! AVOID Abduction/external rotation combination for eight weeks.! Isometrics all planes! GOAL: o Elevation: 120 o ER: 40 Week 7 12! ROM with terminal stretches all planes EXCEPT terminal abduction - external rotation.! Initiate pulley and cane for home program if ROM progressing slowly.! ROM GOAL: Full (equal to opposite side) by 10 weeks post op. Week 12-16! Progress PRE program with free weights or Theraband within limits of motion.! Avoid bench press, flies, military press etc. with position of abduction-external rotation.! NO SPORTS 8

9 Month 4-6! Return to sports with surgeon s ok depending on strength, ROM, and security of repair.! Return is gauged on a case-by-case basis. Most patients allowed full return to sports by 4-6 months. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 9

10 Total Shoulder Arthroplasty Rehabilitation Protocol POD #1 - #2! Hospital stay. Pain control. Shoulder sling and swathe full time.! Hand, wrist, elbow active ROM 4 times daily.! Initiate Codman Program POD #3 - #10! Initiate passive and active assistive elevation in plane of scapula as tolerated.! GOAL: 0-60.! External rotation within limits defined by surgeon! No active internal rotation.! Isometrics all planes except internal rotation.! Full time sling and swathe use otherwise.! Codman program 2 X / day.! Hand, wrist, elbow active ROM 3-4 times daily. Week 2-4! Increase elevation as tolerated. Goal degrees.! Initiate external rotator strengthening w/in limits set by surgeon! No active internal rotation.! Continue isometrics in all planes except internal rotation.! Full time sling use during the day. Sling and swathe use at night.! Codman program 2 X / day.! Hand, wrist, elbow active ROM 3-4 times daily. Week 4-6! Increase elevation as tolerated to limit of 120 degrees.! Discontinue sling and swathe with MD ok.! Continue above restrictions.! Initiate pulley and cane use. 10

11 Week 6-8! Increase elevation as tolerated.! Increase ER, IR, FLEX, EXT, Circumduction as tolerated.! All ranges above may be performed actively.! Progressive terminal stretches in all planes.! PRE all planes. Week 8-12! Continue supervised strengthening and ROM program twice weekly.! GOAL 140 to 160 as per MD instruction.! Instruction for daily home program with terminal stretches. Week 12 24! Advance to home program with exercises, stretches, and conditioning daily. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 11

12 Distal Bicep Tendon Repair Single Incision Endo-Button Technique Rehabilitation Protocol Week 1 2! Remove surgical dressing and apply edema control (Kerlix or ace bandage).! Fabricate a posterior elbow splint, which blocks extension at 30.! Begin A/P flexion and active extension as well as A/P pronation and supination in the splint 8 times per day. Week 3! Begin scar massage.! Elastomer used on scar as needed. Week 6! Discontinue the extension block splint.! Passive extension to the elbow is initiated 8 times per day.! Static progressive or dynamic extension splinting is permitted as needed. Week 9-10! Progressive strengthening is begun with theratubing and/or weights to the elbow, forearm and wrist. Week 12! Full use is permitted Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 12

13 Total Hip Arthroplasty and Hip Resurfacing Rehabilitation Protocol DOS All patients participate in a comprehensive joint program protocol which addresses pre and postoperative pain control and rehabilitation. Patients are in private rooms in an area of the hospital dedicated to joint replacement. In hospital, rehab takes place in this area in a comfortable setting for patients and family. All patients have received a spinal anesthetic and no PCA pump. They have received a preoperative narcotic, Tylenol, Anti-emetic, Coumadin, Antibiotic, and an NSAID. They will be out of bed ambulating or to chair the day of surgery. Expectations: Most patients will use little narcotic after POD # 2 and will ambulating with assistance and discharged on POD #1 or #2 with a few patients discharged on POD#3. POD#1 - #3 OOB to chair twice a day. Initiate teaching protocol of THA restrictions and positions of risk Walker ambulation Partial WB 30-80lbs with press fit femur, WBAT with cemented femur, advance to crutches as able Ankle pumps, Knee Rom, Quad sets Initiate stair climbing instructions Hip ROM is very important ** Hip flexion to 100 degrees, ER gently as tolerated to 45 degrees, NO IR. ** May begin active abduction and SLR as tolerated. Anticipate D/C from hospital around day 1, or 2 with some discharged to rehab centers on day 3. Prior to discharge patient should demonstrate full understanding of positions of risk and how to avoid them during dressing, hygiene, toilet use, and chair, sofa and automobile use. **Patient should have O.T. eval for home aids (reachers, graspers, toilet risers). POD#5-28 Continue weight bearing status as above with crutches or walker; Continue home program of hip, knee and ankle ROM, quad sets, abduction and SLR 13

14 Week 4-6 WB advancement from 30# to Full weight bearing over a 3 week period Advance to one crutch or cane as ordered by MD Initiate stationary bicycle: Goal 15 to 20 minutes every day ** Avoid low seat height ** Week 6-8 Advance to unprotected WB if no limp. If limp present, use cane for two additional weeks. Gait retraining to abolish limp if present. Walking program for abductor strengthening. Continue stationary bicycle program. Specific abductor program if limp present. Week 8-12 Discharge to home program. Dislocation is less of an issue though still a concern. I encourage range of motion in flexion and external rotation up to 45 degrees and flexion to 120 degrees by week 8. May reach down to tie shoes with foot on a small step and with knees apart after week 3. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 14

15 Total Knee Arthroplasty Rehabilitation Protocol DOS All patients participate in a comprehensive joint program protocol which addresses pre and postoperative pain control and rehabilitation. Patients are in private rooms in an area of the hospital dedicated to joint replacement. In hospital, rehab takes place in this area in a comfortable setting for patients and family. All patients have received a spinal anesthetic, femoral, and/or sciatic nerve block to help with postoperative rehab and to achieve superior pain control. All patients will be up out of bed with assistance the day of surgery and will have initiated use of a CPM machine. Patients will have a narcotic, Tylenol, antiemetic, Coumadin, antibiotic, and an NSAID postoperatively as part of a comprehensive joint program protocol. PCA machines are rarely used and narcotic use is minimized due to the effectiveness of this program. Patients can be expected to be discharged on POD #2 in most circumstances. A few patients are discharged on Postoperative day number 1 and 3. POD #1 - #3 OOB to chair two times a day. Walker/crutch ambulation WBAT operated limb. Start CPM degrees. Daily goal of 120 degrees flexion. Ankle pumps, Knee ROM, Quad sets. Initiate stair climbing instructions. Advance to crutches if patient is able and comfortable with this advancement. Knee ROM: Aggressive passive extension stretches 4x per day Passive, active assistive, and active flexion as tolerated. Goal of degrees cold prior to hospital discharge. Ankle Pumps, quad sets, and straight leg raises. **Anticipate D/C from hospital around day 1, 2 or 3. Prior to discharge, patient should demonstrate full understanding of home program including CPM use. **Patient should have O.T. eval for home aids (reachers, graspers, toilet risers). 15

16 POD #6 - #30 Closed chain exercises initiated with above weight limits. ROM GOAL: o o o cold by two weeks postop cold by four weeks maximum expected (more or less depending on thigh size). N.B. If patient is not achieving the above goals with ROM, notify us immediately! **Emphasize extension as aggressively as ACL Rehab. **Extension is the most critical motion. Week 1-6 Continue crutch protection or cane if directed by MD. Initiate stationary bicycle as soon as possible: Goal minutes three times (minimum) weekly. Advance to aggressive closed-chain program. Week 6-24 Advance to unprotected WB if no limp. If limp present, use cane for two additional weeks. Gait training to abolish limp. Continue home program of exercises and conditioning daily. Stationary bicycle minutes per day. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 16

17 Lateral Retinacular Release Rehabilitation Protocol WEEK 1 PWB lbs. with crutches. Knee wrap clean and dry. Do not remove unless instructed to do so by MD. Quad sets, SLR as tolerated. WEEK 2 ADVANCE to WBAT / D/C crutches ACTIVE flexion/extension if minimal effusion, aggressive ham stretches as tolerated. ADD patellar mobilization as tolerated with lateral retinacular stretches. CONTINUE edema control measures with ace wrap day and night. WEEK 3-6 PROGRESS active extension, closed chain strengthening, and aerobic program, if minimal effusion present. If this activity induces effusion, back off intensity and modify program. WEEK 6-12 ADVANCE to plyometrics, sports specific agility and/or running program if knee is quiet with no effusion, and patient is pain-free. DISMISS to home exercise program Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 17

18 Isolated Meniscal Repair Rehabilitation Protocol N.B.: This protocol applies only to isolated meniscal repairs. This DOES NOT apply to meniscal repair performed in conjunction with ACL reconstruction. The ACL protocol should be followed unless otherwise noted on prescription if ACL / MENISCAL REPAIR done jointly. Week 0-4! PWB lbs with crutches.! Knee immobilizer full time except for showers week 0-2. D/C immobilizer after week 2 and initiate AROM as tolerated.! Quad sets, SLR, and ankle pumps 4 times daily.! Well leg stationary bicycle, and or upper extremity ergometer / aerobic program. Week 4-6! ADVANCE to WBAT unprotected when no limp and good quad control noted.! Progress AROM with stretches in flexion and extension. GOAL full ROM by end of week 6.! NO resistance exercises.! Stationary bicycle without resistance. Week 6-8! INITIATE closed chain strengthening.! No kneeling or squatting until after week eight. Week 8-12! INITIATE open chain strengthening. Week 12-16! ADVANCE to protected agility and sports specific exercise.! RETURN to sports with specific ok by MD after four months Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 18

19 Anterior Cruciate Ligament Reconstruction: Bone Tendon Bone (BTB) Accelerated Hamstring Rehabilitation Protocol WEEK 1! Ice and elevation for five days! WBAT! Crutches for five days for balance! Bandage on until office follow up with MD! May shower, rolling saran wrap over the bandage, keeping dressing dry! ROM gentle, but not forced! Extension stretches four times daily for fifteen minutes per session (minimum)! Straight Leg raises, fifty twice daily as tolerated! Start PT three days post op! Ankle pumps every hour! Ted hose twenty hours per day! Aspirin or Advil or Aleve (unless contraindicated) one pill twice daily; continue for a full two weeks WEEK 2 6! EDEMA CONTROL: Cryotherapy unit or ice full time for one week. Expect effusion to be resolved by week two or three with minimal knee swelling thereafter.! BRACE USE: 1) With increasing experience and data available with ACL reconstruction, many patients are not placed in a knee brace post op. We have not seen any increase in untoward effects by not using a brace, and have noted less quad atrophy and quicker thigh muscle recovery post op. Certain injuries or reconstruction techniques do however require brace use. Our patient will be fit intra operatively with either of the following braces as follows if indicated: A) Rehabilitation Brace: Brace to be worn for two weeks, 24 hours a day, except for hygiene; weeks 3-6 for ambulation. Initial range of motion setting usually locked in full extension for two weeks. Open brace fully for therapy sessions during this time, then lock brace at 0; progression of brace motion by MD. Usually after two weeks. Brace use full time during therapy unless noted otherwise by MD. B) Knee Immobilizer: Use for first 24 hours UNLESS NOTED OTHERWISE by MD. Discontinue brace after day one post op. 19

20 RANGE OF MOTION: PASSIVE: As tolerated with emphasis on extension. Extension stretches four times daily (add prone hangs as needed). ACTIVE: as tolerated avoiding open chain extension x 6 weeks. GOALS: Full extension cold by postop day # by four weeks postop by six weeks postop. FOUR QUADRANT LEG LIFTS: Straight leg raises beginning postop day #1. Progress to four quadrant exercises as tolerated. Advance to progressive closed chain exercises when no limp noted and good quad control achieved. CLOSED KINETIC CHAIN EXCERCISES: 1/3 knee bends and unilateral involved leg squats started when tolerated. Bicycle with involved leg against resistance allowed when no limp noted and good quad control achieved; increase resistance as tolerated. Leg presses, rowing machine, Stairmaster, Nordic Track etc. started with involved leg when bicycle tolerated well for fifteen minutes. Avoid all open chain exercises for twelve weeks. PATELLAR GLIDES: Patellar mobilization in all planes (medial, lateral, superior, inferior) to start week one. Perform four times daily for six weeks, then once daily thereafter for six additional weeks. WELL LEG EXERCISES / AEROBIC CONDITIONING: Well leg exercises including bicycle, squats, leg presses etc. to start as tolerated. Upper body ergometer, weights, etc as tolerated to maintain strength and conditioning. WEEK 7 8! GOLF AFTER SIX WEEKS POST OP! AGGRESSIVE ROM stretches, aerobic conditioning on stationary bicycle or elliptical trainer. WEEK 9 12 ADVANCED EXERCISES: Jogging or free wheel biking on level surface, controlled environment, and swimming beginning at week eight with surgeon s ok. Jogging forward and backward against sport cord, treadmill forward and backward, plyometrics, lateral sport cord, ski fitter, mini tramp and jump roping to begin thereafter as tolerated. WEEK 13 16! BRIDGE PROGRAM or equivalent may begin at 12 week mark with bone patellar tendon bone graft. Hamstring graft may start at 16 weeks post op.! Aggressive Short Angle Quad (0 40 degrees) open chain strengthening up to twenty five pounds. Sets of ten until quad fatigues.! Retro walking and Retro biking with resistance for quad specific strengthening WEEK 17 24! RETURN TO SPORTS CRITERIA:! Painless ROM equal to non operated knee! No effusion! Excellent quad contour and control.! Quad girth progressing toward normal.! Agility training and proprioceptive feedback termed excellent. BRACE USE: Functional braces have been shown to have protective effect in contact football (interior linemen), soccer, rugby. Brace will be prescribed by treating surgeon. Current literature does not support brace use in other sports. Knee sleeve has been shown to be as effective as custom braces due to enhance proprioception. 20

21 Anterior Cruciate Ligament Reconstruction: Hamstring Rehabilitation Protocol WEEK 1! Ice and elevation for five days! Partial weight bearing with crutches! Bandage on until office follow up with MD! May shower, rolling saran wrap over the bandage, keeping dressing dry! ROM gentle, but not forced! Straight Leg raises, fifty twice daily as tolerated in brace! Ankle pumps every hour! Ted hose twenty hours per day! Aspirin or Aleve (unless contraindicated) one pill twice daily; continue for a full two weeks WEEK 2 8 EDEMA CONTROL: Cryotherapy unit or ice full time for one week. Expect effusion to be resolved by week two or three with minimal knee swelling thereafter. BRACE USE: Rehabilitation Brace: Week 1-2: Brace worn for 24/7 except for showers Weeks 3-6: Wear brace for ambulation. Settings Brace use during therapy except for stationary bike. RANGE OF MOTION:! PASSIVE: avoid hyperextension.! ACTIVE: as tolerated avoiding open chain extension x 6 weeks.! GOALS: by four weeks postop by six weeks postop. FOUR QUADRANT LEG LIFTS: Straight leg raises beginning postop day #1. Progress to four quadrant exercises as tolerated. Advance to progressive closed chain exercises when no limp noted and good quad control achieved. CLOSED KINETIC CHAIN EXCERCISES: 1/3 knee bends and unilateral involved leg squats started when tolerated. Bicycle with involved leg against resistance allowed when no limp noted and good quad control achieved; increase resistance as tolerated. Leg presses, rowing machine, Stairmaster, Nordic Track etc. started with involved leg when bicycle tolerated well for fifteen minutes. Avoid all open chain exercises for twelve weeks. 21

22 PATELLAR GLIDES: Patellar mobilization in all planes (medial, lateral, superior, inferior) to start week one. Perform four times daily for six weeks, then once daily thereafter for six additional weeks. WELL LEG EXERCISES / AEROBIC CONDITIONING: Well leg exercises including bicycle, squats, leg presses etc. to start as tolerated. Upper body ergometer, weights, etc as tolerated to maintain strength and conditioning. WEEK 9 12! GOLF AFTER EIGHT WEEKS POST OP! AGGRESSIVE ROM stretches, aerobic conditioning on stationary bicycle or elliptical trainer. WEEK 13 16! ADVANCED EXERCISES: Jogging or free wheel biking on level surface, controlled environment, and swimming beginning at week eight with surgeon s ok.! Jogging forward and backward against sport cord, treadmill forward and backward, plyometrics, lateral sport cord, ski fitter, mini tramp and jump roping to begin thereafter as tolerated. WEEK Bridge Program or equivalent may begin at 16 week mark with hamstring graft.! Aggressive Short Angle Quad (0 40 degrees) open chain strengthening up to twenty five pounds. Sets of ten until quad fatigues! Retro walking and Retro biking with resistance for quad specific strengthening WEEK 25 RETURN TO SPORTS CRITERIA:! Painless ROM equal to non operated knee! No effusion! Excellent quad contour and control.! Quad girth progressing toward normal.! Agility training and proprioceptive feedback termed excellent. BRACE USE: Functional braces have been shown to have protective effect in contact football (interior linemen), soccer, rugby. Brace will be prescribed by treating surgeon. Current literature does not support brace use in other sports. Knee sleeve has been shown to be as effective as custom braces due to enhance proprioception. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 22

23 Distal Patellar Realignment Fulkerson / Elmslie-Trillat Rehabilitation Protocol Week 0-2! PWB lbs with crutches! Knee immobilizer full time. Shower, getting wound wet, when ok by MD.! Quad sets and ankle pumps 4 times daily. NO SLR.! Well leg stationary bicycle, and or upper extremity ergometer / aerobic program. Week 3-4! D/C KNEE IMMOBILIZER after two weeks post op.! ROM: active flexion, active assistive extension! Crutch use full time with PWB lbs. Week 5-8! Start formal P.T.! Closed chain strengthening quads. SLR, patellar mobs.! Open chain strengthening hams.! D/C crutches after week 4 Week 9-12! Open chain quads and hams, use McConnell taping techniques or cartilage retraining if patellofemoral pain present. Week 13-24! Independent or home exercise program three times per week.! Return to sports on ok from M.D. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 23

24 Lateral Ankle Ligament Reconstruction Rehabilitation Protocol Weight Bearing: Week 1-3: strict non-weight bearing on crutches. Splint day & night. Remove for showers after MD remove surgical dressing. Week 4-6: Full WB in cast boot. Wear day & night, remove for showers only. Week 7: Ankle brace when out of bed until balance returns. Phase 1: 6 weeks Closed chain ankle reconditioning Isometric exercises with neutral ankle. Work to regain full dorsiflexion and eversion. Avoid plantar flexion and inversion until Phase 2. Mobilization of metatarsal and intermetatarsal joints. Begin one legged stance activities to promote co-contraction stabilization of the foot and ankle. Closed chain reconditioning (i.e. BAPS board, elliptical trainer, treadmill, Total Gym, biking, etc.) Pain-free open chain manual resistance in dorsiflexion and eversion. Phase 2: 8 weeks Proprioceptive and active conditioning ROM in all planes, including plantar flexion and inversion. Multi-plane closed chain and proprioceptive activities (i.e. single leg with perturbations, Lower Extremity Functional Profile testing and training Active resisted closed chain reconditioning. Multi-plane closed chain reconditioning. Phase 3: weeks Return to sports and work Wear lace-up brace for athletics and work on uneven surfaces for 1 year. Advance agility and sports specific exercise/activities in lace-up brace (i.e. side to side and front to back hopping, plyometrics on unloader device progressing to full gravity, etc.) Begin running program (must be able to jog 1 mile before starting cutting activities) 85% Lower Extremity Functional Profile test score (involved compared to uninvolved) to allow return to sports. **Developed in conjunction with Robert Larsen, PT and Kim Reid, PT. 24

25 Ankle Fractures and Foot Fractures Rehabilitation Protocol Bone healing requires immobilization. Bones take an average of 7 weeks to heal about 70% of normal strength. Once healing has started, the process can be stimulated through controlled, progressive strengthening. Common fractures and fusions may follow these guidelines. Crutches: Strict non-weight bearing for 6 weeks after surgery. Advance weight bearing over 3 weeks. Brace Use: Weeks 1-6 complete immobilization in boot or cast. Weeks 7-10 in boot when out of bed. Weeks boot for work/school. Brace for therapy and home. Week 13 brace until stable proprioception with eyes closed. Wear brace for all at risk activities for one year. Physical Therapy: Begins after 6 weeks of immobilization. Modalities: As needed to improve edema and pain control first two weeks in therapy. Cryotherapy after sessions. Range of Motion: Active only first two weeks of therapy. Passive stretch thereafter if not progressing. Motion to include toes, hind food, and ankle. Strength: Isometrics first week of therapy. Progress from closed chain to open chain as pain and motion permit. Goal: Global ankle strength 90% of opposite leg. Proprioception: Progress as tolerated. Recommend brace for all proprioception training. Goal: one-legged balance with eyes closed for 20 seconds. 25

26 Home Exercise Program: Transition over to HEP when appropriate. NOTE: Beware of increased swelling and pain which may indicate incompletely healed bone. Reduce weight bearing and therapy demands as indicated. Please call physician with any concerns. Patients with Diabetes should be delayed 2-4 weeks and should progress very slowly. RETURN TO WORK PROTOCOL: ANKLE & FOOT FRACTURES 0-2 Weeks No work. 3-8 Weeks Seated work only Must use crutches at all times Cast or cast boot on at all times May need to elevate foot to control swelling No driving No limits on upper extremity work 9-12 Weeks Must be in boot except while driving Standing for 15 minutes per hour worked Walking in boot for 15 minutes per hour Stairs one time per hour No squatting, kneeling, lifting or twisting Weeks Must wear ankle brace or lace-up boot to work Standing/walking for 30 minutes per hour Avoid ladders and uneven ground 17 Weeks Return to regular duty *If you have specific work needs or are progressing at a faster rate, please request a functional evaluation from your physical therapist. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 26

27 Achilles Repair Rehabilitation Protocol Weight Bearing: Day 1-14 STRICT non-weight bearing on crutches. Day 14 weight bearing as tolerated with crutches. Day 21 weight bearing as tolerated without crutches. Brace Use: Achilles boot placed on day 14 if skin is healthy to be worn 24 hours/day until day 35 when boot can be removed for sleep. Achilles boot is slowly lowered removing 1 wedge at a time. Day 14: 4 wedges Day 21: 3 wedges Day 28: 2 wedges Day 37: 1 wedge Day 42: All wedges removed, foam pad placed. Day 49: Boot for school/work. Remove boot at home. Wear! inch heel lift in all shoes for 1 month. PHASE 1: Day 21 post-op (limited visits, HEP) AROM and isometrics for inversion/eversion with ankle in plantar flexion. Stationary bike okay with Achilles boot on. Anti-inflammatory modalities and scar tissue mobilization as needed. PHASE 2: Day 42 post-op DO NOT WORK ON DORSIFLEXION UNTIL WEEK 10. Gentle PRE as tolerated using Theraband, BAPS and manual resistance. Proprioception: Stork Stand at 6 weeks with heel wedge if necessary. Ball toss/plyoback at 8 weeks. Agility/Endurance: Non-impact first week. Progress to low impact if pain-free. When single heel raise attained (week 9-10), begin lunges, aquatic, shuttle, euroglide, lateral shuffles/carioca. PHASE 3: 12 weeks post-op Full ROM and weight bearing without limitations. Advance to progressive running, plyometric, and agility program is isokinetic testing 75% or able to do 25 single leg heel raises. Return to heavy work/sports at 6 months if no pain or swelling, 90% normal function. *Developed in conjunction with Robert A. Hawkes Sportsmed P.T. 27

28 Bunionectomy Rehabilitation Protocol WEIGHT BEARING: Non-weight bearing for 2 weeks (3 weeks for shaft) Partial Weight bearing in Boot 2 weeks (3 for shaft) WBAT in Boot 2-4 weeks Transition into supportive shoe with wide toe box. Full weight bearing. TOE BRACING: Week 1 and 2 keep operative bandage in place. Weeks 3 and 4 use foam toe spacer at all times including showers. Weeks 5-8 use toe spacer or neoprene sleeve at all times. Remove for showers. Weeks 9-12 wear toe spacer or neoprene sleeve for sleep. STRENGTH AND MOTION: 6 Weeks Begin passive and active DF/PF of 1st MP joint Intrinsic mobilization and Strength Ankle Proprioception Stationary Bike 8 Weeks Global Ankle Strength Elliptical 12 Weeks Progressive Open chain ankle and foot stresses Outdoor biking Evaluate and correct walking gait abnormalities. 16 Weeks Slow progress to in-line running and impact conditioning. Eventually work on cutting/rotational control if personal activities warrant. HOME EXERCISE PROGRAM: Transition to HEP when appropriate. NOTE: The rate that healing occurs differs between people. This protocol may be enhanced or delayed depending on radiographs, pain, and swelling. Please lessen activities which cause pain and swelling. 28

29 Peroneal Tendon Repair Rehabilitation Protocol Appointments Week before surgery surgery discussion 2 weeks after surgery remove stitches, place boot 6 weeks after surgery ankle brace, start therapy Activity First 48 hrs. Elevate and ice ankle Week 1-2 No weight on leg, use crutches at all times Week 3-4 Toe touch down with crutches Week 5-6 Full weight in boot Week 7-9 Boot for work or school. Full weight in lace up brace for home. Physical Therapy Week 3 Remove twice a day. Inversion only Week 4-5 Active range of motion only. Spell alphabet twice daily. Isometrics with ankle in neutral dorsiflexion. Subtalar neutral. Week 6-7 Closed chain. Avoid max dorsiflexion and max eversion. Week 8 Progressive ROM, strength, proprioception. Week 12 Sports or work related exercises Return to Work Week 1 No work. Week 2-4 Must be on crutches, sedentary work. Week 5-9 May work in boot. Lift 30 lbs., no ladders or stairs. Week May work in lace up brace, lift 50 lbs., no ladders. *May return to work full duty when approved by physical therapist. *Please provide a list of your work duties to your therapist. *You may return to full duty only when the therapist confirms you can perform all your duties. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 29

30 Syndesmosis Repair Rehabilitation Protocol Weight Bearing: Strict non-weight bearing for 4 weeks after surgery in splint day & night. Partial weight bearing in boot 4 weeks, no boot in bed. Full WB in boot 4 weeks (2 weeks before screw out, 2 weeks after screw out). No boot in bed. Pneumatic brace until proprioception returns. Pneumatic brace for sports & at risk for 1 year. Return to sports at 6 months. * Delay all steps of above protocol by 2-4 weeks if patient weights more than 250 lbs. or if delayed surgery. Proprioception Phase 1: Day 42 Edema control, cryotherapy Isometrics only, including proprioception Proprioception Phase 2: 1 week after screw removed (10-12 weeks) Begin ROM all planes Progress to open chain Incorporate endurance Proprioception Phase 3: Week Return to sports and work Wear lace-up brace for athletics and work on uneven surfaces for 1 year Advance agility and sports specific exercise/activities in lace-up brace (i.e. side to side and front to back hopping, plyometrics on unloader device progressing to full gravity, etc.) Begin running program (must be able to jog 1 mile before starting cutting activities) 85% Lower Extremity Functional Profile test score (involved compared to uninvolved) to allow return to sports. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 30

31 Ankle and Foot Fusions Rehabilitation Protocol Weight Bearing: Strict non-weight bearing in cast or splint for 8 weeks after surgery (crutches or knee roller). Advance to weight bearing 25% per week thereafter in boot. (Boot off in bed) Brace Use: Weeks boot for work/school/outdoors. Modified shoe in house. Ankle Fusion: rocker sole or metatarsal bar for shoes. Midfoot Fusion: stiff-soled shoes or metatarsal bar. Modalities: As needed to improve edema and pain control first 2 weeks in therapy. Cryotherapy after sessions. Range of Motion: Intrinsic mobilization after first 6 weeks. Ankle Fusion: subtalar motion after 8 weeks. Midfoot Fusion: ankle and subtalar motion after 8 weeks. Proprioception: Progress as tolerated. Home Exercise Program: Transition over to HEP when appropriate. NOTE: The rate that fusion occurs differs between people. This protocol may be enhanced or delayed depending on radiographs and pain. If a patient you are working with has pain or swelling in the area of the fusion, please stop therapy and place on crutches until radiographs can be obtained. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 31

32 Posterior Tibial Tendon Reconstruction Rehabilitation Protocol Crutches: Patient to receive training one week before surgery. Strict non-weight bearing for 6 weeks after surgery. Advance to weight bearing 25% per week thereafter in boot. Unrestricted weight bearing after 12 weeks if radiographic union. Brace Use: Weeks 1-6 complete immobilization in boot or cast. Weeks 7-12 in boot with orthotic when out of bed. Weeks ASO lace up with medial strap snug! Orthotic in shoe. Lace up brace for 6 months whenever out of bed. Orthotic in all shoes (custom or over-the-counter semi-rigid). Physical Therapy: Begins after 6 weeks of immobilization. Modalities: As needed to improve edema and pain control first 2 weeks in therapy. Cryotherapy after sessions. Range of Motion: Active only, first 2 weeks of therapy. Passive stretch thereafter if not progressing. Must get dorsiflexion and inversion. Strength: Isometrics first week of therapy. Progress from closed chain to open chain as pain and motion permit. Goal: plantar flexion and inversion strength with one-legged stance. Proprioception: Progress as tolerated. Recommend brace for all proprioception training. Goal: one-legged balance with eyes closed for 20 seconds. Home Exercise Program: Transition over to HEP when appropriate. NOTE: This reconstruction often includes bone healing from osteotomies. Beware of increased swelling and pain which may indicate incompletely healed bone. Reduce weight bearing and therapy demands as indicated. 32

33 Navicular Stress Fractures Rehabilitation Protocol Weight Bearing: Weeks 1-6: Formal non-weight bearing with crutches in fiberglass cast. Weeks 7-8: Weight bearing for normal daily activities. Swimming and water running are permitted. Week 9: If no tenderness at navicular, jog on grass 5 minutes every other day for 1 week. If no pain increase to 10 minutes every other day for 1 week. If no pain, faster running at meter intervals can be started every other day for 1 week. Walking recovery can be performed on non-training days. Speed is gradually increased from! to " maximum speed over an additional 2 weeks. Week 15: The athlete is reassessed and if no tenderness, the athlete is permitted to continue to gradually return to full training activities. Bountiful Office 1551 South Renaissance Towne Drive, Suite 400, Bountiful, UT Layton Office 2086 North 1700 West, Layton, UT Telephone (801) , Fax (801) /08 33