author: jorit wijnmaalen, dpt, mba, mtc, ceas educator: jorit wijnmaalen (dr. j) john van ooyen, pt,...

Author: Jorit Wijnmaalen, DPT, MBA, MTC, CEAS Educator: Jorit Wijnmaalen (Dr. J) John van Ooyen, PT, MTC FPTA Approved for 9.5 CEUs (2012)

The Setting Specific Orthopedic Exercise Course is the new version of our Anatomy of Exercise course and now includes exercise protocols for most major Orthopedic and Spine Surgeries. We have added more material to the course and it has been submitted for FPTA approval for 9.5 CEU's. This course is required for the CORS certification, but if you have taken The Anatomy of Exercise in 2012 or 2011, you do not need to take this course to become eligible for the CORS certification. This hands-on exercise course will review in depth clinical protocols that are currently in place for the various, common orthopedic procedures including joint replacement, ligamentous and tendon repairs surgeries and many spine surgeries. This clinical review will include protocols as they are applied in the various rehab settings including Inpatient Acute Care, Subacute Rehab and Skilled Nursing settings, Homecare and Outpatient. About this course:

SunCoast Seminars Why do we need to know and understand the anatomy of muscle? This will allow the clinician to specify their exercise program geared towards the function of the muscle. Different muscles have different functions and these functions are in part defined by the anatomy of the muscle. There are approximately 639 skeletal muscles in the human body. There are different types of muscles, each with their distinct anatomy. Understanding the anatomy of the muscle will help the clinician understand how different (intrinsic and extrinsic) factors can impact muscles and exercising. We are looked upon as the experts when it comes to exercise therapy. Understanding the anatomy of muscles is an important part of being an exercise expert.

Program Objectives: Reviewing muscular anatomy and physiology This will include a review of tissue healing Discuss how extrinsic factors such as medication, progression, exercise objectives etc. may affect the exercise therapy program Discuss how intrinsic factors including disease processes age, vital signs etc. may affect muscles and exercise programs. Discuss the basics of exercise therapy Discuss common exercise principles Open chain vs. closed chain Eccentric isometric concentric

A few rules: We are in a hospital and should be aware of any codes that might be called. Bathrooms are right outside of this room We will break for lunch are around noon Please turn off all cell phones. I would like to make this lecture as interactive as possible. Please feel free to ask questions, share your experiences, opinions etc. with the rest of the group. SunCoast Seminars

About the educator: Background Education Work experience Hobbies SunCoast Seminars

5 educators Dr. Brian Healy Dr. Willem Stegeman Dr. Jorit Wijnmaalen John Van Ooyen, PT Dr. Nathan A. Possert, PT, DPT About SunCoast Seminars

More courses: Orthopedic Joint Replacement course: 9.5 CEU Comprehensive Management of back & neck pain: 9.5 CEU Clinical Imaging for the Rehab Specialist, 9.5 CEU Joint Replacement, online: 7 CEU Thoracic Outlet Syndrome: 6.0 CEU, Online HIV/Medical Errors/Abuse: 4 CEU The Anatomy of Excercise: online An Introduction to Manual Therapy : 9.5 CEU Setting Specific Orthopedic Exercises : 9.5 CEUs CORS: 9.0 CEUs About SunCoast Seminars

Muscular anatomy and physiology Muscle Types: Smooth muscles Cardiac muscles Skeletal muscles SunCoast Seminars

Smooth muscles These muscles are very important in physiological regulation. Help to regulate the flow of blood. Help control BP They control the movement of food through the digestive system. Control of the uterus during labor Contraction of a smooth muscle cell is generated by a sliding mechanism of the myofilaments. Contraction is involuntary and may be initiated by Nerve impulse Hormones (i.e. cardiac function) Mechanical change to the muscle

SunCoast Seminars Smooth Muscles : Crucial difference with skeletal muscles: nervous control is absolutely required for skeletal muscles, smooth muscles can, to a degree, work without nervous stimulation! Lastly, these muscles are not striated (the myofilaments are arranged into light and dark bands as in striated muscles). Striations are formed by alternating segments of thick and thin protein filaments, which are anchored by segments called T-lines

SunCoast Seminars Cardiac Muscles : This muscle may look like a skeletal muscles (especially the contraction of it since they are striated as well) but it acts much like smooth muscle (it does not require nervous system input to function) The attachment site between cells is called an intercalated disc, which is present only in cardiac muscle cells and allows forces to be transmitted from one cell to the next.

SunCoast Seminars Skeletal Muscles: Striated (banded) type. This distinctive banding pattern of striated muscle is an effect that comes from the alignment of sarcomeres in register across the myofibrils Skeletal muscles are under voluntary control; no skeletal muscle works without orders from the nervous system Skeletal muscles have elongated muscle cells (fibers) with multiple nuclei lying along the periphery of the cell. The sarcoplasm of each cell is contained by a sacrolemma (plasma membrane) and an external lamina. Each muscle contains many myofibrils and each myofibril contains thin actine and thick myosin myofilaments. These muscles normally make up the largest portion of a person's lean body mass

SunCoast Seminars Skeletal Muscles These are the muscles that are responsible for all voluntary movements (movements controlled by the central nervous system and which typically are directed at some sort of interaction with the environment) These muscles only contract in response to instructions from the central nervous system (with a few exceptions) In short, skeletal muscles have the following functions: provide joints with the forces necessary to produce movement to control movement to stabilize and protect joints when loads are applied to them. generating heat, maintaining normal body temperature, because they account for 40% of the body mass.

Skeletal Muscles Skeletal muscles are a striated type of muscle with a rich blood supply, extensive afferent and efferent innervations and an extremely high metabolic capacity. Skeletal muscles have a tremendous adaptive capacity that allows them to hypertrophy, atrophy, increase in physiological length, decrease in physiological length and change metabolic capacities. Out of the three muscle types discussed, the skeletal muscle are the muscles that we will be most concerned within this course.

Muscular anatomy and physiology Lets review!

The Anatomy review of a skeletal muscle Each muscle cell is surrounded by a basal lamina and connective tissue. They are bound to each other and to surrounding tissues by connective tissue to form a gross "muscle". Skeletal muscle fibers are NOT joined by cell junctions. The endomysium consists of the basal lamina and thin connective tissue that surrounds individual muscle cells. The perimysium consists of sheets of connective tissue which separate the fibers into groups known as fascicles. The epimysium surrounds the groups of fasicles that comprise the muscle.

Endomysium delicate connective tissue sheeth that encloses each muscle fiber Fasciculus bundle of muscle fibers covered by perimysium (coarser fibrous membrane) Epimysium covers bundle of fasciculi (entire muscle); blends into either: Tendon cord of dense, fibrous tissue attaching a muscle to a bone Aponeurosis fibrous or membranous sheet connecting a muscle and the part is moves (usually found on torso)

The Anatomy review of a skeletal muscle Connective tissue transmits the mechanical force of muscle. Tendons connect muscle to bone. The myotendinous junction occurs at the end of the muscle cell where the terminal actin filaments connect to the plasma membrane Skeletal muscle fibers are multi-nucleated cells that arise by fusion of mono-nucleate myoblasts. The many nuclei are located at the periphery of the cell. Mono-nucleate satellite cells, associate with the muscle fiber and reside within the muscle basal lamina. They promote limited regeneration of muscle in the adult.

The muscle-tendon junction The Yellow line is corresponding to the tendon. How do we classify this Connective tissue? Dense Regular. The yellow arrows are pointing the nuclei of the fibroblasts making the collagen. The blue line is showing where the Striated Muscle is beginning

Innervation of a Skeletal Muscle Skeletal muscle is innervated and highly vascularized, due to its high energy requirements. It is penetrated of blood vessels into the epimysium with branches into the peri- and endomysium.

Innervation of a Skeletal Muscle Motor end plates (neuromuscular junctions) are specialized sites at which a nerve contacts a muscle cell. The terminal branches of motor axons lie in the surface of the muscle cell, where the plasma membrane is highly folded. Muscle action begins at the motor end plate (or neuromuscular junction), which is analogous to a synapse Acetylcholine(ACh) binds to receptors localized in the muscle membrane at the motor end plate, resulting in local depolarization at the end plate. When this depolarization exceeds the threshold, it will result in an action potential

Neuromuscular Junction or Motor End Plate axon of Motor (Efferent) Neuron White arrow - Skeletal Muscle Fiber

Innervation of a Skeletal Muscle Additional proprioceptor endings (Golgi tendon organs) are located at the point where muscle fibers attach to tendon These Golgi tendon organs (GTO) respond to tension (force) exerted by the muscle; activity in these axons inhibits muscle contraction (they are for instance stretched when a joint is swollen).

Nerve Conduction Both nerve cells and muscle cells are excitable Their cell membrane can produce electrochemical impulses and conduct them along the membrane. In muscle cells, this electric phenomenon is also associated with the contraction of the cell The origin of the membrane voltage is the same in nerve cells as in muscle cells. In both cell types, the membrane generates an impulse as a consequence of excitation. The long nerve fiber, the axon, transfers the signal from the cell body to another nerve or to a muscle cell The axon may be covered with an insulating layer called the myelin sheath, which is formed by Schwann cells

Nerve Conduction This myelin sheath is not continuous but divided into sections, separated at regular intervals by the nodes of Ranvier The junction between an axon and the next cell with which it communicates is called the synapse. Information proceeds from the cell body uni-directionally over the synapse, first along the axon and then across the synapse to the next nerve or muscle cell (think about peripheral leasion) The part of the synapse that is on the side of the axon is called the pre-synaptic terminal The part on the side of the adjacent cell is called the postsynaptic terminal. Between these terminals, there exists a gap. A chemical neurotransmitter, released from the pre-synaptic cell, is responsible for the impulse to transfer across the synapse.

Nerve Conduction This transmitter, when released, activates the postsynaptic terminal. The synapse between a motor nerve and the muscle it innervates is called the neuromuscular junction

Nerve Conduction If a nerve cell is stimulated, the trans-membrane voltage necessarily changes. The stimulation may be excitatory (i.e., depolarizing; characterized by a decrease in the normally negative resting voltage) or inhibitory (i.e., hyperpolarizing, characterized by an increase in the magnitude of the membrane voltage). After stimulation the membrane voltage returns to its original resting value If the excitatory stimulus is strong enough, the trans-membrane potential reaches the threshold, and the membrane produces a characteristic electric impulse, the nerve impulse. Remember the Na+/K+ pump?

Nerve Conduction Many factors may affect nerve conductivity but discussion of those factors would be outside the scope of this lecture. Temperature Properties of the membrane Sodium levels Age Anatomical changes because of disease (ALS)

Nerve Conduction A myelinated axon (surrounded by the myelin sheath) can produce a nerve impulse only at the nodes of Ranvier In these axons the nerve impulse propagates from one node to another The myelin sheath increases the conduction velocity The conduction velocity of the myelinated axon is directly proportional to the diameter of the axon

Nerve Conduction

Types of Skeletal muscles Not all skeletal muscles are the same. Some cells are thicker than others Some shorten faster Some produce more tension Some fatigue more rapidly Looking at these different features, there appear to be three major types of skeletal muscles:

Types of Skeletal muscles Slow Twitch Fast Fatigue Resistant Fast Twitch Fatigable

Slow Twitch These muscles produce the least amount of force. They actually produce less than half the force produced by fast twitch fatigue resistant fibers and are most resistant to fatigue. Slow twitch muscles use oxygen for power and have a predominance of aerobic enzymes. Slow twitch muscles are red, because they contain lots of blood vessels. These muscle fibers are "hit", or engorged with nitrogen-rich blood, during higher rep training, specifically in sets of 12 to 20 reps. Slow twitch muscles are used for holding posture

Fast Twitch (Type II) Fast Twitch fibers use anaerobic metabolism to create fuel and so they are much better at generating short bursts of strength or speed than slow muscles. These types of muscles are best trained during sets of 2- 5 repetitions. They fatigue more quickly. Fast twitch fibers generally produce the same amount of force per contraction as slow muscles, but they get their name because they are able to fire more rapidly. Having more fast twitch fibers can be an asset to a sprinter since she needs to quickly generate a lot of force (genetically determined, 50/50 on average; some research suggests that some fibers might be able to convert).

Two Types: Type IIa Fibers / Fast Fatigue Resistant These fast twitch muscle fibers are also known as intermediate fast-twitch fibers. They can use both aerobic and anaerobic metabolism almost equally to create energy. In this way, they are a combination of Type I and Type II muscle fibers. Produce forces greater than slow twitch fibers but less than fast twitch fatigable fiber. These fibers are more resistant to fatigue than fast fatigable but less fatigue resistant than slow twitch fibers.

Type IIb Fibers These fast twitch fibers use anaerobic metabolism to create energy and are the "classic" fast twitch muscle fibers that excel at producing quick, powerful bursts of speed. This muscle fiber has the highest rate of contraction (rapid firing) of all the muscle fiber types, but it also has a much faster rate of fatigue and can't last as long before it needs rest. Produce the greatest amount of force Are least resistant to fatigue Force produced is typically 2-3 times greater than fast twitch fatigue resistant fibers

Low frequency stimulation of motor units of type II fibers transforms these fibers in type I fibers (endurance training, easier to accomplish) High frequency stimulation of motor units of type I fibers transforms these fibers in type II fibers (strength training, harder to accomplish) This is due to rest periods with low frequent stimulation of type II fibers, only metabolism and muscle fiber diameter stay increased.

Conclusion So the lesson here is quite simple. As we are exercising our patients, we must keep in mind the main objective of our exercise program. In order to recruit the largest possible number of muscle fibers of both types during the exercise program, we must vary the repetition ranges. Keeping in mind that on average, there is a 50/50 split of these fibers so Any therapist, who puts a patient on an exercise program that doesn't include a variation of repetition ranges might significantly limit the success of the exercise program.

Skeletal Muscle Fiber Arrangement It is important to realize that there are different alignments of muscle fibers in the various skeletal muscles. These different fiber arrangements will have an effect on the length, mechanical properties and the number of muscle fibers of a muscle. Muscle fibers can be arranged in parallel or at angles to the tendon. Parallel fibered muscles are muscle composed of parallel aligned fibers. These muscles have long muscle fibers that can produce a large excursion on the tendon. Fusiform Triangular Spiral Pinnated fibers muscles are muscles composed of angled fibers Unipinnate Bipinnate Multipinnate

Structure & Function of a Skeletal muscle

The cell comprises a series of striped or striated, thread-like myofibrils. Within each myofibril there are protein filaments that are anchored by dark Z line. The fiber is one long continuous thread-like structure. The smallest cross section of skeletal muscle is called a sarcomere which is the functional unit within the cell. It extends from one Z line to the next attached Z line. The individual sarcomere has alternating thick myosin and thin actin protein filaments. Myosin forms the center or middle of eache M line. Thinner actin filaments form a zig zag pattern along the anchor points or Z line.

Muscle Contraction Upon stimulation by an action potential, skeletal muscles perform a coordinated contraction by shortening each sarcomere. The best proposed model for understanding contraction is the sliding filament model of muscle contraction. Actin and myosin fibers overlap in a contractile motion towards each other. ATP binds to the cross bridges between myosin heads and actin filaments. The release of energy powers the swiveling of the myosin head Myosin filaments have club-shaped heads that project toward the actin filaments. Larger structures along the myosin filament called myosin heads are used to provide attachment points on binding sites for the actin filaments.

Muscle Contraction (cont.) The myosin heads move in a coordinated style, they swivel toward the center of the sarcomere, detach and then reattach to the nearest active site of the actin filament. This is called a rachet type drive system. This process consumes large amounts of adenosine triphosphate (ATP). Calcium ions are required for each cycle of the sarcomere. Calcium is released from the sarcoplasmic reticulum into the sarcomere when a muscle is stimulated to contract. This calcium uncovers the actin binding sites. When the muscle no longer needs to contract, the calcium ions are pumped from the sarcomere and back into storage in the sarcoplasmic reticulum

Images from Purves et al., Life: The Science of Biology, 4th Edition, by Sinauer Associates (www.sinauer.com) and WH Freeman (www.whfreeman.com)www.sinauer.comwww.whfreeman.com

Muscle contraction -In rest the average human body uses as much energy as a 75W light bulb. -During 24 hours of resting one still uses 1400-1800 kcal (25 mile stroll) -During extreme endurance sports the body is able to burn 10500-15000 kcal -Muscle tissue is a very effective power source: power versus weight for a jet motor is 1:5 power versus weight for the biceps muscle is approx. 1:360

Muscle contraction (cont.) ATP is the main source of energy for all muscle contraction. There are several chemical reactions that take place to produce ATP. When a muscle is used, a chemical reaction breaks down ATP to produce energy: ATP + Actin + Myosin Actomyosin + Phosphate + ADP + Energy This is the chemical reaction that produces energy, however, there is only enough ATP stored in the muscle cell for two or three slow twitch contractions, or one burst of power from a fast twitch contraction. Surprisingly muscles store very limited reserves of ATP 4-6 seconds worth at most, just enough to get you going.

ATP is the only energy source used directly for contractile activities. It must be regenerated as fast as its broken down for continuation of the contraction. Fortunately, after ATP is hydrolyzed to ADP and inorganic phosphate in muscle fibers, its generated in a second by one or more of the three pathways, (1) direct phosphorylation of ADP by Creatine Phosphate (2) the anaerobic pathway called glycolysis, which converts glucose to lactic acid (3)Aerobic pathway, aerobic cellular respiration Muscle contraction (cont.)

(1)Direct phosphorylation of ADP by Creatine Phosphate a phosphate group transfers from CP to ADP, regenerating more ATP; CP supplies exhaust in about 20 seconds Duration of energy provision 15 seconds (2) Anaerobic glycolysis and lactic acid formation initial steps of glucose breakdown occur via glycolysis which is anaerobic. Duration of energy provision Glucose -> pyruvic acid with energy captured in ATP bonds (2ATP/ 1 glucose)

(3) Aerobic respiration: provides 95% of ATP at rest and during light Exercise occurs in mitochondria & involves a series of metabolic pathways that use oxygen called oxidative phosphorylation glucose is broken down into CO2 & H2O some released energy is captured in ATP bonds (get 36ATP/1 glucose) There is also another way to look at those three steps, when we talk about the enzyme systems. There are three enzyme systems that can create more ATP. The enzyme system that is used depends on whether the type of muscle is fast twitch or slow twitch, and whether the muscle is used for strength, burst power, or endurance.

Muscle Contraction (Cont.) The Strength Enzyme System When muscle strength is required, ATP is created quickly from the following chemical reaction. The enzyme creatine kinase mediates ATP production from the high energy molecule creatine phosphate by an anaerobic reaction: CP + ADP ATP + Creatine The CP (Creatine Phosphate) is depleted in just a few seconds. This is the reason your maximum power can be maintained for only a few seconds. To continue producing high strength power, the speed enzyme system kicks in.

Muscle Contraction (Cont.) The Burst Power Enzyme System The enzymes required for this reaction are depleted in less than two minutes. This reaction is called Anaerobic Glycolysis because it uses glucose without oxygen. Glucose 2ATP + 2 Lactate Continued muscle usage requires the aerobic system to kick in. The aerobic system uses oxygen and sugar for fuel. The ability to perform well after about two minutes of maximum exertion depends on the aerobic conditioning of the body which is trainable

Muscle Contraction (Cont.) The Endurance Enzyme System This system consists of three processes: 1.Carbohydrate Metabolism: Carbohydrates metabolize most efficiently and are therefore used first 2.Fat Metabolism: If no carbohydrates are available, the body metabolizes fat. 3.Amino Acid Protein Metabolism: If no fat is available, the body metabolizes Amino Acids. The body stores glucose and fatty acids for these reactions. In addition, the cardiovascular system provides a continuous supply of oxygen.

Muscle Contraction (Cont.) Cardiac muscle is adapted to be highly resistant to fatigue: it has a large number of mitochondria, enabling continuous aerobic respiration. The heart is so tuned to aerobic metabolism that it is unable to pump sufficiently in ischaemic conditions. (It has no back up system). At basal metabolic rates, about 1% of energy is derived from anaerobic metabolism. This can increase to 10% under moderately hypoxic conditions, but, under more severe hypoxic conditions, not enough energy can be liberated by lactate production to sustain ventricular contractions. Under basal aerobic conditions, 60% of energy comes from fat (free fatty acids and triglycerides), 35% from carbohydrates, and 5% from amino acids. However, these proportions vary widely according to nutritional state. For example, during starvation, lactate can be recycled by the heart

Muscle Contraction (Cont.) Glycogen is stored in the muscles and liver in sufficient quantities for about two hours of strenuous exercise. This timeframe can be extended by aerobic physical conditioning and high carbohydrate diet. After the glycogen stores are used up, the body obtains its energy from fatty acid metabolism and amino acid protein metabolism. These reactions are not efficient, which consequently causes your strength and endurance to drop drastically (hitting a brick wall or man with the hammer).

Motor Units within a muscle A motor unit is defined as all of the muscle fibers supplied by a single motoneuron, and therefore, by a single axon and its branches Skeletal muscles are organized into hundreds of motor units, each of which involves a motor neuron, attached by a series of thin finger-like structures called axon terminals. These attach to and control discrete bundles of muscle fibers. A coordinated and fine tuned response to a specific circumstance will involve controlling the precise number of motor units used. While individual muscle units contract as a unit, the entire muscle can contract on a predetermined basis due to the structure of the motor unit. Motor unit coordination, balance, and control frequently come under the direction of the cerebellum of the brain. This allows for complex muscular coordination with little conscious effort, such as when one drives a car without thinking about the process.

Motor Units within a muscle Muscles responsible for fine coordination have small motor units. Muscles responsible for gross movements have large motor units. The smaller motor units are more excitable than the larger ones, and are stimulated first when a weak signal is sent by the CNS to contract a muscle As the strength of the signal increases, more motor units are excited in addition to larger ones, with the largest motor units having as much as 50 times the contractile strength as the smaller ones As more and larger motor units are activated, the force of muscle contraction becomes progressively stronger. This concept is know as the size principle.

Motor Units within a muscle: Conclusion At low exercise intensities, like walking or slow running, slow twitch fibers are selectively utilized because they have the lowest threshold for recruitment. If suddenly the pace is increased to a sprint, the larger fast units will be recruited. In general, as the intensity of exercise increases in any muscle, the contribution of the fast fibers will increase. For the muscle, intensity translates to force per contraction and contraction frequency/minute. Motor unit recruitment is regulated by required force. In the unfatigued muscle, a sufficient number of motor units will be recruited to supply the desired force (wave contraction).

Motor Units within a muscle: Conclusion Initially desired force may be accomplished with little or no involvement of fast motor units. However, as slow units become fatigued and fail to produce force, fast units will be recruited as the brain attempts to maintain desired force production by recruiting more motor units. Consequently, the same force production in fatigued muscle will require a greater number of motor units. This additional recruitment brings in fast, fatigable motor units. As a result, fatigue will be accelerated toward the end of long or severe bouts due to the increased lactate produced by the late recruitment of fast units. (Again, the man with the hammer)

Contraction Strength For skeletal muscles, the force exerted by the muscle is controlled by varying the frequency at which action potentials are sent to muscle fibers. Action potentials do not arrive at muscles synchronously, and during a contraction some fraction of the fibers in the muscle will be firing at any given time. Typically when a human is exerting a muscle as hard as they are consciously able, roughly one-third of the fibers in that muscle will be firing at once, but various physiological and psychological factors (including Golgi tendon organs and Renshaw cells) can affect that. This 'low' level of contraction is a protective mechanism to prevent avulsion of the tendon - the force generated by a 95% contraction of all fibers is sufficient to damage the body.

Contraction Strength The repetitive firing of a motor unit creates a train of impulses known as the motor unit action potential train (MUAPT). To sustain muscle contraction, the motor units must be repeatedly activated. As the firing rates of motor units active in a contraction increase, the twitches associated with each firing will eventually fuse to yield large forces The firing rates of earlier recruited motor units are greater than those of later recruited motor units at any given force value The control to the muscle is not designed to generate constant- force contractions.

Maximal Voluntary Contraction (MVC)

Contraction Strength So concluding, the strength of a muscular contraction can be influenced 2 factors: 1.By increasing the number and size of contractile units simultaneously, called multiple fiber summation. 2.By increasing the frequency at which action potentials are sent to muscle fibers, called frequency summation.

Types of Muscle Contraction 1.Concentric muscle contraction 2.Eccentric muscle contraction 3.Isometric muscle contraction 4.Isotonic muscle contraction

Concentric muscle contraction Muscle contraction in which the muscles shorten while generating force. The insertion and origin of the muscle are moving toward eachother. During a concentric contraction muscle fibers slide across each other pulling the Z-lines together During a concentric contraction, a muscle is stimulated to contract according to the sliding filament mechanism. This occurs throughout the length of the muscle, generating force at the musculo-tendinous junction, causing the muscle to shorten and changing the angle of the joint. In relation to the elbow, a concentric contraction of the biceps would cause the arm to bend at the elbow. A concentric contraction of the triceps would change the angle of the joint in the opposite direction, straightening the arm.

Eccentric Muscle Contraction During an eccentric contraction, the muscle elongates while under tension. The origin and the insertion of the muscle are moving away from eachother. The muscle acts to decelerate the joint at the end of a movement or otherwise control the repositioning of a load. This can occur involuntarily (when attempting to move a weight too heavy for the muscle to lift) or voluntarily (when the muscle is 'smoothing out' a movement). Over the short-term, strength training involving both eccentric and concentric contractions appear to increase muscular strength more than training with concentric contractions alone. During an eccentric contraction of the biceps muscle, the elbow starts the movement while bent and then straightens as the hand moves away from the shoulder. During an eccentric contraction of the triceps muscle, the elbow starts the movement straight and then bends as the hand moves towards the shoulder.

Eccentric Muscle Contraction Exercise featuring a heavy eccentric load can actually result in greater muscular damage and delayed onset muscle soreness one to two days after training. Exercise that incorporates both eccentric and concentric muscular contractions (i.e. involving a strong contraction and a controlled lowering of the weight) can produce greater gains in strength than concentric contractions alone. While unaccustomed heavy eccentric contractions can easily lead to overtraining, moderate training may confer protection against injury.

Isometric Muscle Contraction. An isometric contraction of a muscle generates force without changing length. An example can be found in the muscles of the hand and forearm grip an object; the joints of the hand do not move but muscles generate sufficient force to prevent the object from being dropped. Isometrics are done in static positions, rather than being dynamic through a range of motion. The joint and muscle are either worked against an immovable force (overcoming isometric) or are held in a static position while opposed by resistance (yielding isometric).

Eccentric Muscle Contraction Muscles are approximately 10% stronger during eccentric contractions than during concentric contractions Eccentric contractions are being researched for their ability to speed rehab of weak or injured tendons. Achilles tendinitis has been shown to benefit from high load eccentric contractions. During virtually any routine movement, eccentric contractions assist in keeping motions smooth. Muscles undergoing heavy eccentric loading suffer greater damage when overloaded (such as during muscle building or strength training exercise) as compared to concentric loading. During an eccentric contraction, the filaments slide past each other the opposite way, though the actual movement of the myosin heads during an eccentric contraction is not known.

Isotonic Muscle Concentration Isotonic contractions occur when tension in the muscle remains constant despite a change in muscle length. This can occur only when a muscle's maximal force of contraction exceeds the total load on the muscle.

A: Concentric/eccentric B: Isometric

EXERCISING AND BUILDING MUSCLES Muscles change and develop with regular exercise but the effects differ, depending on whether you engage in strength, speed, or endurance training. Strength and burst training causes the muscle fibers to enlarge. Individual muscle fibers increase in diameter as a result of an increase in intracellular protein fibrils. Endurance training causes more blood vessel formation than does speed or strength training, which produces an increased capacity for aerobic metabolism within the muscle cell. This change is seen after a few weeks of training and is maximized in about three months. The aerobic enzymes that metabolize carbohydrates, fats, and proteins, double. It is important to develop your strength and speed systems, but if you want to continue past about two minutes of high intensity workouts, you need to have your aerobic systems developed

EXERCISING AND BUILDING MUSCLES Effect of Exercise on Muscles: Aerobic or endurance exercise Examples biking, jogging, swimming laps Results in stronger more flexible muscles with greater resistance to fatigue blood supply increases individual muscle cells form more mitochondria and store more oxygen (makes overall body metabolism more efficient Improves digestion and elimination of wastes Enhances neuromuscular coordination Makes the skeleton stronger Heart enlarges Fat deposits are cleared from blood vessel walls Lungs become more efficient at gas exchange Does NOT cause muscles to increase in size

EXERCISING AND BUILDING MUSCLES Effects of Exercise on Muscles: Resistance or isometric exercise Examples weightlifting, theraband or medicine ball training, bodyweight exercises like push-ups or pull-ups, plyometrics Key is that muscles are being forced to contract with as much force as possible or as quickly as possible Muscles increase in size and strength Due to enlargement of individual muscle cells (more contractile filaments), not because more muscle fibers are made Size of reinforcing connective tissue also increases to support increased muscle size

Muscle Functions Muscle tissue has four main properties: Excitability or the ability to respond to stimuli Contractibility or the ability to contract Extensibility or the ability of a muscle to be stretched without tearing Elasticity or the ability to return to its normal shape Through contraction, the muscular system performs three important functions: Motion - walking, running etc. Heat production - maintain normal body temperature Maintenance of posture - standing, sitting etc.

Muscle Functions Muscles have two states Relaxed Contracted.

Common Medications and their effect on Exercise Blood thinners: Coumadin, Lovenox, Warfarin, Plavix Aspirin: Watch the side effects. Do not take with NSAIDs (will negate the blood thinning effect). Thinning of mucosa of the stomach wall, gastric ulceration, increased bleeding risk Muscle relaxors: Flexeril, Soma, Valium, Skelaxin Flexeril: Duration of action 12-24 hour Skelaxin: Duration of action 4-6 hours Side effects: Drowsiness, dizziness, vertigo, ataxia, dependency Parkinson's disease: Levodopa, Dopamine agonists, Anti cholinergics Sinemet/dopamine: arrhythmia's, postural hypotension Diuretics: Bumex, Lasix, Aldactone Hypokalemia, hyponatremia, fluid depletion, orthostatic hypotension

Common Medications and their effect on Exercise (continued) Cardiac function controlling medication: Beta blockers (Tenormin, Lopressor, Inderal, Betapace) Digitalis toxicity, dry cough, bradycardia, hypotension BP controlling medication: Beta blockers, Alpha blockers (Cardura, Minipress) Broncho constriction, bradycardia, hypotension HR controlling medication: Norpace, Beta blockers, Cordarone, Cardizem Increase of arrhythmia's, dizziness, hypotension Pulmonary function controlling medication: Albuterol, Epinephrine, Theo-Dur, Pulmicort, Decadron, Aerobid, Cortef Osteoporosis, muscle wasting, skin breakdown, diabetes mellitis, hypertension

The importance of a thorough evaluation The concept is very simple here; without a complete and detailed evaluation, you cannot develop an appropriate exercise program. This evaluation is ongoing and does not stop after the initial evaluation (there is a reason for that name) Understanding the true dysfunction and understanding why that dysfunction exists will put the clinician in the position to address the dysfunction effectively.

Different types of exercises with different objectives Objectives/Goals of exercise: Strength Muscular Dystrophy Coordination Firing Patterns Endurance ROM PROM vs. AROM Endfeel? PROM of the Joint Muscle length (Muscle energy) Muscle tone Decrease of muscle tone Increase of muscle tone Pain control

Components of an effective Exercise Program: Starts with a thorough and complete evaluation (evaluate the complete chain. Have clear outcome objectives. What are you looking to exercise Why are you exercising that What outcome do you expect Depends on patient/age/function/other intrinsic and extrinsic factors Measure and document these objectives ongoing Dont over exercise. Exercise to improve function not too complete a number of reps. When you feel or see the correct movement, continue to the next level.

Components of an effective Exercise program: Get the buy-in from the patient Detailed documentation Quality of the movement Speed Cues given/needed Strength Shaky/Tremorous Coordination Sensation Intensity Activity it is related to improve

Progression/Regression of exercise Establish base point or midline Points of contact: Progress from larger base of support to smaller base of support Open chain vs. Closed chain # of repetitions or sets Speed of the reps Cues: tactile& Verbal Level of resistance Point of reference eccentric Isometric concentric Stabilize vs. destabilize Weight shifting weight bearing Sequence: Instruct correct movement repeat challenge add complexity put into a functional activity Method of observation: visual, tactile, bio feed back

Total Hip Arthroplasty Brief description of procedure: Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. A total hip replacement (total hip arthroplasty) consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head

Variations: Hemi Arthroplasty, Revision, Hip, Resurfacing, ORIF. Muscles involved: Anterior approach: No muscles are cut other than the Piriformis which is transected 50% of the time Posterior approach:The piriformis muscle and the short external rotators (tendons) are taken off the femur Lateral approach: The hip abductors (gluteus medius and gluteus minimus) are elevated not cut to provide access to the joint

When does Rehab start? For most elective orthopedic procedures, the patient can start strengthening prior to the surgery, as allowed by their pain and functional level. Unfortunately, this is typically not reimbursed by insurance companies, or it may take away from their post-op rehab visits. Precautions and time frames Total hip precautions; restricted Hip Adduction, ER and Flexion as per the surgeon. Avoid SIMULTANEOUS/COMBINATION movements of the operative hip. Patients are allowed to flex, extend, abduct, adduct, or rotate their operative hip in cardinal planes of motion with NO restriction to movement. Any combination of motion during the initial three (3) months, post operative period should be avoided.

Weight bearing: Typically WBAT unless there was a surgical complication, so ALWAYS read the operative report. ALWAYS FOLLOW WB INSTRUCTIONS Surgical Hip Precautions

Acute Care Protocol: Hip DOS: Patient should get up with PT on the DOS, unless the patient had surgical complications, or had Total Anasthesia Patient can get up on the surgical or non-surgical site and will use a walker to ambulate with the appropriate WB and may sit in a chair, maintaining the 90 degrees hip angle. Patient should also start Muscle Setting Exercises in bed. Day 1-4:Patient should get up with nursing as well for BRP and for short ambulation. Physical Therapy and Occupational Therapy will focus safe transfers, following WB directions, using a walker, focusing on posture as well. AAROM will be started today in all cardinal planes as well. Walking distance will steadily increase and precautions will be reviewed with the patient and their family.

Ambulation Guidelines: Cemented Prosthesis: Weight bearing as tolerated (WBAT) ambulation. Patients are required to initially use a walker/crutches for a period of time, then are progressed to cane ambulation. The cane is discontinued when the patient is ambulating without a positive Trendelenberg test. Uncemented Prosthesis: Patients are required to ambulate using a walker/crutches and partial weight bearing for 6 post-operative weeks. Patients are progressed to WBAT over the following 2 weeks. When patients are able to ambulate without a positive Tredelenberg test, they may ambulate without any assistive devices. No running or involvement in sporting activities requiring running and/or jumpingfor 12 weeks.

POD #0: Begin isometric exercises and ankle pumps to leg. Encourage the patient to perform these exercises every two hours while awake. Begin assisted bed-to-chair transfers using an assistive device to a chair of appropriate height. Weight bearing status is dependent upon the type of prosthesis implanted. Patients may sit in an upright position if comfortable. Discuss post-operative dislocation precautions/restrictions. Acute Care Protocol: Hip

Post-Operative Day 1: Continue lower extremity isometrics and ankle pumps. Initiate upper extremity and contralateral limb strengthening exercises. Begin assisted ambulation on level surfaces using an assistive device, weight bearing status dependent upon prosthesis used. Begin discharge planning and home needs assessment. Review dislocation precautions/restrictions.

Post Operative Day 2: Review lower extremity isometric and ankle pumping exercises. Begin supine lower extremity active assisted range of motion exercises to the operative extremity. Motions are to the patients tolerance and in cardinal planes. Continue assisted ambulation on level surfaces. Reinforce hip dislocation precautions/restrictions.

Post Operative Day 3: Continue comprehensive exercise program with emphasis on increasing hip ROM and general muscle strength in the operative extremity. Begin sitting exercises. Refine gait pattern and instruct in stair climbing. Review home instructions/exercise program with emphasis on hipdislocation/precautions. Finalize discharge plans. All patients require an assistive device for ambulation, an elevated toilet seat, and follow-up physical therapy.

Hip Surgery: Phase II: Days 3-10 Goals: Achieve functional hip range of motion, within cardinal planes of movement. Muscle strengthening of the entire hip girdle of the operative extremity with emphasis on hip abductor and extensor muscle groups. Attention should also be directed toward any weakness present in the operative extremity as well as any generalized weakness in the upper extremities, trunk or contralateral lower extremity. Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities. Functional training to promote independence in activities of daily living and mobility.

Hip Surgery: Phase II: Days 3-10 Modalities for Pain Control and Edema Reduction: Moist Heat, Ice Therapeutic Exercise: Gentle Passive, Active-Assisted, and active lower extremity range of motion Stationary Biking - No resistance to motion Balance/Proprioception Training: Tandem Walking (line walking) Gait Training: Level Surface Forward Walking Functional Training: Standing Activities Transfer Activities

Hip Surgery: Phase III 10 days to 6 weeks: Goals: Muscle strengthening of the entire hip girdle of the operative extremity with emphasis on hip abductor and extensor muscle groups. Attention should also be directed toward any weakness present in the operative extremity as well as any generalized weakness in the upper extremities, trunk or contralateral lower extremity. Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities. Endurance training to increase cardiovascular fitness. Functional training to promote independence in activities of daily living and mobility. Gait training: Assistive devices are discontinued when the patient is able to ambulate without a positive Trendelendberg test based upon the ambulation guidelines (usually 4-6 weeks).

Hip: Phase III 10 days to 6 weeks: Modalities for Pain Control and Edema Reduction: Moist Heat, Ice Exercises Continue previous exercises Lower Extremity Strengthening Exercises using Theraband Aquatic Therapy/Activities Iliotibial Band Stretches-Supine Scar Massage/Mobility-May be instituted after suture removal when the incision is clean and dry. Advance Passive, Active-Assisted, and active lower extremity range of motion Closed Kinetic Chain Activities Continue stationary bike, progress resistance

Hip: Phase III 10 days to 6 weeks: Balance/Proprioception Training: Weight-Shifting Activities Closed Kinetic Chain Activities Lateral Stepping over/around objects Gait Training: Level Surface Forward Walking Sidestepping Retro Walking Uneven Surfaces Functional Training Lifting, Carrying Pushing or Pulling, Squatting or Crouching Return-To-Work Tasks

Phase IV 6-12 weeks: Exercises: Continue previous exercises Advance Passive, Active-Assisted, and active lower extremity range of motion Nordic Track Stair-Step Machine Iliotibial Band Stretches- standing at twelve (12) weeks post-operatively Develop walking program Continue pool and bike work Endurance Training: UBE Ambulation Activities

Phase IV 6-12 weeks: Balance/Proprioception Training: Obstacle Course Functional Training Lifting Carrying Pushing or Pulling Squatting or Crouching Return to sport tasks

Total Knee Arthroplasty Brief description of procedure The normal knee joint functions as a complex hinge allowing primarily flexion and extension, but also rotation and gliding. The knee joint is made up of three compartments, the lateral, medial and patellofemoral. Damage to the cartilage of one or more compartments may be the result of osteoarthritis (idiopathic or post-traumatic), inflammatory arthritis (rheumatoid, psoriatic, etc.), avascular necrosis, tumors, or congenital deformities. Osteoarthritis and rheumatoid arthritis are the causes of the overwhelming majority of total joint arthroplasties

Total Knee Arthroplasty Brief description of procedure Modern total knee arthroplasty consists of resection of the diseased articular surfaces of the knee, followed by resurfacing with metal and polyethylene prosthetic components. For the properly selected patient, the procedure results in significant pain relief, improved function and quality of life

Variations: Partial Knee Arthroplasty, Fixed Bearing device or Rotating Platform Device. Cemented or Compressed Fit; ACL/PCL sparing, Patella preserving When does Rehab start? For most elective orthopedic procedures, the patient can start strengthening prior to the surgery, as allowed by their pain and functional level. Unfortunately, this is typically not reimbursed by insurance companies, or it may take away from their post-op rehab visits.

Precautions and time frames Follow WB directions Kneeling onto knee is typically not allowed/not recommended. Screen for blood clots Screen for infection Acute Care Phase: Knee Phase I Immediate Postoperative Phase (Day 0 10) Goals: Active quad contraction Safe independent ambulation with walker or crutches as needed Passive knee extension to 0 degrees Knee flexion to 90 degrees or greater Control of swelling, inflammation, bleeding

Total Knee Surgery Protocol Day 0-2: Weight bearing as tolerated with walker/2 crutches as needed starting on Day 0-1 Cryotherapy immediately and continuously unless ambulating ROM of knee to begin immediately post op Exercises, Ankle pumps, PROM/extension to 0 degrees SLR Quad sets Knee flexion to at least 90 degrees Knee extension to 0 degrees Instruct in gait training - safe transfers

Total Knee Surgery Protocol Day 3-10: Weight bearing as tolerated with walker/2 crutches as needed Cryotherapy Exercises: Ankle pumps, PROM knee extension to 0 degrees, SLR, Quad sets AAROM - Knee flexion to at least 90 degrees Hip adduction/abduction Instruct in gait training safe transfers Start stationary bike, low resistance

Total Knee Surgery Protocol Phase II: Motion Phase (Week 2-6) Goals: Improve ROM Enhance muscular strength, endurance Dynamic joint stability Diminish swelling/inflammation Establish return to functional activities Criteria to enter Phase II: Leg control, able to perform SLR AROM 0-90 degrees Minimal pain/swelling Independent ambulation/transfers

Total Knee Surgery Protocol Weeks 2 -4: WBAT with assistive device as needed. Wean from walker to cane or from 2 crutches to 1 by 2 weeks. Wean off all assistive devices by no later than 4 weeks. Exercises: Quad sets, SLR, VMO recruitment during quad sets and SLR Knee extension 90-0 degrees Terminal knee extension 45-0 degrees Hip abduction/adduction Hamstring curls Knee flexion to at least 115 degrees

Total Knee Surgery Protocol Stretching: Hamstrings Gastroc/soleus Quads Passive knee extension stretch Continue stationary bike and advance resistance as tolerated Continue cryotherapy Patellofemoral mobilization Incision mobilization Patients may begin to drive if they are no longer using assistive devices for ambulation (about 2 weeks post op)

Total Knee Surgery Protocol Weeks 4-6: Exercises: Continue previous exercises Initiate front and lateral step ups Advance resistance on stationary bike Initiate progressive walking program Initiate endurance pool program, swimming with flutter kick Return to functional activities Continue compression, ice, elevation as needed for swelling Patients should be walking and driving independently at this point

Total Knee Surgery Protocol Phase III: Intermediate Phase (Weeks 7-12) Goals: Progression of ROM to greater than 115 degrees Enhancement of strength and endurance Eccentric/concentric control of limb Cardiovascular fitness Functional activity performance Criteria to enter Phase III: ROM 0-115 degrees Voluntary quad control Independent ambulation Minimal pain

Total Knee Surgery Protocol Weeks 7-12: Exercises: Continue previous exercises Continue pool activities Continue walking Continue stationary bike Aggressive AROM 0-115 degrees Strengthen quad/hamstrings

Total Knee Surgery Protocol Phase IV: Advanced Activity Phase (Weeks 12 and beyond) Goals: Allow patients to return to advanced level of function such as recreational sports Maintain/improve strength and endurance of lower extremity Return to normal life and routine Criteria to enter Phase IV: Full non painful ROM 0-115 Strength 90% of contralateral limb (if contralateral limb is normal) Minimal pain and swelling Satisfactory clinical examination

Total Knee Surgery Protocol Exercises: Quad sets, SLR, Hip abduction/adduction, Step ups, Knee extension Stationary bike Swimming Walking Stretching 0-115 degrees Return to pre op activities and develop HEP to maintain function of leg. NO SQUATS OR LUNGES AT ANY TIME!

Partial Knee Surgery: Brief Description of the procedure. Unicompartmental knee replacement is an option for a small percentage of patients with osteoarthritis of the knee In a unicompartmental knee replacement, only the damaged compartment is replaced with metal and plastic Partial Knee Replacement can only be revised with a Total Knee Replacement

Partial Knee Surgery Protocol General Considerations: All times are to be considered approximate, with actual progression based upon clinical presentation. Patients are full weight bearing with the use of crutches, a walker, or a cane to assist walking until they are able to demonstrate good walking mechanics. Early emphasis is on achieving full extension equal to the opposite leg as soon as able. No passive or active flexion range of motion greater than 90 for the first two weeks. No two-legged biking or flexion exercises for at least two weeks. Well-leg biking is fine. Regular manual treatment should be conducted to the patella and all incisions so they remain mobile. Early exercises should focus on recruitment of the vastus medialis obliquus (VMO). No resisted leg extension machines (isotonic or isokinetic) at any point in the rehabilitation process.

Partial Knee Surgery Protocol Hospital Stay is typically 24 hours and as soon as the sensation and motor control is back in the surgical leg and as soon as the patient is able to void, the patient will go home and start OP PT. Initial focus is on transfers, ambulation and AROM. 90 % are done on the medial aspect of the knee May become OP procedure surgery soon

Partial Knee Surgery Protocol Week 1: Goal is to allow the medial arthrotomy to heal and decrease swelling. MD visit on post-op Day 1 to change dressing and review home exercise program. Icing, elevation, and aggressive edema control (i.e. circumferential massage, compression wraps). Straight leg raise exercises (standing and seated), and passive and active ROM exercises. OK to gently bend knee < 90 1 - 2x per day. Initiate quadricep/adduction/gluteal sets, gait training, balance/proprioception exercises. Well-leg cycling and upper body conditioning. Soft tissue treatments and gentle mobilization to the posterior musculature, patella, and incisions to avoid flexion or patella contracture.

Partial Knee Surgery Protocol Weeks 2 - 4: Clinic visit at 14 days for suture removal and check-up. Continue with home program, progress flexion range of motion, gait training, soft tissue treatments, and balance/proprioception exercises. Incorporate functional exercises as able (i.e. seated/standing marching, hamstring carpet drags, hip/gluteal exercises, and core stabilization exercises). Aerobic exercise as tolerated (i.e. bilateral stationary cycling as able, UBE, pool workouts once incisions are healed.)

Partial Knee Surgery Protocol Weeks 4 - 6: MD visit at 4 weeks post-op. Increase the intensity of functional exercises (i.e. progress to walking outside, introducing weight machines as able). Continue balance/proprioception exercises (i.e. heel- to-toe walking, assisted single leg balance). Slow-to- normal walking without a limp.

Partial Knee Surgery Protocol Weeks 6 - 8: Add lateral training exercises (i.e. lateral steps, lateral step-ups, step overs) as able. Incorporate single leg exercises as able (eccentric focus early on). Patients should be walking without a limp and range of motion should be 110 flexion.

Partial Knee Surgery Protocol Weeks 8 - 12: Begin to incorporate activity-specific training (i.e. household chores, gardening, sporting activities). Low-impact activities until after Week 12. Patients should be weaned into a home/gym program with emphasis on their particular activity/sport. NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.

Plyometrics (also known as "plyos" and "jumping") is a type of exercise training designed to produce fast, powerful movements, and improve the functions of the nervous system, generally for the purpose of improving performance in sports. Plyometric exercises may also be referred to as explosive exercises. Plyometric movements, in which a muscle is loaded and then contracted in rapid sequence, use the strength, elasticity and innervation of muscle and surrounding tissues to jump higher, run faster, throw farther, or hit harder, depending on the desired training goal.

Plyometrics is used to increase the speed or force of muscular contractions, providing explosiveness for a variety of sport-specific activities. Plyometrics has been shown across the literature to be beneficial to a variety of athletes. Benefits range from injury prevention, power development and sprint performance amongst others

Plyometric training involves and uses practicing plyometric movements to enhance tissues abilities and train nerve cells to stimulate a specific pattern of [muscle contraction] so the muscle generates as strong a contraction as possible in the shortest amount of time. A plyometric contraction involves first a rapid muscle lengthening movement (eccentric phase), followed by a short resting phase (amortization phase), then an explosive muscle shortening movement (concentric phase), which enables muscles to work together in doing the particular motion. Plyometric training engages the myotatic reflex, which is the automatic contraction of muscles when their stretch sensory receptors are stimulated (PNF).

Knee Surgery Protocol : Meniscopy The intent of this protocol is to provide the clinician with a guideline of the post-operative rehabilitation course of a patient that has undergone a meniscal repair. It is no means intended to be a substitute for ones clinical decision making regarding the progression of a patients post-operative course based on their physical exam/findings, individual progress, and/or the presence of post-operative complications. If you require assistance in the progression of a post- operative patient you should consult with the referring Surgeon.

Knee Surgery Protocol : Meniscectomy Description of procedure: Removal of a part of one of the menisci of the knee or part thereof through an arthroscopic procedure, typically done at an ASC. General Considerations: Weight-bearing as tolerated. Walk with crutches. Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op. Regular assessment of gait to avoid compensatory patterns. Regular manual mobilizations to surgical wounds and associated soft tissue to decrease the incidence of fibrosis. No resisted leg extension machines (isotonic or isokinetic). No high impact or cutting/twisting activities for at least 4 months post-op

Knee Surgery Protocol : Meniscectomy General Considerations: Weight-bearing as tolerated. Walk with crutches. Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op. Regular assessment of gait to avoid compensatory patterns. Regular manual mobilizations to surgical wounds and associated soft tissue to decrease the incidence of fibrosis. No resisted leg extension machines (isotonic or isokinetic). No high impact or cutting/twisting activities for at least 4 months post-op

Knee Surgery Protocol : Meniscectomy Progression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate. Key Factors in determining progression of rehabilitation after Meniscal repair include: Anatomic site of tear Suture fixation (failure can be caused by too vigorous rehabilitation) Location of tear (anterior or posterior) Other pathology (ligamentous injury)

Knee Surgery Protocol : Meniscectomy Phase I Maximum Protection- Weeks 1-6: Goals: Diminish inflammation and swelling Restore ROM Reestablish quadriceps muscle activity Stage 1: Immediate Postoperative Day 1- Week 3 Ice, compression, elevation Electrical muscle stimulation Brace locked at 0 degrees ROM 0-90

Knee Surgery Protocol : Meniscectomy Meniscal Repair Protocol Motion is limited for the first 7-21 days, depending on the development of scar tissue around the repair site. Gradual increase in flexion ROM is based on assessment of pain and site of repair (0-90 degrees). Patellar mobilization Scar tissue mobilization Passive ROM

Knee Surgery Protocol : Meniscectomy Exercises Quadriceps isometrics Hamstring isometrics (if posterior horn repair, no hamstring exercises for 6 weeks) Hip abduction and adduction Weight-bearing as tolerated with crutches and brace locked at 0 degrees Proprioception training with brace locked at 0 degrees

Knee Surgery Protocol : Meniscectomy Stage 2: Weeks 4-6 Progressive resistance exercises (PREs) 1-5 pounds. Limited range knee extension (in range less likely to impinge or pull on repair) Toe raises Mini-squats (less than 90 degrees flexion) Cycling (no resistance) PNF with resistance Unloaded flexibility exercises

Knee Surgery Protocol : Meniscectomy Phase II: Moderate Protection- Weeks 6-10 Criteria for progression to phase II: ROM 0-90 degrees No change in pain or effusion Quadriceps control (MMT 4/5) Goals: Increased strength, power, endurance Normalize ROM of knee Prepare patients for advanced exercises

Knee Surgery Protocol : Meniscectomy Exercises: Strength- progression Flexibility exercises Lateral step-ups Mini-squats Endurance Program: Swimming (no frog kick), pool running- if available Cycling Stair machine Coordination Program: Balance board Pool sprinting- if pool available Backward walking Plyometrics

Knee Surgery Protocol : Meniscectomy Phase III: Advanced Phase- Weeks 11-15 Criteria for progression to phase III: Full, pain free ROM No pain or tenderness Satisfactory clinical examination SLR without lag Gait without device, brace unlocked Goals: Increase power and endurance Emphasize return to skill activities Prepare for return to full unrestricted activities

Knee Surgery Protocol : Meniscectomy Exercises: Continue all exercises Increase plyometrics, pool program Initiate running program Return to Activity: Criteria Full, pain free ROM Satisfactory clinical examination Criteria for discharge from skilled therapy: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE strength at least 4/5 4) Independent with home program 5) Normal age appropriate balance and proprioception 6) Resolved palpable edema

Knee Surgery Protocol : Partial Meniscectomy Rehabilitation after a partial meniscectomy may progress aggressively because there is no anatomic structure that requires protection.

Knee Surgery Protocol : Partial Meniscectomy Phase I Acute Phase: Goals: Diminish pain, edema Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90 degrees of flexion to progress to phase II)2 Reestablish quadriceps muscle activity/re-education (goal of no quad lag during SLR Educate the patient regarding Weight bearing as tolerated, use of crutches, icing, elevation and the rehabilitation process Weight bearing: Weight bearing as tolerated. Use two crutches initially progressing to weaning crutches as swelling and quadriceps status dictates.

Knee Surgery Protocol : Partial Meniscectomy Modalities: Cryotherapy for 15 min 4 times a day 1 Electrical stimulation to quadriceps for functional retraining as appropriate Electrical stimulation for edema control- high volt galvanic or interferential stimulation as needed

Knee Surgery Protocol : Partial Meniscectomy Therapeutic Exercise: Quadriceps sets SLR Hip adduction, abduction and extension Ankle pumps Gluteal sets Heel slides squats Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance) Hamstring and gastroc/ soleus and quadriceps stretches Use of compression wrap or brace Bicycle for ROM when patient has sufficient knee ROM. May begin partial revolutions to recover motion if the patient does not have sufficient knee flexion

Knee Surgery Protocol : Partial Meniscectomy Phase II: Internal Phase : Goals: Restore and improve muscular strength and endurance Reestablish full pain free ROM Gradual return to functional activities Restore normal gait without an assistive device Improve balance and proprioception Weight bearing status: Patients may progress to full weight bearing as tolerated without antalgia. Patients may require one crutch or cane to normalize gait before ambulating without assistive device.

Knee Surgery Protocol : Partial Meniscectomy Therapeutic exercise: Continue all exercises as needed from phase one Toe raises- calf raises Hamstring curls Continue bike for motion and endurance Cardio equipment- stairmaster, elliptical trainer, treadmill and bike as above. Lunges- lateral and front Leg press Lateral step ups, step downs, and front step ups Knee extension 90-40 degrees Closed kinetic chain exercise terminal knee extension Four way hip exercise in standing Proprioceptive and balance training Stretching exercises- as above, may need to add ITB and/or hip flexor stretches

Knee Surgery Protocol : Partial Meniscectomy Phase III Advanced activity phase: Goals: Enhance muscular strength and endurance Maintain full ROM Return to sport/functional activities/work tasks Therapeutic Exercise: Continue to emphasize closed-kinetic chain exercises May begin plyometrics/ vertical jumping Begin running program and agility drills (walk-jog) progression, forward and backward running, cutting, figure of eight and carioca program Sport specific drills

Knee Surgery Protocol : Partial Meniscectomy Criteria for discharge from skilled therapy: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE strength at least 4+/5 4) Independent with home program 5) Normal age appropriate balance and proprioception 6) Resolved palpable edema

Knee Surgery Protocol : ACL Reconstruction, Allograft (donor tissue) Brief description: Allograft is most commonly used in lower demand patients, or patients who are undergoing revision ACL surgery (when an ACL reconstruction fails). Biomechanical studies show that allograft (donor tissue from a cadaver) is not as strong as a patient's own tissue (autograft). For many patients, however, the strength of the reconstructed ACL using an allograft is sufficient for their demands. Therefore this may be an excellent option for patients not planning to participate in high-demand sports (e.g. soccer, basketball, etc.).

Knee Surgery Protocol : AUTOGRAFT BONE-PATELLA TENDON-BONE and ALLOGRAFT PROTOCOL Variation: Autograft, ACL repair, Patello Tendon Autograft, Hamstring tendon Autograft. Phase I-Early Functional (Weeks 1-2) Goals: 1. Educate re: the proper use of continuous passive motion (CPM) machine a Home exercise program (HEP). 2. Decrease pain and effusion. 3. Educate re: the importance of icing. 4. Independent donning,doffing, adjusting hinges, and use of knee brace. 5. Safe ambulation with assistant device and knee brace WEIGHT BEARING AS TOLERATED (WBAT) on the involved leg. 6. Promote normal gait mechanics. 7. Early balance control. 8. Attain full extension and functional flexion of the involved knee. 9. Obtain baseline values for the uninvolved limb (isokinetic testing). 10. Initiate early neuromotor control of all muscle groups.

Knee Surgery Protocol : ACL Reconstruction, Allograft Phase I-Early Functional (Weeks 1-2) Goals: 1. Educate re: the proper use of continuous passive motion (CPM) machine a Home exercise program (HEP). 2. Decrease pain and effusion. 3. Educate re: the importance of icing. 4. Independent donning,doffing, adjusting hinges, and use of knee brace. 5. Safe ambulation with assistant device and knee brace WEIGHT BEARING AS TOLERATED (WBAT) on the involved leg.

Knee Surgery Protocol : ACL Reconstruction, Allograft 6. Promote normal gait mechanics. 7. Early balance control. 8. Attain full extension and functional flexion of the involved knee. 9. Obtain baseline values for the uninvolved limb (isokinetic testing). 10. Initiate early neuromotor control of all muscle groups.

Knee Surgery Protocol : ACL Reconstruction, Allograft Day of Surgery: Ambulate WBAT with knee brace range from 0 to tolerated active flexion (maximum 60) on level surfaces with axillary crutches. The brace will initially be set by the physical therapist. CPM will be set at 0 to 60 unless otherwise documented. -Brace SHOULD NOT be worn while the operated limb is in the CPM. -Brace is required only when ambulating and while performing straight leg raise (SLR) exercises outlined below.

Knee Surgery Protocol : ACL Reconstruction, Allograft Post-Operative Day #1: - Ambulate as above on level surfaces and stairs. - CPM progression can be 10 20 daily but should not exceed 5 every 3 hours. - Review of patient ACL ( PATELLA TENDON-BONE GRAFT) Home instructions. - KNEE BRACE MUST BE WORN WITH THE STRAIGHT LEGRAISE (SLR) EXERCISES LOCKED AT 0. - ankle strengthening for all planes with theraband. - quad set with towel roll under the ankle to promote full extension. - heel slides. - hamstring sets. - seated hip flexion. - seated active assisted knee extension. - straight leg raises (SLR) in all 4 planes with BRACE LOCKED AT 0.

Knee Surgery Protocol : ACL Reconstruction, Allograft Post-operative Day #2-7: - Continue with above ambulation and exercise guidelines. - Increase knee brace setting with active knee motion. - Continue CPM until 90 active knee flexion is achieved. CPM progression can be 10 20 daily but should not exceed 5 every 3 hours. - BAPS- in sitting. - Stationary bicycle- start with a low, comfortable seat height to promote flexion, most force through non-operated limb-increase seatheight in subsequent sessions. - Supine wall slides- allow gravity to assist with knee flexion. DO NOT perform wall slides in the upright or stance position. - Home stretching for quadriceps, hamstrings, and gastrocnemius. - Balance activities begin with bilateral stance activities and progress to unilateral on the ground.

Knee Surgery Protocol : ACL Reconstruction, Allograft Bilateral standing modified knee bends (0-30)-begin with body weight and then add light extrinsic weight accordingly. - Marching in place- begin in sitting and progress to standing. - Sidestepping - Multi hip to involved lower limb. Be sure weight is applied proximal to the knee. (flexion, extension, abduction, adduction, terminal knee extension) - Retro walking Begin with body weight then progress to pulling a weighted sled. Increase the load as tolerated. - Quadriceps isometrics at varied degrees of knee flexion. - Active knee extension of the involved knee (full) as tolerated. - Active knee flexion full. - Rolling chair activity active hamstring/quad activity by performing forward propulsion/retropulsion of rolling chair using alternating lower extremities (90-0).

Knee Surgery Protocol : ACL Reconstruction, Allograft Proprioceptive training: static stabilizing technique at various degrees of knee flexion using therapeutic ball. Begin in supine with legs on the ball then progress to sitting on the ball (90-0). Heel raises begin with bilateral lower limbs then progress to unilateral.

Knee Surgery Protocol : ACL Reconstruction, Allograft ** IN ALL CLOSED CHAIN KNEE EXERCISES, DO NOT ALLOW THE ANTERIOR ASPECT OF THE KNEE TO PASS THE TOES.** BY THE END OF WEEK 1: AROM: PROM: 0-80 0-90 0-105 0-120 0-120 0-125 **DO NOT PUSH >125 WITH PASSIVE RANGE OF MOTION. CONTINUE TO CHECK RANGE OF MOTION PERIODICALLY TO MAKE SURE RANGE IS MAINTAINED.**

Knee Surgery Protocol : ACL Reconstruction, Allograft Post-operative Day #8-14: - Continue as above. - Straight leg raises- without the brace if the patient demonstrates good quad control, with resistance applied proximal to the knee. Use the brace locked at 0 if an extension lag still exists. - Standing leg curl- begin in standing with no added weight. The patient must demonstrate easy effort prior to adding weight. - Multi hip- to bilateral lower limbs. (Flexion, extension, abduction, adduction, terminal knee extension). - Leg press- begin using bilateral lower limbs (30 - 0). Begin with low extrinsic weight (10-50% maximum of the patients body weight) and progress weight if the patient demonstrates good quad control during terminal knee extension. The patient at this time may begin unilateral leg press (10-30% maximum of the patients body weight). - Balance activities progress to bilateral activities on the disc the unilateral. - Discontinue crutches at POD #14 if proper gait mechanics are obtained.

Knee Surgery Protocol : ACL Reconstruction, Allograft Phase II-Progressive Functional (Weeks 3-11) Goals: 1. Decrease pain and effusion. 2. Discontinue the postoperative brace when the patient demonstrates good quad control. 3. Continue the development of neuromotor control of all muscle groups. 4. Retrain for proprioception and normalize responses to dynamic challenges.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 3 through 4: Continue as above. Cable column- should be performed once the patient is able to straight leg raise with resistance distal to the knee with good quad control. Begin with flexion and extension followed by abduction and adduction. Be more cautious with those patients who have meniscal, medial or lateral collateral involvement. Unilateral modified knee bends (0-30)- Stand erect. Extend hip and flex the knee and place the dorsum of the foot on a bench or box behind you. With support to the upper limb, lower the torso, allowing your stance knee to flex to 45. **DO NOT ALLOW THE ANTERIOR ASPECT OF THE KNEES TO PASS THE TOES.** Begin with body weight and progress with light extrinsic weight. Step ups- begin with body weight then add weights and step height gradually. Discontinue if the patient has any complaints of pain. Balance activities- incorporate multi task activities, i.e. unilateral modified knee bend while performing arm curls while balancing on a disc.

Knee Surgery Protocol : ACL Reconstruction, Allograft Closed chain step machine (0-30)- begin with low resistance and maintain short steps throughout. Swimming- the patient may perform side stroke or flutter kick initiating motion from the hip. No butterfly.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 5 through 6: Continue as above. Progressive resisted knee extension- perform activity with a slow controlled motion. Begin with cuff weights for the involved leg and continue to do so until the patient can comfortably lift 20 lbs. Do not allow the activity to begin with >80 of knee flexion. Advanced hamstring activity with the trunk flexed perform hip extension with upper extremity support, with the hip extended to midrange perform a hamstring curl, in the supine position perform bridging on the theraball with hip flexion, and relaxed knee dead lifts if there is no history of low back problems. Cross friction massage to scar.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 7 through 8: Continue as above. Lateral activities begin by increasing the speed with lateral stepping progressing to lateral shuffles, ski simulator, modified slide board activities (restricted distance slide board) to full range slide board. **WITH ALL OF THESE EXERCISES BE AWARE OF VALGUS STRESSES** Cable column simulated running once the patient exhibits good control with single plane motion progress to multi joint motion. Crossover stepping progress to cariocas as tolerated. BAPS in standing. Beware of rotation occurring at the knee and valgus/varus stresses.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 8 through 11: Continue as above. Standing bicycle- with high resistance, may progress to a bike spectrum. Plyometrics- begin with mini jumps on the leg press at approximately 30% of body weight.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 8 through 11: Continue as above. Standing bicycle- with high resistance, may progress to a bike spectrum. Plyometrics- begin with mini jumps on the leg press at approximately 30% of body weight. Phase III-Functional (Weeks 12-16) Goals: 1. Master functional tasks of desired physical activity. 2. Optimize force production and absorption with various activities.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 12-15: Continue as above. Lateral shuffles weighted, Stop and Go. Slide board with the patient wearing a weighted vest (or holding a hand dumbbell) incorporating a ball toss. Begin Dynamic skills progression- (jumping, hopping, and leaping). Agility drill May initiate light jogging program if the patient demonstrates good force production (i.e. jumping) and absorption (i.e. landing), especially when leaping from uninvolved to the involved limb. 10RM testing as 12 weeks: begin heavy, moderate and light workout days according to strength assessment guidelines.

Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 16+: Continue as above. May initiate running of the patient demonstrates good force production and absorption, especially when leaping from uninvolved to involved. The patient may return to activity without a derotation brace if: 1. Pain free with ADL and rehab activities including agility and sport specific drills. 2. No c/o stiffness during or after all above activities. 3. No c/o giving way during all above activities. Objective: 1. Full AROM and PROM (0-135).

Knee Surgery Protocol : PCL Reconstruction ISOLATED AND COMBINED PCL RECONSTRUCTION POST- OP REHABILITATION PROTOCOL GENERAL PRINCIPLES No open chain hamstring work Assume 8 weeks for graft to bone healing time Caution against posterior tibial translation (gravity, muscle action) CPM 0-60 to start PCL with posterolateral corner or LCL repair follows different post-op care, i.e., crutches x 3 months Supervised physical therapy takes place for approximately 3-5 months post-op.

Knee Surgery Protocol : PCL Reconstruction GENERAL PROGRSSION OF ACTIVITIES OF DAILY LIVING (ADLs) Patients may begin the following activities at the post-op dates listed (unless otherwise specified by the physician): Bathing/Showering without brace (surgical incisions should be healed before immersion in water) 1 week post-op Sleep without brace 8 weeks post-op Driving 6-8 weeks post-op Full weight bearing without assistive devices 8 weeks post-op (with physician clearance)

Knee Surgery Protocol : PCL Reconstruction PHYSICAL THERAPY ATTENDANCE The following is an approximate schedule for supervised physical therapy visits: 0 to 1 month: 1 x week 1 to 3 months: 2-3 x week 3 to 9 months: 2 x month 9 to 12 months: 1 x month

Knee Surgery Protocol : PCL Reconstruction REHABILITATION PROGRESSION 0-1 WEEK POST-OP Brace: Locked at 0-60 maximum Weight bearing Status: WBAT with crutches, with brace locked Special Considerations: Pillow under proximal posterior tibia at rest to prevent posterior sag Therapy: Quad Sets Ankle Pumps SLR Hip Alphabets Hip AB/AD

Knee Surgery Protocol : PCL Reconstruction 7-28 DAYS POST-OP Brace: Locked except for protected range of motion performed by physical therapist. WB Status: WBAT with crutches, with brace locked Special Considerations: Continue use of pillow under tibia at rest.

Knee Surgery Protocol : PCL Reconstruction Therapy: PT Assisted knee flexion For PCL only patients: Maintain anterior pressure on proximal tibia as knee is flexed. For combined PCL/ACL patients, maintain neutral position of proximal tibia as knee is flexed. It is important to prevent posterior tibial sagging at all times. Hamstring and Calf stretching Calf press with Theraband Standing calf raises with full knee extension Standing hip extension from neutral

Knee Surgery Protocol : PCL Reconstruction 4-8 WEEKS Brace: 4-8 weeks: Brace is unlocked for supervised gait training only (patients must be under the direct supervision of a PT) WB status: WBAT with crutches Ther. Ex: - When patient exhibits independent quad control, may begin open chain extension, if no flexion contracture exists. Wall slides (0 to 45) Begin isometric, progress to active against body weight. Ambulation in pool (only while in physical therapy) Continue to maintain hamstring flexibility

Knee Surgery Protocol : PCL Reconstruction 8-12 WEEKS D/C Brace 8 weeks WB status: Wean off crutches at 8 weeks post- op May D/C crutches if patient exhibits: No quad lag with SLR Full knee extension Knee flexion 90-100 Normal gait pattern Therapy: Stationary bike: Foot forward on pedal (no toe clips), seat high Balance and proprioception, Seated calf raises Leg press (within available range of motion)

Knee Surgery Protocol : PCL Reconstruction 12 WEEKS (3 MONTHS) Progress functional and symptomatically Therapy: Treadmill walking Jogging in pool with Swimm

author: jorit wijnmaalen, dpt, mba, mtc, ceas educator: jorit wijnmaalen (dr. j) john van ooyen, pt,...

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