REVIEW ARTICLE

Rehabilitation After Multiple-Ligament Reconstruction of the Knee

Craig J. Edson, MS, PT, ATC, Gregory C. Fanelli, MD, and John D. Beck, MD

Abstract: Diagnosis and management of multiple-ligament knee injuries has evolved over the years, and now treatment often includes surgical intervention. Rehabilitation after multiple-knee ligament reconstruction requires a precarious balance between restoring range of motion and function to the knee without compromising the static stability and integrity of the grafted tissues. It is imperative that the patient is aware of the time commitment, restrictions, and the fact that the entire rehabilitation process will likely take a full year before returning to unrestricted activity. The purpose of this study is to dene the current approach to postsurgical management after posterior cruciate ligament-based multiple knee-ligament reconstruction. Key Words: multiple-ligament injured knee, knee dislocation, rehabilitation techniques, postoperative management

on the eects of exercises and daily activities on the reconstructed PCL. Studies that do describe the postoperative rehabilitation rarely provide the reasoning behind their protocols.3 In vivo measurements of the forces and strains on the reconstructed grafts are currently impractical. Some studies exist that measure tibiofemoral stresses during activities such as squatting, stair climbing, and squatting.47 With these concepts in mind, it remains imperative to design a rehabilitation program that protects the graft during the early healing phase and provides the patient with a knee that allows them to return to their desired level of function.

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REHABILITATION AFTER ACL/PCL/ POSTEROLATERAL CORNER AND/OR MEDIAL SIDE RECONSTRUCTION

The immediate postoperative course after multipleligament reconstructions involves 6 weeks of nonweightbearing ambulation. When the patient is standing statically, they are permitted to bear weight equally on each leg. We feel that this weight bearing can provide several benets. First, the patient will likely have better static balance when standing on both legs, thus minimizing the risks of falls. In addition, occasional weight bearing will stimulate tunnel healing and graft incorporation. Finally, intermittent weight bearing may promote the production of synovial uid to bathe the articular cartilage (Table 1). A long-leg hinged ROM brace is used and is locked in full extension during the initial 5 weeks of the postoperative program. This position has been shown to minimize forces on the PCL8 and prevents the development of an early exion contracture. The patients are instructed to use the brace 24 hours/day with the exception of showering or cleansing the leg. As this brace does allow access to the knee, patients are encouraged to perform self-patella mobilization once the postoperative dressings have been removed. In addition, electrical stimulation can be used for quadriceps reeducation. Quadriceps inhibition and atrophy is the most dicult, but crucial factor to control in the immediate postoperative phase. Swelling is a signicant contributor to atrophy and also needs to be minimized.9 Exercises that are recommended during this early postoperative stage include quadriceps sets and ankle pumps. These promote improved blood ow and, to a small degree, inhibit atrophy. The application of ice on a routine basis is encouraged to combat swelling, however, a water-resistant barrier is recommended until the incisions are fully healed. Once the incisions have closed, scar massage is also encouraged. Completely eliminating ROM during the rst 5 weeks postoperatively has resulted in the best outcomes with regards to healing of the PCL graft and restoring static stability. In a small percentage of patients, loss of knee Sports Med Arthrosc Rev


ehabilitation after multiple-ligament reconstruction requires a precarious balance between restoring range of motion (ROM) and function to the knee without compromising the static stability and integrity of the grafted tissues. It is imperative that the patient is aware of the time commitment, restrictions and the fact that the entire rehabilitation process will likely take a full year before returning to full activity is realistic. In addition, when the posterior cruciate ligament (PCL) is involved, a 10 to 15 degree loss of exion is common. Knowing this information before surgery often improves patient compliance and the nal outcome.

DESIGNING POSTOPERATIVE PROGRAMS

The determination of the best rehabilitative approach after multiple-ligament reconstructions will often be at the discretion of the surgeon. One thing that is evident, is that this approach needs to be more conservative than those principles and techniques used after anterior cruciate ligament (ACL) reconstruction.1 For instance, allowing weight bearing during the immediate postoperative period is likely more deleterious to the PCL, as it is considered the primary static stabilizer of the knee.2 Accompany this with the fact that multiple-ligament reconstruction often involves both medial and lateral repair or reconstruction, then the cyclic motion of the knee during ambulation needs to be minimized to avoid overstressing of these structures. Further complicating the development of eective rehabilitation programs is the relative lack of empirical research
From the GHS Orthopaedics Woodbine, Danville, PA. Reprints: Gregory C. Fanelli, MD, GHS Orthopaedics and Sports Medicine, 115 Woodbine Lane, Danville, PA, (e-mail: gregorycfanelli@ gmail.com). Copyright r 2011 by Lippincott Williams & Wilkins

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TABLE 1. Multiple Ligament Reconstruction Rehabilitation Phase I: 0-5 wk Goals Maximum protection of grafts Maintain patella mobility Minimize quadriceps atrophy Maintain full passive extension Control pain and swelling Program Nonweight bearing ambulation with crutches Brace locked in extension 24 h/d Crotherapy Quad setsenhance with low-intensity electrical stimulation or biofeedback Patella mobilization Low-intensity gastrocsoleus and hamstring stretching Phase II: 6-10 wk Goals Initiate weight bearing for articular cartilage nourishment Increase knee exion gradually to 90 to 100 degrees Improve quadriceps tone/strength Improve proprioception Avoidance of isolated quadriceps and hamstring contractions Program Begin partial weight bearing, grossly 20% body weight and increase by 20% per week over the next 5 wk to full weight bearing by the end of postoperative week number 10 Open brace to full exion and discontinue brace for sleeping Prone hangs Passive exion exercises High-intensity electrical stimulation with knee at 60-70 degrees (optional) Initiate closed-chain strengthening once full weight bearing and quadriceps strength of 3+/5 or greater Advance proprioception Fit for functional brace after 10 wk. Discontinue range of motion brace Phase III: 10 wk to 6 mo Goals Increase knee exion to at least 120 degrees by end of month 6 Progress closed-chain strengthening Initiate open-chain quadriceps strengthening by end of month 4 Initiate straight-line jogging at end of month 5 Improve cardiovascular endurance Program Progressive resistive closed-chain exercises avoiding exion beyond 70 degrees Isolated quadriceps strengthening at end of month 4 Single-leg proprioception on unsteady surface Aggressive exion exercises if necessaryconsider manipulation if range of motion is <90 degrees by end of month 4 Hip passive resistance exercises Straight-line jogging at end of month 5 Initiate low-intensity plyometrics at end of month 6 Phase IV: 7 mo to 12 mo Goals Maximum exion 10-15 degree terminal exion loss is common Quadriceps strength 90% or greater of nonsurgical side Progress to sport-specic activities Return to sports between month 9 and 12 Program Progression of strengthening, conditioning, and agility exercises to achieve goals Progressive plyometric proprioceptive proram (jump program) Return to sports if the following criteria are met: 1. Minimal or no pain and swelling 2. Completion of all functional tests within 10% of the uninvolved side 3. Ability to spring without any gait alteration 4. Compliance with functional bracing

exion results in the need for manipulation under anesthesia and arthroscopic debridement of scar tissue.10 However, in our experience, allowing patients earlier ROM have shown detrimental eects on static stability. This not only occurs at the PCL, but also at the medial or lateral stabilizers when reconstruction of these structures is involved. The decision
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to be made is does one wish to sacrice stability for mobility? For the long-term outcome of the knee, stability is imperative. However, ideally, sucient motion is also required to allow the patient to return to their desired level of activity and promotes more satisfactory functional outcomes. www.sportsmedarthro.com |

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POSTOPERATIVE WEEKS 5 TO 10
At the beginning of postoperative week 6, the ROM brace is unlocked and opened to full exion. At this time, the patient is allowed to begin partial weight bearing with the crutches. Although the patient is instructed to place approximately 20% of their body weight on the involved leg, we do not expect this to be a precise amount and serves simply as a means to introduce weight-bearing forces to the surgical grafts. In addition, continued use of the crutches and protective weight bearing minimizes the patients risk of falling due to signicant quadriceps atrophy and weakness. Isolated hamstring strengthening is completely avoided to increase knee exion. However, the patient is encouraged to begin exing his knee passively. This can be accomplished with several techniques including a stair stretch in which the patient places the involved leg on a stair and gently rocks forward, thus allowing the knee to bend. In addition, the patient can perform passive-assisted heel slides as long as the knee is maintained in neutral alignment. This consists of using the uninvolved leg to gently push the knee into exion while the surgical leg is resting on a towel and on a smooth surface. Once a exion stretch is felt, the patient should use the nonsurgical leg to extend the knee back to neutral. Other methods are available as long as they are done without any active hamstring involvement. With regards to the degree of exion, the patient is advised to progress gradually. This allows the grafts and soft tissue structures to adapt slowly to changes in length. If the patient, or a therapist, attempts to force exion too quickly, the grafts may be compromised. In fact, there have been instances when a patient has torn their graft simply by being too aggressive with their exion during the early phase of healing. As a landmark, the patient is encouraged to attain approximately 90 degrees of exion by the end of postoperative week 10. The passive exion exercises and quadriceps strengthening are progressed over the next 5 weeks. In addition, the patient progresses their weight bearing by 20% each week so that they have attained full weight bearing by the end of postoperative week 10. At that point, the crutches are discontinued as is the long-leg brace, and the patient is tted for a functional brace. This brace needs to be multiinstability-specic in that it provides anteriorly and posteriorly directed forces on the tibia while also supporting the medial and lateral structures.

10 WEEKS TO 6 MONTHS POSTOPERATIVELY

Often times, the patient will be on a self-regulated rehabilitation program up until this point, based on specic guidelines given by the rehabilitation specialist. This is dependent upon several factors including geographic location, level of quadriceps tone and strength, and the amount of exion obtained. This decision, at our institution, is made by the surgeon. If the patient seems to be having diculty regaining strength or motion, than a therapist is often used to assist the patient with adherence to the postoperative guidelines. If a therapist has not been involved before this time, then the patient is encouraged to begin a structured rehabilitation program under a therapists supervision. The focus of the rehabilitation program at 10 weeks postoperatively continues to be on improving ROM and quadriceps strength. In addition, as the patient is now full weight bearing, they are trained on proper gait mechanics

and proprioception exercises. Katonis et al11 determined that the native PCL contained numerous mechanoreceptors that communicated with the central nervous system. They determined that the loss of these receptors contributed to joint laxity and muscle dysfunction. Similar ndings have been reported for the ACL as well.12 Consequently, it is crucial to train the surrounding mechanoreceptors so that joint proprioception is restored during gait and daily activities. To further assist proprioception, closed-chain exercises are now used. Lutz et al,13 has shown that there is a decrease in shear forces at the tibiofemoral joint during these exercises due to the axial orientation of the applied force and muscular cocontraction. Initially, the closed chain exercises are done with only body weight for resistance; however, as strength and volitional control improve, resistive exercises are implemented. The patient is advised to limit knee exion to 60 degrees during these exercises. Wilk14 has shown that quadriceps and hamstring ratios are similar during the rst 60 degrees of exion, thus minimizing tibial translation in anterior and posterior directions. Restoring quadriceps strength is easily the largest hurdle to minimizing pain and swelling, and improving joint function. In a recent study, Palmieri-Smith et al9 suggested that quadriceps weakness was not solely a result of disuse or lack of adequate exercise intensity, but also a result of arthrogenic muscle inhibition. This was theorized to be a result of reex activity in which altered aerent signal originating from the injured joint leads to a diminished eerent motor drive to the muscles. In other words, the patient is unable to volitionally recruit sucient muscle bers to increase strength, regardless of the amount of resistance applied. To combat this inhibition, they suggest minimizing joint eusion, using cryotherapy, and incorporating transcutaneous electrical nerve stimulation and/or neuromuscular stimulation. All of these techniques can be benecial in allowing the patient to regain quadriceps recruitment and strength. Of course, reexive inhibition is only 1 component of quadriceps atrophy and weakness. When beginning resistive exercises, eccentric exercises play an important role in improving strength. Gerber et al15 found that negative resistance training in combination with standard concentric exercises had a 2-fold greater increase in quadriceps peak cross-sectional area and volume when compared with patients receiving standard rehabilitation only after ACL reconstruction. One nal component of improving quadriceps strength is the use of open kinetic chain exercises. These have been shown to create larger anterior shear forces than do closed chain exercises. Consequently, these exercises are avoided for the rst 4 months. As these types of exercises may challenge the quadriceps more eectively than closed chain exercises, they are implemented gradually and with regards to patients subjective reports. We have found that 1 risk to these exercises is the potential development of anterior knee pain, specically patella tendonitis. This may be a result of excessive force on these structures that, over time, causes them to break down and become inamed. Close monitoring of the patients response to these exercises and the use of cryotherapy after exercising can reduce the incidence of this potential complication. Finally, the ROM goal at the end of postoperative month 3 is 100 to 110 degrees of exion. As the patient is advanced through progressive resistive exercises and proprioceptive training, more challenging activities can be implemented. The patient is allowed straight-line jogging at the end of postoperative
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month 5 assuming that quadriceps strength is adequate to permit this activity. The patients running gait is monitored and the patient is allowed to continue only when they can do so without altered mechanics or other obvious dysfunction. In addition, the patient performs more single-leg strengthening. Escamilla et al4 have shown that PCL forces were signicantly lower in 1-leg squat exercises up to 70 degrees compared with a bilateral leg squat to 90 degrees. Dynamic stabilization, proximal strengthening, and core exercises play an important role at this point as a measure to improve overall strength and conditioning. There are several techniques to achieve this goal and are too numerous to address individually for the purpose of this study. They are intended to provide the patient with overall stability to allow progression to more aggressive and nonlinear activities. At the end of postoperative month 4, the patients exion ROM ideally would be approximately 120 degrees. Months 6 through 9 are when the exercises are geared more toward sport or work-related activities. With regards to the athletic population, running in nonlinear directions and low-intensity cutting activities are initiated. This is also when low-level plyometrics are incorporated, including bilateral and single-leg exercises. Emphasis is placed on proper landing mechanics and the ability to maintain this position for 2 to 5 seconds once the jump is concluded. These training programs have been reported in the literature as both postoperative and preventative techniques for the ACL.1519 Isolated hamstring exercises are also initiated at this time but they are done without additional resistance. We do not nd hamstring weakness and/or atrophy to be a common nding in our patients. Before this point, the detrimental eects of isolated hamstring exercises on the PCL seem to outweigh the benets they provide. The plyometric program typically takes 6 weeks to complete and the patient is progressed through the individual stages based on successful completion of the earlier stage. The program is designed to progressively increase load and enhance the functional abilities with minimal exposure to potential injury risk positions. The patient is monitored carefully for signs of increased joint soreness or swelling and appropriate measures are taken to avoid any progression of these symptoms. Ideally, the completion of this program coincides with the end of postoperative month 9 at which time a return to sports or heavy manual labor is considered. The return to sports is a multifactorial decision and a careful balance of the athletes desire to return based on their perceived readiness versus objective measures of their actual function and lingering impairments. With regards to functional testing, there does not seem to be a gold standard that best determines an athletes ability to return to sports. In a recent study by Bjorklund et al20 they examined various functional tests for validity and accuracy in determining performance at 2 separate postoperative intervals after ACL reconstruction (4 and 8 mo). They developed a series of 8 tasks; 3 consisted of bilateral tests, whereas 5 consisted of single-leg activities. The patients rated their outcomes using the International Knee Documentation Committee form, and objective criteria were developed to assess the patients performance during the 8 functional tests. They determined that these tests were reliable and appropriate for assessing a patients functional ability after ACL reconstruction. One possible obstacle to this assessment is the inclusion of clinical assessment of a patient while performing functional tests. Certainly, it is possible that, based on a clinicians experience and
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expertize, there could be a wide range of dierences when attempting to objectively quantify a functional test. It seems that the most eective method to assess a patients skill and tolerance to functional tests is to include objective and measurable criteria. For example, single-leg hop for distance, single-leg timed hop for distance, shuttle runs, and single-leg vertical jumps for height to name a few. A patient should be within 10% of the uninvolved leg with all functional tests to be considered for return to sports. Prophylactic bracing is a controversial issue and one that will not be analyzed within this treatise. As we incorporate a functional brace early within the postoperative rehabilitation, we recommend that the patient continue to use this brace during sports or other activities that could place the knee at risk. This is done until the patient reaches 18 months postoperatively, at which time the use of the brace becomes optional.

RESULTS
Our results of PCL-based multiple-ligament reconstructions have been previously published (Refs.10,2130). The keys to successful PCL reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and backup graft xation, and use the appropriate postoperative rehabilitation program. Adherence to these technical details results in successful single and double bundle arthroscopic transtibial tunnel PCL reconstruction documented with stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.10,2130 In conclusion, the purpose of this study is to outline the rehabilitation guidelines that are used at our institution after multiple-ligament reconstruction of the knee and to describe the scientic rationale behind them. As the results indicate, this approach has resulted in a high level of patient satisfaction and the ability to return to their desired level of function. REFERENCES
1. Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go. Arthroscopy. 2003;24:234235. 2. Van Dommelon BA, Fowler PJ. Anatomy of the posterior cruciate ligament: a review. Am J Sports Med. 1989;17:2429. 3. Jackson WFM, Van der Tempel WM, Salmon LJ, et al. Endoscopically-assisted single-bundle posterior cruciate ligament reconstruction: results at minimum ten-year follow-up. J Bone Joint Surg. 2008;90B:13281333. 4. Escamilla RF, Zheng N, Imamura R, et al. Cruciate ligament force during the wall squat and the one-leg squat. Med Sci Sports Exerc. 2009;41:408417. 5. Li G, Pappannagari R, Meng Li MS, et al. Eect of posterior cruciate ligament deciency in vivo translation and rotation of the knee during weightbearing exion. Am J Sports Med. 2008;36:474479. 6. Defrate LE, Gill TJ, Li G. In vivo function of the posterior cruciate ligament during weightbearing knee exion. Am J Sports Med. 2004;32:19231928. 7. Pappannagari R, Defrate LE, Nha KW. Function of posterior cruciate bundles during in vivo knee exion. Am J Sports Med. 2007;35:15071512. 8. Shelbourne KD, Klootwyck TE, Wickens JH. Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in an accelerated rehabilitation program. Am J Sports Med. 1995;23:574579.

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