**3.1 Medical procedure and rehabilitation**

After diagnostic examinations (knee joint X-ray examination) and excluding the damage of the popliteal artery and the peroneal nerve (ultrasound diagnosis of the popliteal fossa), the knee was reset into the proper position and immobilized by means of a knee joint immobilization bar (Sporlastic Genustabil 0°). A week later, the MRI examination revealed ruptured anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and fibular and tibial collateral ligaments (MCL) with grade 1 injury to the medial meniscus. The operating intervention involved two separate reconstruction procedures. The first one concerned the posterior cruciate ligament, whereas the second was used to reconstruct the anterior and fibular ligaments. An additional procedure used before the reconstruction was arthroscopy in order to remove arthrofibrosis.

The individual program of rehabilitation developed for the purposes of the discussed case took into consideration the damages to all structures formed during the injury, guidelines of the case physician, and the basic principles of rehabilitation [9]. The complete rehabilitation procedure was divided into four stages.

The first stage directly after the injury lasted 10 weeks. The most important elements of the rehabilitation procedure together with the marked moment of their implementation are presented below (**Table 1**).

Due to the damaged falciform cartilage, the first stage focused on creation of the conditions for the cartilage growth: immobilization of the joint for 4 weeks, complete absence of the load to the limb. At this stage, the activities also involved stimulation of creation of the scar in the location of the tibial collateral ligament through transverse massage (this ligament is fused with the joint capsule and the correctly formed scar can successfully overtake the function of the ligament). An additional recommendation in the period of immobilization was to use a Medi PTS orthosis, which ensured complete extension of the leg and, through the special pad fixed under the knee, it pushed the lower leg to the front, thus preventing the joint capsule contraction. Preparation of the joint for posterior cruciate ligament reconstruction was started after 4 weeks from immobilization and consisted mainly in reaching 100–110° of relaxed flexion movement in the knee joint (the range required for reconstruction). After around 2 weeks and reaching 90°, the meniscal block was observed. After consultation with the doctor, the meniscus was excluded as a cause of mobility limitation and, since the range of motion needed for the reconstruction was not achieved, the arthroscopy was performed to remove arthrofibrosis.

After the arthroscopy which was performed to remove the resulting arthrofibrosis (ROM 0–80), the second stage of rehabilitation was started for 6 weeks and focused on the preparation of the joint and limb for reconstruction (**Table 2**).

**Stage 1: directly after the injury: MRI: total rupture of ACL, PCL, MLC, PLC, grade 1 injury to the medial meniscus.**


#### **Table 1.**

*The first stage of rehabilitation.*


#### **Table 2.**

*The second stage of rehabilitation.*

The procedure following the arthroscopy was oriented at reaching 110° of the knee flexion as soon as possible. The active joint movement on the first day following the intervention was ca. 70°, which was a good prognosis for further improvement in mobility. The required range of motion was reached after 2 weeks. Therefore, active exercises were included, focused on increasing the strength of the quadriceps femoris muscles, hamstring muscles, and the gastrocnemius muscle. In order not to lead to tibia displacements with respect to the femur that are observed during muscle contraction, the exercises were performed only in closed kinematic chain (CKC). The elements of the proprioception training were also introduced

**37**

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament…*

(initially with partial load and then with full load), approaching it more as learning and preparation to the postreconstruction period. It was suggested that a dynamic orthosis (Jack PCL) that pushes the lower leg to the front with constant force during limb loading and knee movements should be used for the remaining 4 weeks after

The third stage started just after the reconstruction of the posterior cruciate ligament. The components of the rehabilitation procedure together with the time interval in which they were introduced for therapy are presented in **Table 3**. Attention can be paid, among others, delayed mobilization and loading of the limb. Four months after the injury, PCL was already reconstructed. For the first 2 weeks, the isometric contraction of the quadriceps femoris muscles, thigh adductors, and knee flexors was performed. The knee joint during these exercises was slightly flexed and a pad was inserted under the lower leg to push the tibia forward. Similar extension of the knee joint occurred at a light knee flexion. The iliotibial band was relaxed manually and the patella was mobilized. All these interventions were continued for the following weeks. After 2 weeks, the passive movement in the joint was introduced, with the range of 10–30°. This is the range of motion in which none of the parts of the anterior cruciate ligament are tensed. During passive movements in the open kinematic chain, the tissues of the anterolateral fascicle are contracted up to 30°, whereas for the posteromedial fascicle—at full extension [10]. In order to maintain knee extension, the exercises of extension in the range of 30–0° were performed in closed kinematic chain (pressing the foot against the mattress leaning against the wall; later, the mattress was replaced with a ball). Closing the system and pressing the articular surfaces against each other minimized tension of the posteromedial fascicle (safe range of motion for the posterior cruciate ligament in the closed chain is 0–60°, [11]). After 4 weeks, these exercises were performed in partial load to the limb (using the crutches/ladder). With the reduced graft strength [12], the patient was informed about the absolute prohibition of performing the twisting movement of the limb, waving the limb, and maintaining relaxed limb in the standing position. The patient was wearing the orthosis all the time (the orthosis was removed only for the time of exercises), initially using the Medi PTS and, when the hydrarthrosis reduced, Jack PCL was used over the night and Medi PTS was worn at night. Joint mobilization was started after 8 weeks. Although the threshold of 30° was not exceeded for a long time, the knee responded very well to passive movements, with the range of motion increasing gradually (it was 0–90 after 2 weeks). Furthermore, the patients performed exercises that supported flexion combined with active extensions at home, in the lying position, with the healthy leg resting on the wall at a right angle and the operated leg (straight) moved downward sliding on the wall and returning to the initial position (initially the healthy leg put under the heel of the operated leg). After introduction of gentle joint immobilization in week 13, the flexion reached 120°. The focus was on increasing strength, with much work in closed kinematic chains in the range of 0–60 (the highest shear forces were recorded for 85–105°) and open kinematic chain (extension)—initially in the range of 0–30 increasing gradually to 0–75° (shear forces were the highest for 75–90°) and in flexion (due to high shear forces, it is safe to introduce them 4 months after reconstruction) [13, 14]. Wherever the hamstring group was engaged, the tibia was additionally protected against the posterior translation (counterpressure) [10]. The components of proprioceptive training were added, with gradually increased difficulty (by e.g. more unstable ground, i.e. patient distraction) and the elements of preoperative patient's activity were added. From week 15, the patients exercised on her own, focusing on increasing the strength and muscle endurance. All the exercises except for proprioceptive training were performed while wearing a Jack PCL orthosis (at maximal lower leg pushing

*DOI: http://dx.doi.org/10.5772/intechopen.89649*

the surgery.

### *Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament… DOI: http://dx.doi.org/10.5772/intechopen.89649*

(initially with partial load and then with full load), approaching it more as learning and preparation to the postreconstruction period. It was suggested that a dynamic orthosis (Jack PCL) that pushes the lower leg to the front with constant force during limb loading and knee movements should be used for the remaining 4 weeks after the surgery.

The third stage started just after the reconstruction of the posterior cruciate ligament. The components of the rehabilitation procedure together with the time interval in which they were introduced for therapy are presented in **Table 3**. Attention can be paid, among others, delayed mobilization and loading of the limb.

Four months after the injury, PCL was already reconstructed. For the first 2 weeks, the isometric contraction of the quadriceps femoris muscles, thigh adductors, and knee flexors was performed. The knee joint during these exercises was slightly flexed and a pad was inserted under the lower leg to push the tibia forward. Similar extension of the knee joint occurred at a light knee flexion. The iliotibial band was relaxed manually and the patella was mobilized. All these interventions were continued for the following weeks. After 2 weeks, the passive movement in the joint was introduced, with the range of 10–30°. This is the range of motion in which none of the parts of the anterior cruciate ligament are tensed. During passive movements in the open kinematic chain, the tissues of the anterolateral fascicle are contracted up to 30°, whereas for the posteromedial fascicle—at full extension [10]. In order to maintain knee extension, the exercises of extension in the range of 30–0° were performed in closed kinematic chain (pressing the foot against the mattress leaning against the wall; later, the mattress was replaced with a ball). Closing the system and pressing the articular surfaces against each other minimized tension of the posteromedial fascicle (safe range of motion for the posterior cruciate ligament in the closed chain is 0–60°, [11]). After 4 weeks, these exercises were performed in partial load to the limb (using the crutches/ladder). With the reduced graft strength [12], the patient was informed about the absolute prohibition of performing the twisting movement of the limb, waving the limb, and maintaining relaxed limb in the standing position. The patient was wearing the orthosis all the time (the orthosis was removed only for the time of exercises), initially using the Medi PTS and, when the hydrarthrosis reduced, Jack PCL was used over the night and Medi PTS was worn at night. Joint mobilization was started after 8 weeks. Although the threshold of 30° was not exceeded for a long time, the knee responded very well to passive movements, with the range of motion increasing gradually (it was 0–90 after 2 weeks). Furthermore, the patients performed exercises that supported flexion combined with active extensions at home, in the lying position, with the healthy leg resting on the wall at a right angle and the operated leg (straight) moved downward sliding on the wall and returning to the initial position (initially the healthy leg put under the heel of the operated leg). After introduction of gentle joint immobilization in week 13, the flexion reached 120°. The focus was on increasing strength, with much work in closed kinematic chains in the range of 0–60 (the highest shear forces were recorded for 85–105°) and open kinematic chain (extension)—initially in the range of 0–30 increasing gradually to 0–75° (shear forces were the highest for 75–90°) and in flexion (due to high shear forces, it is safe to introduce them 4 months after reconstruction) [13, 14]. Wherever the hamstring group was engaged, the tibia was additionally protected against the posterior translation (counterpressure) [10]. The components of proprioceptive training were added, with gradually increased difficulty (by e.g. more unstable ground, i.e. patient distraction) and the elements of preoperative patient's activity were added. From week 15, the patients exercised on her own, focusing on increasing the strength and muscle endurance. All the exercises except for proprioceptive training were performed while wearing a Jack PCL orthosis (at maximal lower leg pushing

*Sports, Health and Exercise Medicine*

**meniscus.**

of the thigh

mobilization

**Table 1.**

chain (CKC), mobilization

*The first stage of rehabilitation.*

**36**

**Table 2.**

*The second stage of rehabilitation.*

The procedure following the arthroscopy was oriented at reaching 110° of the knee flexion as soon as possible. The active joint movement on the first day following the intervention was ca. 70°, which was a good prognosis for further improvement in mobility. The required range of motion was reached after 2 weeks. Therefore, active exercises were included, focused on increasing the strength of the quadriceps femoris muscles, hamstring muscles, and the gastrocnemius muscle. In order not to lead to tibia displacements with respect to the femur that are observed during muscle contraction, the exercises were performed only in closed kinematic chain (CKC). The elements of the proprioception training were also introduced

**Stage 2: following the arthroscopy aimed to remove arthrofibrosis and ACL stump debridement**

Partial loading/learning to walk on crutches — — +

Proprioception learning — — + + Full load — — — +

**Stage 1: directly after the injury: MRI: total rupture of ACL, PCL, MLC, PLC, grade 1 injury to the medial** 

Immobilization using Medi PTC (day/night) orthosis +/+ +/+ −/+ −/+

**injury (weeks)**

Partial loading + +

Isometric exercises + +

Immobilization using Medi PTC (day/night) orthosis −/+ −/+ −/+

Stretching (to remove muscle tone) of the hamstring muscles — + + Proprioception learning — + + Full load — — + Strengthening exercises (load + CKC) — — +

**injury (weeks)**

**Day 1–3 1–2 3+**

**1 2–4 5–7 8–10**

— + + +

— — — +

— — +

**Procedure Time after** 

**Procedure Time after** 

Stretching (to remove muscle tone) of muscles of rear and medial parts

Joint mobilization (0–60°): passive, self-controlled exercises, patella

Further joint mobilization (>60°): active exercises in closed kinematic

PRICE and kinesiotaping (to reduce hematoma and edema) +

Elimination of the load to the joint + +

Isometric exercises + +

*Orthosis Jack PCL worn over the day from the second week.*

PRICE and kinesiotaping (to reduce edema) + Joint mobilization (>90°): passive, self-controlled exercises + **Stage 3: following the PCL reconstruction (***double-strand ST and G tendons, TightRope fixation with bioabsorbable screw, tibia-interference screw (bioabsorbable), additional fixation: bone bridge with Hi-Fi suture thread, repair of posteromedial fascicle of the PCL using the titanium anchor with double Hi-Fi suture thread)*


*Medi PTS orthosis for first 4 weeks (24 h), and next (from the moment when load was added) Jack PCL orthosis worn over the day and Medi PTS worn at night.*

*\*Performed in light flexion.*

*\*\*With counterpressure at proximal section of the calf (orthosis pad, therapist hands).*

#### **Table 3.**

*The third stage of rehabilitation.*

force). A clear surgeon's recommendation was used to this type of orthosis during all activities for half a year following the reconstruction.

The second stage of recovery of the knee joint stabilizing structure, i.e. ACL reconstruction combined with fibular collateral ligament reconstruction was performed 18 weeks following the anterior cruciate ligament reconstruction and it was the starting point for the last—fourth stage of rehabilitation. The rehabilitation

**39**

**Table 4.**

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament…*

proceedings differed significantly from the rehabilitation protocols after the reconstruction of the anterior cruciate ligament itself. Therapeutic elements, also with

Orthopedic surgeon's recommendation was to immobilize the joint for 6 weeks. The procedure for the first 2 weeks differed from the previous stage, in that the lower leg was not supported in the posterior part in lying supine, and the isometric contraction was accompanied by co-contraction of the hamstrings. After 2 weeks, minimal flexion movements were added (passively, with the help of the therapist, 0–20°), with

**Stage 4: following the reconstruction of ACL and PLC** *(ACL: middle third of the quadriceps femoris aponeurosis with bone block of the patella; fixation: thigh—7* **×** *20 mm titanium interference screw, tibia: 9* **×** *25 mm titanium interference screw, PLC (modified Larson's method) double-strand ST tendon from the contralateral limb; fixation: thigh—TightRope, peroneum—bone bridge around the peroneum with Hi-Fi* 

> **Day 1–3**

+

Passive exercises in the range of 0–20° — — + + +

Partial loading — — + + +

+ +

— — +

Proprioception learning — — + + + + +

Endurance exercises for the limb — — — — — + + *Medi PTS orthosis worn for first 2 weeks (24 h), without the pad pushing the lower leg forward, and next (from the moment when load was introduced) Jack PCL orthosis worn over the day (with minimal pushing force) and Medi* 

Full load — — — + + +

+ + + + +

— + + + + +

— — — + + +

— — — — + +

— — — — + + +

— — — — — + +

— — — — — + +

**1–2 3–4 5–6 7–12 13–15 16+**

*DOI: http://dx.doi.org/10.5772/intechopen.89649*

time reference, are shown in **Table 4**.

**Procedure Time after** 

PRICE and kinesiotaping (to reduce

Isometric exercises of the quadriceps femoris muscle and adductors of the hip

Stretching (to remove muscle tone) of the

Mobilization of the patella and iliotibial

Isometric exercises with co-contraction at full extension and slight flexion

**injury (weeks)**

Joint immobilization + +

*suture thread)*

edema)

hamstring muscles

band (prevention of PFPF)

Joint mobilization >20°: passive, self-controlled exercises (with active

Correct gait exercises, exercises for proprioception with load

0–60° with co-contraction

*The fourth stage of rehabilitation.*

Active exercises in CKC in the range of

Vigorous muscle strength exercises in

Muscle strength exercises in OKC in extension (without range 30–0) and

extension)

CKC, 0–90

flexion (20–90)

*PTS worn at night.*

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament… DOI: http://dx.doi.org/10.5772/intechopen.89649*

proceedings differed significantly from the rehabilitation protocols after the reconstruction of the anterior cruciate ligament itself. Therapeutic elements, also with time reference, are shown in **Table 4**.

Orthopedic surgeon's recommendation was to immobilize the joint for 6 weeks. The procedure for the first 2 weeks differed from the previous stage, in that the lower leg was not supported in the posterior part in lying supine, and the isometric contraction was accompanied by co-contraction of the hamstrings. After 2 weeks, minimal flexion movements were added (passively, with the help of the therapist, 0–20°), with

**Stage 4: following the reconstruction of ACL and PLC** *(ACL: middle third of the quadriceps femoris aponeurosis with bone block of the patella; fixation: thigh—7* **×** *20 mm titanium interference screw, tibia: 9* **×** *25 mm titanium interference screw, PLC (modified Larson's method) double-strand ST tendon from the contralateral limb; fixation: thigh—TightRope, peroneum—bone bridge around the peroneum with Hi-Fi suture thread)*


*Medi PTS orthosis worn for first 2 weeks (24 h), without the pad pushing the lower leg forward, and next (from the moment when load was introduced) Jack PCL orthosis worn over the day (with minimal pushing force) and Medi PTS worn at night.*

## **Table 4.**

*The fourth stage of rehabilitation.*

*Sports, Health and Exercise Medicine*

**Procedure Time** 

PRICE and kinesiotaping (to

Isometric exercises of the quadriceps femoris muscle and adductors of the hip\*,\*\*

Stretching exercises of the muscles of the hamstrings and

mobilization of the patella and iliotibial band (ITB), prevention of the patellofemoral pain syndrome (PFPS)

Passive exercises in the range

Passive exercises of extension in CKC in the range of 0–30°\*\*

Joint mobilization (>30°): passive, self-controlled exercises (with active extension)

Strengthening exercises (load + CKC 0–60°)

75–0) and flexion

*\*Performed in light flexion.*

*The third stage of rehabilitation.*

limb

**Table 3.**

Endurance exercises for the

Muscle strength exercises in the open kinematic chain (OKC) in extension (initially 30–0, next

*worn over the day and Medi PTS worn at night.*

**after injury (weeks)**

Joint immobilization + +

**Day 1–3**

+

Partial loading — — — + +

+ +

*suture thread)*

reduce edema)

the calf\*,\*\*

of 10–30°

**38**

force). A clear surgeon's recommendation was used to this type of orthosis during

*Medi PTS orthosis for first 4 weeks (24 h), and next (from the moment when load was added) Jack PCL orthosis* 

**Stage 3: following the PCL reconstruction (***double-strand ST and G tendons, TightRope fixation with bioabsorbable screw, tibia-interference screw (bioabsorbable), additional fixation: bone bridge with Hi-Fi suture thread, repair of posteromedial fascicle of the PCL using the titanium anchor with double Hi-Fi* 

+ + + + +

— — + + +

— — + + +

Proprioception learning — — — + + + + +

Full load — — — — — + +

— + + + + + +

— — — — — + +

— — — — — — + +

— — — — — — — +

— — — — — — — +

**1–2 3–4 5–6 7–8 9–10 11–15 16+**

The second stage of recovery of the knee joint stabilizing structure, i.e. ACL reconstruction combined with fibular collateral ligament reconstruction was performed 18 weeks following the anterior cruciate ligament reconstruction and it was the starting point for the last—fourth stage of rehabilitation. The rehabilitation

all activities for half a year following the reconstruction.

*\*\*With counterpressure at proximal section of the calf (orthosis pad, therapist hands).*

the isometric contractions with co-contraction of the hamstring muscles performed in full extension and in flexion of ca. 15°. Light flexion also allowed for proprioception exercises without load. Early introduction of the components of proprioceptive training (preferably already in the acute phase) accelerates regaining muscular control, which, with the knee extension, minimizes the risk of patellofemoral pain syndrome, and allows for maintaining the proper gait pattern [15]. Joint mobilization was started in the week 6. The large part of time was devoted to the improved proprioception: initially more in the sitting position and lying supine using balls and next in standing on the unstable ground (sensorimotor pads, mattresses with various softness, or platform for balance exercises) with both feet and then standing on one leg. Gait exercises were started after reaching the range of motion of 70° (ca. 2 weeks after mobilization started). Similar to the procedure following the PCL reconstruction, the focus was on gait symmetry and balance elements were added. Exercises of muscle force in closed kinematic chains were performed in the range of 0–60° excluding co-contraction of the hamstring muscles (half-squats with body forward inclination). In the 12th week, range of motion was 120°. After 12th week, new ligaments showed greater mechanical resistance [16], which allowed for introduction of muscle strength exercises with greater intensity: squats with load, mini-squats on one leg, and exercises with a stair stepper. Range of motion for the exercises in closed kinematic chain was 0–90°. In the open kinematic chain, the flexion movements were initially performed at 20–60°, whereas extension was 90–70° (the range was increased to 90–30° after ca. 4 months). No extension exercises were used in the range of motion of 30–0°, which leads to excessive tension of the graft [17]. Endurance training was also introduced (stair stepper, cycle ergometer) and components of proprioception training were extended by the components of various sports.
