Rehabilitation Guideline after meniscus repair surgery

Meniscus injuries within the knee are a common occurrence.  In spite of this high event, numerous irregularities keep on existing in the restoration of a patient after meniscus repair surgery, especially including the rate of weight bearing and range of movement.

Rehabilitation Follow Meniscus Repair

Restoration after surgical debridement of the meniscus is entirely clear. We restore the patient’s range  of movement, quality and function,  their manifestations and let pain and swelling guide the recovery procedure (an exceptionally broad guide yet one frequently utilized by numerous rehabilitation specialists).

In any case, when the meniscus is really repaired and not only debrided, there are different variables to consider. At the point when a meniscus is repaired, the tear is approximated utilizing stitches to enable the tear to heal.

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

So if we’re going to talk some  protocols, take a look at these studies from way back when from Shelbourne et al  and Barber et al   that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave et al  and Lind et al on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

Again, these studies show meniscal repair outcomes are no different while using restricted weight bearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

 Weightbearing After Meniscus Repair : 

Things being what they are, if immobilized in extension, for what reason do we restrict weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are believed to help the healing procedure in many tears by approximating the tissue.

Besides, the compressive loads connected while weightbearing in full expansion following a vertical, longitudinal repair or container handle repair have been appeared to lessen the meniscus and settle the tear, as noted by Rodeo et al.  and all the more as of late by McCulloch et al.

There are studies said “A repaired longitudinal medial meniscal tear undergo compression, not gapping, during simulated gait ”

What about early range of motion? 

 

 

 

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Gluteal Amnesia and selecting the most effective interventions

Most people spend a huge proportion of their time in a position of hip flexion (sitting down). An inactive lifestyle is a Janda approachsure-fire way to create glute dysfunction. Extended periods of time in this posture over the long term will lead to negative adaptations in the hip flexor muscles.

Shortened hip flexors don’t allow for full hip extension, which is where your glutes are able to contract with the most force. Additionally, being an antagonistic pair, short and tight hip flexors will actually inhibit your glutes. The actual physical compression associated with sitting on your gluteus maximus will also impair blood flow and neuromuscular function.

Gluteal amnesia is a condition where your body can’t or forgets how to properly activate the gluteal muscles, whether it’s due to postural flaws or lack of use. As a result, you may lose the ability to move your hips through a full range of motion which adds stress to your knee, lower back, and even your shoulder joints! Common injuries associated with gluteal amnesia are patellofemoral pain syndrome, Iliotibial Band Syndrome, Disc Herniation, and Piriformis Syndrome. Fortunately, you can reverse this condition with the right corrective exercises.

A postural flaw that can lead to gluteal amnesia is known as anterior pelvic tilt. This occurs when the pelvis tilts forward and the stomach protrudes. The forward tilt of the pelvis stretches your gluteals into a relaxed state which decreases your ability to properly activate them. Other causes of gluteal amnesia are as follows:

• Too many quadriceps dominant exercises.
• Poor sitting or static posture.
• Improper abdominal training.
• Soft tissue contractures (i.e., tight hip flexors and low back extensors).
• Articular (joint) fixations.
• Not landing properly from jumps (i.e., landing from a rebound in basketball).
• Knee or back pain sufferer.

The gluteus maximus and lower back stability
Activating and strengthening the glutes needs to form an important part of your core routine.

Co-contraction of the gluteus maximus with the psoas major contributes to lumbo-sacral stabilisation The gluteus maximus provides stability to the sacroiliac joint (SI joint) by bracing and compression. Excess movement at the SI joint would compromise the L5-S1 intervertebral joints and disc and could lead to SI joint dysfunction and low back pain.

kinetic chain, gluteus maximmus, eric dalton

Coutrsey : Ericdalton

The gluteus maximus also provides lower back stability through its connection with the erector spinae and thoraco-lumbar fascia. Some of its fibres are continuous with the fibres of the erector spinae. A contraction of the gluteus maximus will generate tension in the erector spinae muscle on the same side, providing stiffness to the spinal column.

Gluteus maximus contraction also exerts a pull on the lower end of the thoraco-lumbar fascia, which is a thick layer of ligamentous connective tissue. Tightening of this fascia stabilises the vertebras. People with low back pain often have weak and deconditioned glutes.

Here are some simple but superbly effective exercises to tone up glutes muscles.

Gluteal Squeeze :

Purpose: Strengthen the hips (especially for the gluteus maximus).
Start in a standing position with your feet shoulder-width apart.
Squeeze the gluteal muscles for two seconds, then relax for two seconds. Count the two seconds out loud to avoid holding your breath.
Sets/Reps: 1-2 x 10, with 5-10-second holds and 5-10 seconds rest.

Bird Dog :Core stability, proactive physio

Purpose: Strengthen the hips (especially for the gluteus maximus).

Start on your hands and knees. Slowly raise your right arm and left leg so they are level to the floor. Turn your left foot slightly outward so you feel your gluteus maximus tightening. Hold this position for 10 seconds. Repeat with the opposite arm and leg.
Suggested Sets/Reps: 1-2 x 10 of 10-second holds.

Double-Leg Squat Series :

 

Purpose: Strengthen the hips and legs.

Stand with your feet shoulder-width apart. Looking straight ahead, slowly squat down until your thighs are parallel to the floor while simultaneously raising both arms out in front of you like you are guarding an opponent in basketball or skiing down a hill.
Try to keep your knees behind your toes, maintain a normal arch in your lower back and keep your core tight. Once you master perfect technique using your body weight with this simple exercise (feet side by side)

Single-Leg Squats :

Purpose: Strengthen the hips and legs.

Stand facing a step and hold on to a rail. Slowly step up and down on one side. Repeat with the opposite leg. Alternate version: perform the Step-Ups from the side, and progress by varying the step height from 4 or 6 inches to 8 inches.
Suggested Sets/Reps: 1-2 x 10-15

Side-Step Walking :

Purpose: Strengthen the hips and legs.

Start in a squatting position with your feet slightly wider than hip-width as if you were guarding an opponent in basketball.
Take five to 10 steps to the right. Your step lengths should be approximately 50 percent of the starting position distance between your feet.
Keep your knees aligned with the second toe. Repeat five to 10 steps to the left.
Once you master perfect technique using your own body weight.

Side-Lying Straight-Leg Abduction :

Hip abduction, core and posture st

Courtsey:Dr. Alex Jimenez D.C.,C.C.S.T

Purpose: Strengthen the hips and core.

Start by lying on your right side with your top leg straight and bottom leg bent. Place your top hand on the floor or mat in front of you for good support. Slowly raise your top leg up to approximately 40 degrees for the designated sets/reps.
Keep your hips level and don’t over-arch your back.
Repeat on the other side.
To increase the difficulty, place an elastic band around your thighs (just above the knees) or an ankle weight just above your ankle.
Sets/Reps: 2-3x 0-15

Side-Lying Bent-Leg Abductions: gluteus strengthning, gluteus activation

Purpose: Strengthen the hips and core

Start by lying on your right side with both knees bent 90 degrees and hips bent 45 degrees. Place your right arm under your head and your left arm on the floor in front of you for stability. Slowly raise your top leg up to 30 degrees of abduction, then lower slowly for the designated sets/reps. To increase the difficulty, hold the 30-degree hip-abducted position for five to 30 seconds as a single repetition.
Sets/Reps: 2-3×10-15

Supine Bridge:proactive physiotherapy

Purpose: Strengthen the hips and core

Start by lying on your back with your knees bent 90 degrees and feet hip-width apart. Place a small, soft ball between your knees and squeeze with no more than 50 percent effort.
Lift your hips off the floor approximately 4 inches, then slowly lower them while relaxing the squeeze between your knees.
To increase the difficulty, hold for five to 10 seconds as a single set.
Sets/Reps: 2-3×10-15

 

Referances :

  1. Distefano LJ, Blackburn JT, Marshall SW, Padua DA, Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. Jul;39(7):532-40, 2009.
  2. Vleeming A, Van Wingerden JP, Snijders CJ, Stoeckart R and Stijnen T (1989): Load application to the sacrotuberous ligament; influences on sacroiliac joint mechanics. Clinical Biomechanics, 4(4), 204-209.
  3. Snijders CJ, Vleeming A and Stoeckart R (1993): Transfer of lumbosacral load to iliac bones and legs. Clinical Biomechanics 8, 285-294.
  4. Sean GT Gibbons and Mark J Comerford (2001) Strength versus stability: Part 1: Concept and terms. Orthopaedic Division Review. March / April: 21-27
  5. Gibbons SGT 2005 Integrating the psoas major and deep sacral guteus maximus muscles into the lumbar cylinder model. Proceedings of: “The Spine”: World Congress on Manual Therapy. October 7th – 9th, 2005, Rome, Italy.
  6.  Kankaanpää M, Taimela S, Laaksonen D, Hanninen O and Airaksinen O (1998): Back and hip extensor fatigability in chronic low back pain patients and controls. Archives of 100 NZ Journal of Physiotherapy – November 2005. Vol. 33, 3 Physical Medical Rehabilitation 79, 412-417.

 

Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lumbar pain during flexion movement  is one of the commonest symptoms that we all face in our routine practice. There are a number of clinical reasoning processes, which need to be considered.

Much of the literature focuses on the changes in intra-discal pressure associated with spinal flexion. Which indicate that spinal flexion pain is associated with increased disc strain.  In order to strengthen the hypothesis of disc related flexion pain the clinician needs to establish other components of discogenic characteristics to support the hypothesis.

Here are some few things to remember when patient come with lower back pain.

  1. Observe everything, from entering into our examination room, starting with the client rising from a chair.
  2. History – link injury mechanisms, pain mechanisms with specific activities and past exercise regimens. Is there any “red flags” appear or not .
  3. Perform provocative tests – what loads, postures and motions exacerbate, what are relieving factors and what are aggravating factors? This needs to be address.
  4. Perform functional screens and tests – Are there perturbed postural, motion and motor patterns?
  5. If the clinical picture is complex and beyond your comfort zone, develop a referral relationship with a competent corrective exercise specialist.

It is not a matter of client performing an exercise – it is a matter of the client performing the exercise with perfection.

Observation Point:

  • Look for a dysfunctional movement pattern
  • Not able to hip hinge properly.
  • Allow the lower lumbar spine to flex forward.
  • Look for the patient get up from their seat
  • Do they difficulty to maintain neutral spine or bend forward into flexion as they arise?
  • Do they have pain while getting up from chair?
  • In the treatment room, watch them take off their shoes.
  • Ask patient to pick object from floor and observe behavior pattern of movement.
  • Look for fear or uncertainty at the prospect of bending forward.

Physical examination :

This is the main part one should find out what exact pathology it is.

  • Positive straight leg raise. Often you’ll see more subtle findings than in classic sciatica. They may experience more tightness in the back of the leg on one side or the other. They may experience buttock pain. I prefer the sitting straight leg raise. If needed, add foot dorsiflexion, have the patient bend forward, and/or add a Valsalva maneuver.
  • One of Comerford’s tests for flexion control is called the waiter’s bow. Briefly teach the patient to bend forward while maintaining the spine in neutral. Stand to the side and watch them do this. Do they do it well or do they lose neutral? For tactile feedback, place your index finger horizontally on the sacrum, and the other hand’s index finger just above, across the L5 spinous process. Now have the patient bend forward using the waiter’s bow. Do your fingers separate? Recheck between L5 and L4. If your fingers are separating, the patient’s lumbar spine in moving into flexion. It means that even when they are trying to, they cannot control flexion. See pictures below.

  • Palpate the interspace for tenderness. Place the patient prone with a pillow under their abdomen, so the lumbar spine is in slight flexion. Apply deep digital pressure to the interspinous spaces and the inferior spinous process, pushing simultaneously posterior to anterior and inferior to superior. I start with L5-S1 and work upward to at least L3-4. Is the interspace tender? Ask them to rate the tenderness on a 1-3 scale: 1-mild, 2-moderate or 3-severe. (I used to think this was the ideal test, but it is not always positive, even in those I know have flexion intolerance. Maybe it represents increased inflammation in those with flexion intolerance.)
  • Repeated end-range loading of extension This can be done prone or standing. Does this relieve or centralize their pain?
  • If they are not in acute pain, you can do repeated end-range loading of flexion, either from standing or in a long sit posture. Ask them to slump forward. Does this aggravate their pain; does this elicit increased buttock or leg pain, or sensory changes?
  • Palpate the lower lumbar paraspinal muscles. In disc-related pain, a discrete area will often feel atrophied, often unilaterally. There is often a divot, a hole, a small area of atrophy, at the level of the disc injury. As chiropractors, we are much more used to getting information on the restricted side, rather than the side that is moving too much.

 Unlock the mystery of pain

  • Treatment of flexion-intolerant pain is primarily self-care. Yes, your soft-tissue work and mobilizations can help, but self-care is primary and essential. There is no magic you can do that will override what the patient is doing 24/7. You have to teach them to move differently to solve flexion-intolerant pain. According toStuart McGill, “The first step in any exercise progression is to remove the cause of the pain, namely the perturbed motion and motor patterns.”9
  • There are two components of self-care. First, have them quit doing stupid stuff that is reinjuring them over and over. Totally stop the sit-ups and crunches. They cannot do yoga-style prolonged flexion. Pilates is not much effective as it often uses too much uncontrolled flexion. Don’t assume the patient knows this; they likely don’t. If they are sitting too much and for too long, help them figure out how to change that habit via frequent breaks and/or by utilizing a standing workstation.
  • Second, train them to move differently.
  • Yes, they need to strengthen their inhibited core muscles, but they need start with these simple movements, done precisely.

References

  1. Yin-gang Zhang, Tuan-mao Guo, Xiong Guo, Shi-xun Wu. Clinical diagnosis for discogenic low back pain.Int J Biol Sci, 2009;5(7):647-658.
  2. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain.Spine, 1996;21(23):2763-2769.
  3. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.Spine, 1993;19(2):165-172.
  4. O’Sullivan P, Twomey L, Allison G, et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain.Aust J Physio, 1997;43:91-98.
  5. MacDonald D, Moseley GL, Hodges PW. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms.Spine, 2010 Apr 1;35(7):818-24.
  6. Gibbons SGT, Comerford MJ. Strength versus stability. Part 1: Concept and terms.Orthopaedic Division Review. March / April: 2001:21-27.
  7. Liebenson C. “Flexion Intolerant Back” (10-minute video). Toronto, Ontario, 2011; filmed and edited by Phillip Snell.
  8. McGill S. “Designing Back Exercise: From Rehabilitation to Enhancing Performance.” (Guide to training the flexion-intolerant back.)

 

Courtsey : http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56837