Authors

Prof Leo Pinczewski MBBS, FRACS

Dr Keran Sundaraj MBBS, MSc (Trauma), FRACS, FAOA

Dr Lucy Salmon BAppSc(Phty), PhD

Emma Heath MPthy, BAppSc

Contents

Stage 1 (Week 1-2)

Stage 2 (Weeks 2-6)

Stage 3 (6 weeks – 3 months)

Stage 4 (>12 weeks)

Stage 1 (Week 1-2)

Aims

• To facilitate bony union of fracture site

• Minimise concurrent postoperative complications

• Minimise muscular atrophy and maintain bone density

Treatment Guidelines

• Brace to remain on at all times for 6 weeks postop

• Toe touch weight bearing (TTWB) on crutches – pain is guiding factor

• Instruction regarding use of crutches with TTWB

• Reduction of swelling and pain using ice, elevation and exercises

• Exercises instructed from day 1 postop: static quad contractions; isometric co-contractions of quads and hamstrings simultaneously in full extension, 10 and 20 degrees of flexion; straight leg raises (do not lift heel up off surface if unable to maintain full knee extension); ankle and hip ROM exercises

• NOTE: if lumbar pain is experienced, cease exercises and seek physiotherapy advice

Stage 2 (Weeks 2-6)

Aims

• Facilitation of bony union through pain free partial weight bearing (PWB) with crutches

• Minimise concurrent postoperative complications

• Minimise muscular atrophy and maintain bone density

• Achieve weight bearing with 50% body weight through affected limb by week 6 postop

Treatment Guidelines

• Continue exercises as above

• Commence PWB on crutches adding 10-15% of body weight through affected limb per week (this can be tested using bathroom/kitchen scales)

• Once able to weight bear with 50% of body weight through affected limb, you can mobilise with one crutch (used on the opposite side)

 Stage 3 (6 weeks – 3 months)

Aims

• To achieve full weight bearing

• Restoration of normal gait pattern

• Restoration of muscular strength and range of motion

Treatment Guidelines

• Gait retraining focusing on correct heel strike/toe off and VMO activation during stance

• Aim for a full range of motion using active and passive techniques
  Encourage VMO activation with co-contraction and biofeedback techniques. Progress by increasing repetitions, length of contraction and dynamic conditions

• Hamstring strengthening with static weight bearing co-contractions progressing to active free hamstring contractions then to resisted hamstring strengthening

• Gym equipment can be introduced such as stationary bike (encourage daily), stepper, leg press, mini trampoline, cross trainer with minimal resistance

• Pool work starting with deep water running. Swimming with pool buoy progressing to free kicking

• Muscle tightness can be addressed with soft tissue techniques and stretching particularly hamstrings and calf muscles

• Open chain exercises should be avoided, rather use closed chain exercises performed with co-contraction of hamstrings and quadriceps which lessen the patello-femoral joint forces and ensure more functional stresses on the joint and entire limb

• Once full ROM achieved, commence rower

• Once sufficient quadriceps strength achieved, commence functional eccentric quad exercises such as step downs starting with a ~10cm high platform and progress by increasing the height of the step

• Treat beyond the knee joint for any deficits, e.g. gluteal control, tight hamstrings, ITB, gastrocs and soleus, etc

 Stage 4 (>12 weeks) 

Aims

• Continuation of functional rehabilitation

Treatment Guidelines

• Ensure successful gait restoration or continue instructions as above

• Progress co-contractions to more dynamic movements, e.g. step lunges, half squats, wall squats

• Start cycling on normal bicycle

• Progress resistance on gym equipment such as exercise bike, rower, cross trainer

• Pool work can include using flippers