5/8/2017

1

Case Study: Intercollegiate Football Running Back with

Traumatic Knee Dislocation and Multiple Ligament Injury

Ron Courson, ATC, PT, NRAEMT, CSCS

Senior Associate Athletic Director – Sports Medicine

University of Georgia Athletic Association

Athens, GA

Objectives

• Review mechanism of injury and

on-field clinical findings with knee dislocation

• Discuss emergency care

considerations

• Review role of diagnostic testing

with knee dislocation

• Review surgical considerations with multiple-ligament injury

• Discuss coordination of pre- and

post-op rehabilitation and use of

novel techniques within rehabilitation

Traumatic Knee Dislocations

• Traumatic knee dislocations

leading to multiple ligament injury are relatively uncommon

but not rare injuries

• These injuries demand prompt

and appropriate attention

• Knee dislocations represent one of the few true orthopedic

emergencies due to potential

limb-threatening nature

• Post-operative management must be carefully coordinated

with early ROM to restore

functional motion without compromising knee stability

Mechanism of Injury

Initial Exam

• NV check (serial exams)

• Stabilize extremity

• Thorough exam

• Appropriate supporting studies

Work up• Xrays

• MRI

• CT scan

5/8/2017

2

Selective Arteriography (CTA)

Serial Physical Exam (6, 24, 48hrs)

Equal pulses

• ABI <0.9

• Expanding hematoma

• Hx dysvascular foot

• 90% positive predictive value

• 100% negative predictive value

– Stannard 2004

Surgical Plan

• Multiple surgeons

• Multiple injuries

• Multiple scenarios

• Multiple options

Plan

• Scope, I & D

• Open Lateral repair +/-reconstrxn

• Scope repair PCL, MMT’s

Case Study• Post-Operative Diagnosis:

– PCL tear

– Posterior lateral corner tear

– LCL tear

– Biceps femoris tear

– Medial mensicus tear both anterior and

posterior horns

• Procedure:

– Arthroscopically assisted PCL repair

– Medial meniscus repairs anterior and

posterior with debridement

– Open LCL, posterolateral corner and biceps femoris repairs with peronealnerve neurolysis and allograft figure-of-

eight posterolateral corner reconstruction

Lateral Approach 3 Working Windows

5/8/2017

3

Bony Preparation Fibular-Based PLC Recon

Arthroscopic

Portion

• Proximal PCL Repair

• Ant and Post horn MMR

Immediate Postop

• “Controlled Arthrofibrosis”

• Hinged knee brace locked in

full extension for 1st 2 wks

Rehab Program Considerations• Problem-solving approach

– physiologic healing constraints

– pain

– swelling

– ROM restrictions

– muscle atrophy

– decreased

balance/proprioception

– DVT/PE prophylaxis

– deconditioning/weight loss

Rehab Program Considerations

• Is rehabilitation program:

– evidence based ?

– communicated with all parties

?

– challenging/fun ?

• Does rehabilitation:

– avoid redundancy ?

– vary rehab activities ?

– utilize all available resources ?

• Is progression based upon:

– physiologic healing

constraints ?

– achieving rehab goals ?

– MD direction ?

5/8/2017

4

Acute Rehab Phase

• NWB x 6 weeks

• Dynamic PCL brace

• locked in full extension x 2 weeks

• Pain/Swelling control

• DVT/PE prophylaxis:

• Xarelto

• VenoPro

• ROM:

• started prone PROM at 2 weeks

• started CPM with posterior strap

on proximal tibia to prevent sag

• opened brace at 2 weeks with 0-90 degree motion restrictions

Acute Rehab Phase• PRE:

• quad sets/SLR isometrics

• active assisted with ESC

• biofeedback

• no isolated active hamstring PRE x 4 months

Intermediate Rehab Phase

• 6 weeks post-op

– deep-water running in pool

– KAATSU blood flow restriction therapy

• 7 weeks post-op

– Flexinator (knee ROM)

• 8 weeks post-op

– full weight-bearing

Intermediate Rehab Phase

• 8 weeks post-op:

– CKC exercise progression

• squat variations

• step-up variations

• leg press (single and

double)

• lunges

– Gait training

• hurdle stepping

– forward, back, side

– Basic balance/proprioception

Intermediate Rehab Phase

• 10 weeks postop:

– Eccentron eccentric quadriceps training with emphasis on both strength development and force control

Intermediate Rehab Phase

• 12 weeks post-op:

– OKC knee extensions

– running on underwater treadmill

5/8/2017

5

Intermediate Rehab Phase

14 weeks post-op:

• began walking stadium steps

• gradual progression in time and number

• body weight initially with progression over time to 20 lb. weight vest

Advanced Rehab Phase15 weeks post-op: advanced

balance/proprioception activities

Advanced Rehab Phase

� 16 weeks post-op:

� straight ahead running on land

� 18 weeks post-op:

� began jumping

� 20 weeks post-op:

� began change of direction drills

� L drill

� 5-10-5 drill

� Hoop drill

� LEFT test (Davies)

� Reaction drills

Functional Progression• Form running drills:

– Dynamic flexibility

– High knees

– Kick backs

– Skipping

– A, B, C skips

– Backpeddle

– Lateral slide

– Carrioca

– Ladder drills

• flat

• Raised

– Sled push/pull

Functional Progression

• Progression to non-contact football drills:

– QB/RB ball exchange

– pitches

– passes out of backfield

– simulated plays

Return to ActivityTae Kwon Do: 22 weeks post-op

� Performed under strict supervision 1 on 1

� Emphasis on kicking to promote terminal extension, quadriceps development, and confidence in planting on foot

� Ground based fighting to develop core and assist with knee flexion

5/8/2017

6

Return to ActivityTae Kwon Do:

– Performed under strict supervision 1 on 1

– Emphasis on kicking to promote terminal extension, quadriceps development, and confidence in planting on foot

– Ground based fighting to develop core and assist with knee flexion

Return to ActivityTae Kwon Do:

– Performed under strict supervision 1 on 1

– Emphasis on kicking to promote terminal extension, quadriceps development, and confidence in planting on foot

– Ground based fighting to develop core and assist with knee flexion

Return to ActivityTae Kwon Do:

– Performed under strict supervision 1 on 1

– Emphasis on kicking to promote terminal extension, quadriceps development, and confidence in planting on foot

– Ground based fighting to develop core and assist with knee flexion

Functional Progression

Sprint training:

– 24 weeks post-op

– Curved treadmill

– Keiser resistance runner

– Track practice under supervision of sprint coach

Functional Progression

• 26 weeks post-op:

– progressed to full S&C activities without restrictions

• 30 weeks post-op:

– summer football work-outs without restrictions

• 40 weeks post-op:

– pre-season FB camp without restrictions (29 practices)

Functional Progression• 40 weeks post-op: pre-season FB camp without

restrictions (29 practices)

• 42 weeks post-op: 1st scrimmage wearing brace limited snaps

• 43 weeks post-op: 2nd scrimmage lighter brace full snaps

5/8/2017

7

Return to Activity

• 45 weeks post-op:

– 1st game returning from injury vs. UNC

• 32 rushing attempts

• 222 yards

• 2 TDs

Return to Activity

• 2016 Season Statistics

– 224 rushes

– 1130 yards

– 8 TDs

– 5.0 avg. yds/rush

– long rush 55 yds.

– 5 receptions for 86 yds. and 1 TD

Follow-Up