Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults

Posterior oblique ligament of the knee: state of the art

The posterior oblique ligament (POL) is the predominant ligamentous structure on the posterior medial corner of the knee joint. A thorough understanding of the anatomy, biomechanics, diagnosis, treatment and rehabilitation of POL injuries will aid orthopaedic surgeons in the management of these injuries.

The resulting rotational instability, in addition to valgus laxity, may not be tolerated by athletes participating in pivoting sports. The most common mechanism of injury – accounting for 72% of cases – is related to sports activity, particularly football, basketball and skiing. Moreover, three different injury patterns have been reported: those associated with injury to the capsular arm of the semimembranosus (SM), those involving a complete peripheral meniscal detachment and those involving disruption of the SM and peripheral meniscal detachment.

The hallmark of an injury related to POL lesions is the presence of anteromedial rotatory instability (AMRI), which is defined as ‘external rotation with anterior subluxation of the medial tibial plateau relative to the distal femur’.

In acute settings, POL lesions can be easily identified using coronal and axial magnetic resonance imaging (MRI) where the medial collateral ligament (MCL) and POL appear as separate structures. However, MRI is not sensitive in chronic cases.

Surgical treatment of the medial side leads to satisfactory clinical results in a multi-ligamentous reconstruction scenario, but it is known to be associated with secondary stiffness.

In young patients with high functional demands, return to sports is allowed no earlier than 9–12 months after they have undergone a thorough rehabilitation programme.

Cite this article: EFORT Open Rev 2021;6:364-371. DOI: 10.1302/2058-5241.6.200127

The Effect of Longer versus Shorter Duration of Supervised Physiotherapy after ACL Reconstruction on the Vertical Jump Landing Limb Symmetry

The study investigated the vertical jump landing limb symmetry after ACLR between a group of patients receiving a longer supervised physiotherapeutic procedure and following a shorter supervised physiotherapy. Group I (n = 20) and Group II (n = 15) were males averagely 30 weeks after ACLR. The time since ACLR in both groups (Group I, 27.95 ± 8.26 weeks; Group II, 32.47 ± 7.74 weeks) was insignificant, although the duration of supervised physiotherapy between the two groups (Group I, 27.9 ± 8.26 weeks; Group II, 11.28 ± 8.20 weeks) significantly differenced. Group III (n = 20) were controls. Two-legged and one-legged vertical jumps landing vertical ground reaction force (VGRF) were bilaterally measured in all groups using force plates. The intragroup comparison of two-legged jump landing VGRF revealed p = 0.01 between the involved and uninvolved limbs in Group II. The intergroup comparison revealed p ≤ 0.001 in the two-legged vertical jump between Groups II and III, and I and II. The one-legged limb symmetry was comparable in studied groups. In the group following shorter supervised physiotherapy, the two-legged landing limb symmetry was on a worse level than in the group of patients receiving fully supervised procedure and healthy individuals. A fully supervised postoperative physiotherapy is more effective for improving two-legged vertical jump landing limb symmetry.

Where does magnetic resonance imaging stand in the diagnosis of knee injuries?

BACKGROUND

The aim of this study was to determine the diagnostic value of magnetic resonance imaging (MRI) in the diagnosis of knee injuries.

MATERIALS AND METHODS

Ninety-eight consecutive patients were enrolled in the study. In all patients, MRI and arthroscopy were performed and the results were compared.

RESULTS

MRI was most sensitive in the detection of medial meniscus injuries, and the highest specificity and negative predictive value (NPV) were found in the detection of posterior cruciate ligament injuries.

CONCLUSION

MRI is a valuable tool, and according to its high NPV, normal MRI can prevent unnecessary arthroscopic interventions.

Effectiveness of cryotherapy after anterior cruciate ligament reconstruction

OBJECTIVE

The purpose of this study was to evaluate cryotherapy effectiveness in the immediate postoperative period of ACL reconstruction to improve pain and range of motion (ROM) of the knee.

METHODS

This is a pilot study of a prospective and randomized clinical trial. Patients (n=25) were divided into two groups: Intervention (A) group (n=10): patients were submitted to an inpatient physical therapy protocol and received ice compress for 20 minutes, twice a day; Control (B) group (n=9): patients had the same protocol, twice a day. The pain intensity was evaluated with the visual analogic scale (VAS) and range of motion was measured with a goniometer.

RESULTS

The Intervention (A) group had important absolute and percentual improvement when compared with the Control (B) group regarding measures of pain and knee flexion/extension ROM.

CONCLUSION

Cryotherapy in the immediate postoperative period of ACL reconstruction was effective to improve pain and range of motion of the knee. Level of Evidence I, Randomized Clinical Trial .

Physiotherapy-guided versus home-based, unsupervised rehabilitation in isolated anterior cruciate injuries following surgical reconstruction

PURPOSE

The aim of this study was to investigate the outcome after ACL reconstruction between a group of patients receiving a standardized, supervised, physiotherapy-guided rehabilitation programme and a group of patients who followed an unsupervised, home-based rehabilitation programme.

METHODS

Forty patients with isolated anterior cruciate ligament injuries were allocated to either a supervised physiotherapy intervention group or home-based exercise group. Patients were investigated by an independent examiner pre-operative, 3, 6, 9 and 12 months post-surgery using the following outcome measures: Lysholm Score and Tegner Activity Scale, functional hopping tests, and isometric and isokinetic strength assessments.

RESULTS

Both groups improved significantly (P = 0.01-0.04) following 12 months after surgery. The median Lysholm score increased from 57 (34-90) to 94 (90-100) in the supervised group and 60 (41-87) to 97 (95-100) in the unsupervised group. The median Tegner Activity Scale increased from 3 (2-8) to 6 (3-8) in the supervised group and 4 (2-8) to 5 (3-10) in the unsupervised group. The combined mean symmetry indices for the hopping tests improved from 77.3 ± 18.7 to 86.8 ± 11.1 (supervised) and from 78.1 ± 30.5 to 88.3 ± 10.9 (unsupervised). Isometric and isokinetic strength symmetry indices for knee extension improved from 68.9 ± 23.5 to 82.8 ± 11.9, respectively, 63.7 + 22.8 to 82.7 + 15.1 in the supervised group and from 73.6 ± 20.5 to 76.5 ± 17.9, respectively, 69.5 ± 24.3 to 76.9 ± 16.9 in the unsupervised group. Eccentric strength symmetry indices for knee extension improved from 67.9 ± 27.7 to 87.8 ± 6.8 in the supervised group and from 71.3 ± 17.8 to 82.6 ± 15.6 in the unsupervised group.

CONCLUSION

This study could not demonstrate a benefit in a rehabilitation programme supervised by a physiotherapist in our population compared to an unsupervised cohort.

Risk factors for neck and upper extremity disorders among computers users and the effect of interventions: an overview of systematic reviews

BACKGROUND

To summarize systematic reviews that 1) assessed the evidence for causal relationships between computer work and the occurrence of carpal tunnel syndrome (CTS) or upper extremity musculoskeletal disorders (UEMSDs), or 2) reported on intervention studies among computer users/or office workers.

METHODOLOGY/PRINCIPAL FINDINGS

PubMed, Embase, CINAHL and Web of Science were searched for reviews published between 1999 and 2010. Additional publications were provided by content area experts. The primary author extracted all data using a purpose-built form, while two of the authors evaluated the quality of the reviews using recommended standard criteria from AMSTAR; disagreements were resolved by discussion. The quality of evidence syntheses in the included reviews was assessed qualitatively for each outcome and for the interventions. Altogether, 1,349 review titles were identified, 47 reviews were retrieved for full text relevance assessment, and 17 reviews were finally included as being relevant and of sufficient quality. The degrees of focus and rigorousness of these 17 reviews were highly variable. Three reviews on risk factors for carpal tunnel syndrome were rated moderate to high quality, 8 reviews on risk factors for UEMSDs ranged from low to moderate/high quality, and 6 reviews on intervention studies were of moderate to high quality. The quality of the evidence for computer use as a risk factor for CTS was insufficient, while the evidence for computer use and UEMSDs was moderate regarding pain complaints and limited for specific musculoskeletal disorders. From the reviews on intervention studies no strong evidence based recommendations could be given.

CONCLUSIONS/SIGNIFICANCE

Computer use is associated with pain complaints, but it is still not very clear if this association is causal. The evidence for specific disorders or diseases is limited. No effective interventions have yet been documented.

Outcome of knee injuries in general practice: 1-year follow-up

BACKGROUND

Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.

AIM

To assess the outcome and management of knee injuries at 12 months' follow-up in general practice.

DESIGN OF STUDY

A prospective observational cohort study with a 1-year follow-up.

SETTING

Primary health care.

METHOD

Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months' follow-up.

RESULTS

At 12 months' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.

CONCLUSION

The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.

Exercise therapy for the management of osteoarthritis of the hip joint: a systematic review

INTRODUCTION

Recent guidelines pertaining to exercise for individuals with osteoarthritis have been released. These guidelines have been based primarily on studies of knee-joint osteoarthritis. The current study was focused on the hip joint, which has different biomechanical features and risk factors for osteoarthritis and has received much less attention in the literature. The purpose was to conduct a systematic review of the literature to evaluate the exercise programs used in intervention studies focused solely on hip-joint osteoarthritis, to decide whether their exercise regimens met the new guidelines, and to determine the level of support for exercise-therapy interventions in the management of hip-joint osteoarthritis.

METHODS

A systematic literature search of 14 electronic databases was undertaken to identify interventions that used exercise therapy as a treatment modality for hip osteoarthritis. The quality of each article was critically appraised and graded according to standardized methodologic approaches. A 'pattern-of-evidence' approach was used to determine the overall level of evidence in support of exercise-therapy interventions for treating hip osteoarthritis.

RESULTS

More than 4,000 articles were identified, of which 338 were considered suitable for abstract review. Of these, only 6 intervention studies met the inclusion criteria. Few well-designed studies specifically investigated the use of exercise-therapy management on hip-joint osteoarthritis. Insufficient evidence was found to suggest that exercise therapy can be an effective short-term management approach for reducing pain levels, improving joint function and the quality of life.

CONCLUSIONS

Limited information was available on which conclusions regarding the efficacy of exercise could be clearly based. No studies met the level of exercise recommended for individuals with osteoarthritis. High-quality trials are needed, and further consideration should be given to establishing the optimal exercises and exposure levels necessary for achieving long-term gains in the management of osteoarthritis of the hip.

A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. This part of the article discusses open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. Topics discussed in this part of the article include continuous passive motion, early weight bearing in motion, postoperative bracing, and home-based rehabilitation.

A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics

Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. This part of the article discusses open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematic review

Considered from medical, social or economic perspectives, the cost of musculoskeletal injuries experienced in the workplace is substantial, and there is a need to identify the most efficacious interventions for their effective prevention, management and rehabilitation. Previous reviews have highlighted the limited number of studies that focus on upper extremity intervention programmes. The aim of this study was to evaluate the findings of primary, secondary and/or tertiary intervention studies for neck/upper extremity conditions undertaken between 1999 and 2004 and to compare these results with those of previous reviews. Relevant studies were retrieved through the use of a systematic approach to literature searching and evaluated using a standardised tool. Evidence was then classified according to a "pattern of evidence" approach. Studies were categorised into subgroups depending on the type of intervention: mechanical exposure interventions; production systems/organisational culture interventions and modifier interventions. 31 intervention studies met the inclusion criteria. The findings provided evidence to support the use of some mechanical and modifier interventions as approaches for preventing and managing neck/upper extremity musculoskeletal conditions and fibromyalgia. Evidence to support the benefits of production systems/organisational culture interventions was found to be lacking. This review identified no single-dimensional or multi-dimensional strategy for intervention that was considered effective across occupational settings. There is limited information to support the establishment of evidence-based guidelines applicable to a number of industrial sectors.