KNEE Rehab. Ex Speaker : JDI Sports Clinic Cho, Jong-Hyun The Knee Joint 4 bones : Femur Patella Tibia, Fibula 3 joints: Patellofemoral Tibiofemoral Tibiofibular joint Knee Joint Movement Flexion Extension small amount of rotation at partial flexed condition KNEE JOINT Hinge joint Unstable joint ligaments Extensor Flexor Rotator meniscus Quadriceps G.max GCM Soleus ITB etc Hamstring Gracilis Sartorius GCM Plantaris Popliteus Sartorius Gracilis Semitendinosus Semimembran osus Biceps femoris Support tendon muscle 조종현, 1999 Knee joint support body mass control direction during physical activities National Athletic Trainers' Association, 1996 Daniel et al., 1985 Knee injuries 14% to 16% of all musculoskeletal injuries ranked knee injury frequency second to ankle injuries. National Athletic Trainers' Association, 1996 1
Types of knee injuries Meniscus, LCL, ACL, PCL, MCL, chondromalacia, patella dislocation, patella fracture The Most Common Sites of Athletic Injuries in Adults Men Women Injury Site % Injury Site % Timm, 1988 Knee 27 Knee 29 Ankle 10 Ankle 10 Lower Back 9 Lower Back 9 Lower Leg 7 Lower Leg 6 Achilles Tendon 7 Metatarsal Region 3 Upper extremity 4 Toes 3 Hip 3 Calf 3 Elbow 3 Achilles Tendon 3 Heel 3 Sole 2 Calf 3 Hip 2 Br J Sports Med 1997 ; 21:37-39 KNEE PROBLEMS Type of injury Tendons 이경수 ( 배구 ) Ligaments Meniscus Chronic KNEE Bone Acute Cartilage ACL PCL ACL Incidence(USA): 1/3000, 95,000 new ACL injury/yr 50,000 knee reconstruction/yr 2,000 article published/20yrs 210 article in KOREA since 1962 30 25 20 MCL LCL Meniscus Patellar Cartilage 15 10 5 0 1962-1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 1990 2
Mechanism of Injury ACL : Injury Mechanism External rotation and valgus Internal rotation and hyperextension PCL : Injury Mechanism Meniscus :Injury Mechanism 슬굴곡위에서회전운동이가해질때발생 내측손상이약 2-7배높다 : 내측반월상연골은외측보다크고유동성이적어쉽게손상 MCL/LCL :Injury Mechanism 슬관절손상의재활목표 내측측부인대 관절외측으로부터의외력또는관절의외회전, 외전등에의한외반력 (valgus stress) 구조복원 (structural recovery) Surgery 기능회복 (functional recovery) Rehabilitation Exercise 유상철, 김도근 ( 축구 ) 외측측부인대 내전, 내회전등의내반력 (varus stress) 무릎내측의태클에의한손상이많다 치료의궁극적인목표는 구조의복원 을기본으로하여 신체기능 을회복하는것 3
INJURY EVALUATION X-Ray Fairbank sign X-ray MRI MRI PHYSICAL EXAMINTION ROM PHYSICAL EXAMINTION PHYSICAL EXAMINTION Pivot-shift McMurray anterior-drawer 4
PHYSICAL EXAMINTION PHYSICAL EXAMINTION posterior-drawer lachmans-test PHYSICAL EXAMINTION PHYSICAL EXAMINTION MCL-valgus-stress Patellar apprehension PHYSICAL EXAMINTION PHYSICAL EXAMINTION quadriceps-active-test Pivot-shift 5
Need for Knee Surgery Surgery / Conservative Tx. Symptomatic Instability Recurrent Injury Meniscal Damage Cartilage Damage Osteoarthritis 박주영 ( 축구 ) 수술전검사 (PREOP TEST) Preoperative rehabilitation 1. decreasing joint effusion 2. restoring full ROM 3. strengthening 4. restoring a normal gait pattern Preoperative strengthening Timing of Knee OP 1) regaining full ROM 2) resolve swelling 3) review postop rehab. program 4) mental preparation for surgery 리온트리밍햄 ( 농구 ) 6
SURGERY 상해유형별수술기법에이해 동반손상된부위의처치결과 수술기법을고려한재활프로그램수립 Meniscus : Meniscal repair Meniscectomy Return to sports activity Meniscectomy About 2 6 weeks Meniscal repair About 3 4 months ACLR : BPTB ACLR : Hamstring ACLR : Quadriceps ACLR Choice of the Graft - Patellar tendon -Hamstring - Quadriceps tendon - Allograft 7
Lateral Meniscus : O shape Medial Meniscus : C shape Meniscus provides important function : shock absorption stability proprioception etc 김려섭, 2000 ; Frank, 2005 Total menisectomy Subtotal menisectomy menisectomy degenerative arthritis pain, swelling, OA change Partial menisectomy Meniscal repair Meniscal repair Re injury additional operative treatment 8
Allogenic meniscal transplantation Meniscectomy Meniscal repair Meniscal transplantation After Knee surgery muscle atrophy of thigh hamstring < quadriceps (especially vastus medialis) To return to ADL Regaining of postural stability Muscle strength Flexibility Proprioception Brindle et al., 2001 Proprioceptive deficits Meniscus injury Traditional Rehab. Program Repetitive injury Instability Proprioceptive deficits Functional instability Decreased neuromuscular control TRAINING : Weight shift, BAPS board, mini-trampoline, rocker board Accelerated Rehab. Program (especially proprioception) 9
Knee treatment SURGERY REHABITATION THERAPEUTIC EXERCISE structural recovery Surgery functional recovery Rehabilitation Exercise 현주엽 ( 농구 ) 김주성, 옥범준 ( 농구 ) Rehabilitation Protocols - Shelbourne and Nitz - Accelerated rehabilitation program - patients who undergone ACL reconstruction with a PT autograft - Emphasis on restoration of full hyperextension equal to the contralateral knee, early weight bearing, and restoration of quadriceps control. 김도근 ( 축구 ) Postoperative Rehabilitation 40% quadriceps atrophy after 5wks of immobilization more atrophy with immobilization in joint flexion (Erikson & Huggmark) Accelerated & Aggressive Rehabilitation Early Full Extension Early Weight Bearing Closed Kinetic Chain Exercise (Shelbourne and Nitz) 김영만 ( 농구 ) Traditional Rehabilitation protocol Accelerated Rehabilitation Program. 6 weeks : partial weight- bearing with crutches 7-8 months : agility training began 9 months : return to all activities with a knee brace 10
Accelerated Rehabilitation protocol Range of motion(average) results for each group by time after reconstruction Time after reconstruction Group I (TG) (deg) Group II(AG) (deg) 1day : 2-3 weeks 5/75 0/104 weight- bearing without crutches 6-7 weeks 3/93 0/121 2 months : 2-3 months 2/121 0/130 return to light sports activities 6-7 months 0/132 0/135 4-6 months : 8-9 months 0/135 0/136 return to all activities 11-12 months 0/136 0/139 2 years 0/136 0/135 The American Journal of Sports Medicine 1990 Vol. 18, No.3 Differences in KT-1000 measurement of injured knee compared to non-injured knee at 20 pounds 100 90 80 70 60 % 50 40 30 20 10 0-6.0 and below -5.9-3.1-3.0- -1.1-1.1-3.0 3.1-5.9 Group I(TG) Group II(AG) Instability( 20 pounds) 6.0 and above The American Journal of Sports Medicine 1990 Vol. 18, No.3 Isokinetic quadriceps percentages at 180/sec 100 90 80 70 % 60 50 40 30 20 10 0 2-3 months 4-6 months 7-10 months 1 year 1+ year 손현 ( 배구 ) Group I(TG) Group II(AG) Time after reconstruction The American Journal of Sports Medicine 1990 Vol. 18, No.3 1st 2weeks after surgery 1) obtain full hyperextension 2) allow wound healing 3) maintain active quadriceps leg control 4) decrease swelling 5) achieve more than 100 o of knee flexion POD 3wks to 5wks 1) resume a normal gait pattern 2) obtain full flexion 3) increase knee bends, step-ups, calf raises, leg press, stair master, bicycle 4) begin sport-specific activities 유상철 ( 축구 ) 11
end of 5th wks~ knee is fully rehab. 1) If strength is adequate, start lat shuffles, carioca, jumping rope, light running program 2) continue sport-specific activities and return Meniscal repair with ACL recon. : same rehab. 1) but wt-bearing is partial for 6 wks 2) wall sits with the knee at 90 o of flexion are not begun until the 7th wks to competition as rehab. progress allows ACL recon. Meniscal repair 김남일 ( 축구 ) 박주영 ( 축구 ) Joint Effusion Criteria for return to sports 1. full ROM 2. no joint effusion 3. isokinetic test quadriceps strength : 80-90% 4. isokinetic test hamstring strength: 85-90% 5. one-leg hop test : 85% compared uninvolved leg 6. minimum 9 Mon. after surgery (4-6Mo) 12% with ACL recon. significant Q-atrophy ice, compression limb elevation active Q-setting exercise ankle pump cryo cuff aspiration 손현 ( 배구 ) Rehab.Exercise Progression 상해 / 수술 (Injury & Surgery) 상해정도파악 / 수술여부등의처치방법결정 CONTROL INFLAMMATION/PAIN/SWELLING 염증 / 통증 / 부종조절 (Control Inflammation/ Pain/Swelling) 물리치료 (PT) / 약물치료 / 보조기 (Brace) 등 관절가동범위운동 (ROM Exercise) 근력운동 (Strengthening) 기능적운동 (Functional Exercise) 수동적 (Passive) / 능동보조 (Active assist) / 능동적 (Active) / Stretching / PNF 등척성 (Isometric) / 등장성 (Isotonic) / 등속성 (Isokinetic) 동심성 (Concentric) / 편심성 (eccentric) 열린사슬운동 (OKC) / 닫힌사슬운동 (CKC) / 고유체위감각운동 (Proprioceptive Training) 플라이오메트릭운동 (Plyometric Exercise) 스포츠특화훈련 (Specific Sports Drills) 김세진 ( 배구 ) 스포츠활동복귀 (Return to Sports) 객관적인복귀기준 심폐지구력 (CV), 몸통 (Core Body), 타부위 (Other) 운동 12
CONTROL INFLAMMATION/PAIN/SWELLING PRICE Medication Injection Physical therapy HEAT THERAPY CRYOTHERAPY ELECTRICAL THERAPY MECHANICAL THERAPY LIGHT THERAPY 김주성, 현주엽 ( 농구 ) Type of Therapeutic Exercise Type of Exercise Therapeutic Exercise Active Dynamic Passive Static Isometic RANGE OF MOTION EXERCISE ROM Active Stretching Resistive (Open & Closed chain) Cardiovascular ROM Stretching Mobilization Manipulation Isotonic Variable resistance Isokinetic Manual resistance Concentric & Eccentric contractions Functional Plyometric Proprioception Specific Sports Drills R.O.M. gain ROM exercise 0 o - 90 o : 2 wk 0 o -120 o : 6 wk full ROM : 3 Mo 김희진 ( 수중발레 ) full knee extension (equal to uninvolved knee) within 2 to 3wks after surgery full flexion within 8wks ( Fu et al, 1992) Patella Mobilization Passive : CPM 13
ROM exercise ROM exercise Active Assist Wall Slide Prone Hangs 김경희 ( 농구 ) Active FLEXIBILITY STRENGTHENING Isometric contraction Isotonic contraction Isokinetic contraction 황진원 ( 농구 ) Concentric contraction Eccentric contraction Open Kinetic Chain Exercise Closed Kinetic Chain Exercise Isometric Type of exercise Advantage - equal length of the muscle - early in the rehabilitation program - increases static muscular strength - no specific equipment is needed - no joint movement Disadvantage - high joint compressive forces during maximal contractions - no increase in endurance Isometric Isotonic 하승진 ( 농구 ) Isokinetic - strength increases specific to exercised joint position - absence of feedback from objective increases in strength - difficult to provide patient motivation 14
Isometric contraction applied by rule of tens Isometric - multiple joint angle isometrics - rules of tens : 10 sec contraction, 10 sec rest, 10 angles 6 Seconds Hold progressed to maximal contraction as tolerated Hip Adduction Hip Abduction 2 Seconds build-up started with submaximal contraction 2 Seconds release Starting Force Ending Force Hip Extension Isotonics Advantage - More functional performed over a full ROM, monitored by measuring the amount of weight lifted Disadvantage - Potentially dangerous require adequate supervision unable to provide truly constant resistance through the lift. - Concentric : The muscle shortens and works against gravity. An isotonic contraction where the muscle shortens and works against gravity. - Eccentric : The muscle lengthens as it returns to its original position. An isotonic contraction where the muscle lengthens & returns to its original position. 신병호 ( 축구 ) 신병호 ( 축구 ) OPEN KINETIC CHAIN the distal part - no weight bearing the distal part - not fiexed focus on isolated training of individual muscles used in strength and endurance training CLOSED KINETIC CHAIN the distal part - weight bearing the distal part - fixed focus on functional training increased dynamic stabilizaton used in stability, strength, endurance and sensory motor training Closed Kinetic Chain (CKC) Exercise Effects 1. co-contraction and increase stability through increased joint compression loads 2. minimize the ant translation on the tibia 3. reduce strain on the ACL 4. significant decrease patellofemoral joint force 5. re-educate proprioception 6. enhance neuromuscular coordination and proprioception 15
Example of CKC progression of the minisquat Open Kinetic Chain (OKC) Exercise Weight shifts with support Weight shifts without support Bilateral minisquats with support Bilateral minisquats without support Bilateral minisquats against wall Bilateral minisquats against wall with weights in hands One-legged minisquats with support One-legged minisquats without support One-legged minisquats against wall One-legged minisquats against wall with weights in hands Bilateral minisquats with tubing One-legged minisquats with tubing Gradually increase tubing strength and speed of movement Effects 1. OKC quadriceps exercise through a full ROM damage the graft (from 30 o to full extension - excessive strain on ACL graft) 2. Restricted ROM OKC quadriceps exercise : isolated Q strengthening Isokinetic Exercise QUADRICEPS & PATELLA Advantage - training a specific speeds at fast or slow speeds - quantifying existing levels of muscular strength - full range of speed for testing and exercise - very powerful tool for the evaluate & rehabilitation of sport related injuries Disadvantage - exercise occurs primarily from non-wt bearing OKC position - soccer kick-hip jt 400 deg/sec, knee jt 1,200deg/sec - baseball pitchers-6,500 & 7,200 deg/sec - lack of specialist for use and interpretation - expensive cost of equipement - limited to isolated muscle groups Stage of resistive exercise progression continuum C.V Exercise I II III Multiple Angle Isometric Sub - Maximal Multiple Angle Isometric Maximal Short Arc Isokinetics Sub - Maximal IV V VI Short Arc Isotonic Short Arc Isokinetics Maximal Full ROM Isokinetics Sub - Maximal 송인석 ( 배구 ) UBE 성한수, 신병호 ( 축구 ) VII Full ROM Isotonic VIII Full ROM Isokinetic Maximal Bicycle Stairmaster 16
C.V Exercise Core Body Exercise Rotary Torso Treadmill Back Extension Abdominal Core Body Exercise Other Exercise 김주성, 옥범준 ( 농구 ), 이경수 ( 배구 ) 신혜인, 하승진, 양희승 ( 농구 ), 후인정 ( 배구 ) OVER-DOSAGE OF EXERCISE Functional Exercise 1. POST-EX. PAIN ---2-3 Hrs 2. UNDUE FATIGUE 3. INCREASED WEAKNESS 4. INCREASED SWELLING 5. DECREASED ROM Plyometric Proprioception Specific Sports Drills 17
PROPRIOCEPTIVE TRAINING Proprioceptive training 고유수용감각 (Proprioception) : 피부, 근육, 관절, 건으로부터수용된자극을중추신경으로전달하는감각신경 신체의위치감각을전달하고정보를해석하는기능 민첩성, 평형성, 협응성등을종합적으로조절 고유수용감각의종류 피부수용기 (Cutaneous receptors) 근육과건수용기 (Muscle and tendon receptors) 관절수용기 (Joint receptors) 기타수용기 (Other receptors) 현주엽 ( 농구 ) Proprioceptive training Plyometric exercise 왓슨 ( 농구 ), 김경일 ( 축구 ), 임도헌, 송인석, 정승용 ( 배구 ) Plyometric exercise 민첩성 (Agility) Pyramiding Box Jump 18
Field Training Specific Sports Drills - Specific Sports Drills - Warming - Up Specific Sports Drills Sample Protocol 1. Begin with a 5-min warm-up of light aerobics and active range of motion exercises. 2. Follow warm-up with stretching program. 3. Perform vigorous aerobics and strengthening exercises after stretching. 4. Initially aerobic exercise should be low impact. Begin with 5-10-min duration and increase weekly. Attempt to reach 60-80% of target heart rate (220 - age) during exercise. 5. Strength training should include balanced upper-and lower-body concentric and eccentric, open- and closed-chain exercises. 6. Complete exercise with a 15-min cooldown of active range of motion and light aerobic exercises. Average amount of time 1) running - 4.3 months (6wk-12mo) 2) jumping - 6.5mo (3-12mo) 3) light sports - 5mo (3-9mo) 4) mod sports - 5.8mo (4-9mo) 5) strenuous sports - 8.1mo (4-18mo) (Reference : Knee Surgery, Sports Traumatology, Arthroscopy, 2001 August) Speed Power Agility Balance Coordination Flexibility Body composition Muscular strength Muscular endurance Cardiorespiratory endurance Complete Rehab. Traditional Rehab. 19
Biology of healing of the graft Biologic remodeling process is complete in human patient range from 9 months to 3 years or more Criteria for return to sports Shelbourne & Nitz Paulos & Stern 1. 60,180,240 deg/sec 에서 Quadriceps Ioskinetic 검사시건측의 80% 이상 2. 슬관절부종이없을것 3. 달리기에어려움이없을것 4. Arthrometer 검사에서정상 5. 수술후재활운동을정상적으로실시 6. 슬관절가동범위 (ROM) 가정상 1. 2. 3. 4. 5. 6. 7. 수술후최소한 9개월이후슬관절부종이없을것달리기에어려움이없을것 Quadriceps가건측의 85% 이상 Hamstrings이건측의85% 이상 Single hop 검사가건측의 85% 이상슬관절가동범위 (ROM) 가정상 Criteria for return to sports JDI Sports Clinic 1. No Inflammation/ Pain/Swelling 2. Normal ROM(Full ROM) 3. Isokinetic test indicates muscle strength : 85-90% compared uninvolved site 4. Functional test indicates 80% or greater compared uninvolved site or pre-injury level - proprioception / plyometric / sports-specific agility 5. Successful completion of running program 6. Satisfactory clinical exam Criteria for return to sports 명확한기준을제시하기는어려움. 환자상태, 스포츠의특성등을고려하여결정. Q& A 20