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SOAP Note

S: 19 year old female collegiate gymnast was doing giants on the pit bar and hands slipped off mid swing. Landed into the pit below with more weight on the right leg, felt knee buckle bad, and heard a pop. She had to be pulled out of the pit because of how unstable her knee felt. She reports an initial pain of 9/10 when the fall happened there was sharp pain. She has a history of hyperextending her knees. She has not done anything for the injury, it just occurred

O: Major deformity of the knee, tibia and femur misaligned. Inflammation and heat over area, severe muscle guarding. Athlete is not able to perform any range of motion or manual muscles test. Neurovascular is intact but slightly diminished on affected leg; pulse can be felt in the posterior distal tibia region and the dorsal pedal region.

A: Knee dislocation with possible multi-ligament injuries (ACL, PCL, MCL)

P: Athlete was immediately taken to the hospital for further tests and attempted reduction of dislocation; referred by team physician on site. Further plans will be made when diagnosis is final; most likely surgery will occur to repair damage done followed by treatment to return to gymnastics.

Surgical Procedure

The surgical procedure for multi-ligament reconstruction is used to provide a functional and stable joint. Typically the ACL and PCL are reconstructed in the standard way and the MCL, depending on the severity, is seen to heal on its own with functional bracing1. A combined PCL and ACL reconstruction surgery begins with the decision of what type of graft to use. It is recommended an Achilles allograft is used for the PCL and a hamstring autograft is used for the ACL1. The tissue is prepared and arthroscopic instruments are placed in the correct position. To resect the hamstring graft the surgeon will make an incision along the anterior tibia where the hamstring attaches. The tendons are arranged into three or four strips, which will increase the strength of the graft, then the surgeon stiches the strips together to hold them in place1.Arthroscopic instruments are placed in the superior lateral portal, inferior lateral patellar portal, inferior medial patellar portal, and the superior medial portal1. An accessory extracapsular extra-articular posteromedial safety incision is used to protect the neurovascular structures1. Notch preparation is performed and removal of any debris of the torn ligaments is removed. The arm of the PCL/ACL guide is inserted to make the tibial tunnel for the PCL graft; the tunnel is drilled to the posterior cortex of the tibia2. The surgeon will insert their finger into the safety incision to confirm the placement of the guide wire and graft. The femoral tunnel can be made from the inside out; the right size guide wire is drilled through the aimer, through the bone, and out through a small skin incision2. The aimer is removed and an acorn reamer is used to finish the tunnel for the PCL graft. It will be anchored with a bioabsorbable interference screw and spiked ligament washer back-up fixation2. The ACL tunnels can be made with a single-incision technique2. The tibial tunnel begins externally and comes through the stump of the previous ACL footprint. The femoral tunnel is positioned on the medial wall of the lateral condyle2. The ACL graft is then put in position and anchored, by a bioabsorbable interference screw and spiked ligament washer back-up fixation, on the femoral side followed by tensioning and fixation on the tibial side2. Tension is placed on each of the grafts and the knee is put through a full range of motion as well as all the corresponding special tests (i.e. anterior drawer, lachmans, etc)1. The arthroscopic incisions as well as the hamstring incision from where the graft was taken from are stitch closed and the patient is bandaged and braced to be sent to recovery.

Goals

0-12 Weeks: Full Range of Motion, Full weight bearing and out of brace, Begin proprioceptive and strengthening exercises

4-6 Months: Start walking normally and progress to running by month 6

7-12 Months: Return to Full Activity

Rehabilitation

Phase 1 (0-6 weeks): immobilized to begin, control inflammation and effusion, muscle re-education, ROM 0-120°, full weight bearing3-12

Weeks 1-3

|General Observation |-Immobilized in brace, non weight bearing | |

|Goals |-ROM 0-110° (Passive with Active Ext) | |

| |-Adequate quad Contraction | |

| |-Partial weight bearing | |

| |-control inflammation and effusion | |

| |-protect insertion sites | |

|Range of Motion |-PROM: pull with band |20 cycles |

| |-Patella Mobilization | |

| |-Ankle Pumps w/ resistance |3x15 |

| |-Light hamstring, gastroc/soleous stretches|30 sec go through 3 times |

| | | |

| |-Straight leg raises(flexion) | |

|Strength |-Quad Sets |3x10 |

| |-Knee extension(active-assisted) |3x10 |

| | |3x10 |

| |-Cryotherapy(ice with compression) | |

| |-E-stem(NMES: small muscle contraction with| |

|Modalities |pain and edema control) |20 minutes; 3 times per day |

| | | |

| | |10 pps/bps; 10 sec on 30 off for 10 minutes|

Weeks 4-6

|General Observation |-brace when needed, partial weight bearing,| |

| |controlled pain | |

|Goals |-ROM 110-120° (Passive with Active Ext) | |

| |-Muscle Control | |

| |-Full weight bearing | |

|Range of Motion |-PROM: pull with band, possibly wall |20 cycles |

| |slides, stationary bike | |

| |-Patella Mobilization | |

| |-Hamstring, gastroc/soleous stretch |3x30” |

| | | |

| |-Leg raises (flexion, ABD/ADD) | |

| |-Multi-direction isometrics | |

|Strength |-Mini Squats |3x10 |

| |-small leg kicks(knee extension) | |

| |Calf Raises |3x15 |

| | |3x10 |

| |-Water Walking |3x10 |

| |-Upper Body Conditioning(bicep/tricep | |

| |curls, lats, crunches/sit ups/obliques) |3x20 |

| | | |

|Aerobic Training |-Cryotherapy(ice with compression) |15 minutes |

| |-E-stem(NMES: muscle firing and holds) | |

| | |3x20 per exercise |

| | | |

| | | |

| | | |

|Modalities | |20 minutes, 3 times per day |

| | | |

| | |30 pps/bps; 10 sec on 30 off for 10 minutes|

Phase 2 (7-12 Weeks): Full weight bearing, use of mobile brace into Patellar sleeve, ROM 120-135°, Begin CKC strengthening and use of Proprioceptive training, improve muscle control3-12

Weeks 7-9

|General Observation |-Full weight bearing | |

| |-no effusion | |

| |-painless ROM 120° | |

|Goals |-Normal Gait | |

| |-Increase Strength and Endurance | |

| |-Normal ADLs | |

| |-Increased Muscle Control | |

|Range of Motion |-120-130° Wall slides, stationary bike, |20 cycles |

| |manual manipulation | |

| |-Patellar Mobilization | |

| |-Hamstring, gastroc/soleous, quad, ABD/ADD,| |

| |ITB stretch |3x30” |

| | | |

| |-Straight leg raises(3-way) | |

| |-Knee ext( leg kicks off table) | |

|Strength |-Leg Press |3x15 |

| |-Wall sits |3x15 |

| |-Mini squats | |

| |-Calf raises |3x10 |

| | |5 repsx30” |

| |-double/single leg stance |3x20 |

| | |3x20 |

| |-Upper Body Conditioning (bicep/tricep | |

|Balance |curls, rows/TIY, abs on ball) |3x30” |

| |-Water Walking(inc speed) | |

|Aerobic Training | |3x25 each |

| |-Cryotherapy(Ice with compression) | |

| |-E-stem(NMES: muscle movement, get full | |

| |contraction) |10 minutes |

| | | |

|Modalities | |20 mins; 3 times per day |

| | | |

| | |70 pps/bps; 10 sec on 30 off for 7 minutes |

Weeks 9-12

|General Observation |-Full weight Bearing | |

| |-Painless ROM 130° | |

| |-Normal ADLs | |

|Goals |-Increase Strength and Endurance | |

| |-ROM 130-135° | |

| |-Walking on Treadmill 15 minutes without | |

| |pain | |

| |-Joint Stability | |

|Range of Motion |-Flex/Ext(wall slide, stationary bike, |30 cycles |

| |prone hang, manual manipulation) | |

| |-Hamstring, Gastroc/Soleous, Quad, ITB | |

| |Stretches |3x30” |

| | | |

| |-Straight Leg Raises (4-way, weighted) | |

| |-Hamstring Curls | |

|Strength |-Lunges |3x15 with 3# |

| |-Mini squats | |

| |-Heel Taps |3x10 |

| |-Lateral Step Ups |3x10 |

| | |3x20 |

| |-BAPS |3x15 |

| |-Balance on Airex(work to single leg |3x10 |

| |balance) | |

|Balance | |3x20” |

| |-Walk on Treadmill |3x45” |

| |-Upper Body Conditioning(resistance bands, | |

| |Lat pulls, dead bugs, toe touches) | |

|Aerobic Training | |15 minutes |

| |-Cryotherapy (Ice) |3x30 each |

| | | |

| | | |

| | | |

| | | |

|Modalities | |20 minutes; 3 times per day |

| | | |

Phase 3 (4-6 Months): Increase strength and endurance, Begin functionality exercises, start jogging3-11

4-6 Months

|General Observations |-Walk 20 mins without p! | |

| |-Perform all ADLs | |

| |-Full ROM all directions | |

| |-Pain Free | |

|Range of Motion |-Stretch all lower extremity muscles (need | |

| |to work back into the splits) | |

| | | |

| |-Leg Raises (4-way) | |

|Strength |-Leg Press/Ham Curls |3x25 with 7# |

| |-Heel Taps(Step-BOSU) |3x20 |

| |-Lunges (3 way floor-BOSU) |3x20 |

| |-Squats(floor-BOSU) |3x15 |

| |-Wall Sits | |

| |-Bridges |3x15 |

| |-Monster walks (3-way) |5x45” |

| | |3x20 |

| |-Single Leg Dyna Disc |5 passes each direction |

| |-Cup pick up | |

|Balance |-Balance on BOSU and catch a ball |3x1’ |

| |-Walk across beam(multi-direction with |5 times through |

| |pivots) |3x20 |

| | | |

| |-Eliptical-Treadmill (jogging) |5 passes |

| |-Walking Backward | |

| |-Upper Body(pushups, burpees, deadbugs/bird| |

|Aerobic |dogs, row punch/TYI) |10 minutes |

| | | |

| |Cryotherapy |5 minutes |

| | |3x25 each |

| | | |

| | | |

| | | |

|Modalities | |20 minutes twice a day |

Phase 4 (7-12 Months): Run (multi-directional)-sprinting, Maintain Strength and Endurance, Fully Functional3-11

7-12 Months

|General Observations |-Jogging 10 mins | |

| |-Full Joint Stability | |

| |-Increasing Strength | |

|Range of Motion |-Stretch all lower extremity(splits all |10 minutes a day |

| |three ways) | |

| | | |

| |-Weighted Ham curls/Leg Press (multi-way) | |

|Strength |-Lunges on Slide Board(3-way) |3x20 |

| |-Monster walks with weighted ball (3-way) | |

| |-BOSU Squats/Heel Taps |3x20 |

| |-Donkey Kicks/Fire Hydrants | |

| |-Bridges with ball(Dbl-single leg) |4 passes each way |

| |-Single Leg Calf Raises | |

| | |3x25 |

| |-Cup Pick up |3x30 |

| |-BOSU Balance catch weighted ball | |

| |-Balance on Beam (multi-directional single |3x20 |

| |leg work up to turning) | |

| | |3x40 |

|Balance |-Treadmill Running | |

| |-Upper Body (burpees, one leg tramp toss, |7 times through |

| |jumping jacks) |3x20 |

| | | |

| |-Box Jumps |10 passes; 10 stuck turns |

| |-Slide Board | |

| |-Latters (Multi directional) | |

|Aerobic |-T-Test | |

| |-Power Skips |15 minutes |

| |-Agility Shuttle |3x30 each |

| |-Sprint jump on spring board onto mat | |

| |-Leaps and Jumps | |

| | | |

|Functional |-Basic Tumbling |5 passes |

| | |3x25 |

| | |twice through each step |

| | |3 times through |

| | |5 passes |

| | |3 times timed |

| | |7 passes |

| | | |

| | |10 of each sequence and jumps |

| | |work on basic passes and ease back into |

| | |required |

Citations

1. Fanelli GC, Feldmann DD. Management of Combined Anterior Cruciate Ligament/Posterior Cruciate Ligament/Posterolateral Complex Injuries of the Knee. Operative Techniques in Sports Medicine. 1999;7(3):143-149.

2. Boyd JL, Fanelli GC, Levy BA, MacDonald PB, Marx RG, Stannard JP, Stuart MJ, Whelan DB. Management of Complex Ligament Injuries. J Bone Joint Surg Am. 2010;92(12):2235-2246.

3. Brotzman SB, Manske RC. Clinical Orthopaedic Rehabilitation: An Evidence Based Approach. Phiadelphia PA: Mosby Inc. 2011. Print. 211-423

4. Brotzman SB, Wilk KE. Handbook of Orthopaedic Rehabilitation. Philidelphia PA: Mosby Inc. 2007. Print. 375-532.

5. Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther. 2012;42(3):221-33.

6. Escamilla RF, Macleod TD, Wilk KE, Paulos L, Andrews JR. Anterior cruciate ligament strain and tensile forces for weight-bearing and non-weight-bearing exercises: a guide to exercise selection. J Orthop Sports Phys Ther. 2012;42(3):208-20.

7. Van grinsven S, Van cingel RE, Holla CJ, Van loon CJ. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1128-44.

8. Howells NR, Brunton LR, Robinson J, Porteus AJ, Eldridge JD, Murray JR. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury. 2011;42(11):1198-204.

9. Fukuda TY, Fingerhut D, Moreira VC, et al. Open Kinetic Chain Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Clinical Trial. Am J Sports Med. 2013;20(10):1-7.

10. Draper DO, Knight KL. Therapeutic Modalities: The Art and Science. Baltimore, MD: Lippincott Williams and Wilkins. 2008. Print. 168-169.

11. Ingersoll CD, Knight KL, Merrick MA, Potteiger JA. The Effects of Ice and Compression Wraps on Intramuscular Temperatures at Various Depths. J Athl Train. 1993;28(3):236-245

12. Selkowitz DM. Improvement in Isometric Strength of the Quadriceps Femoris Muscle After Train with Electrical Stimulation. J Am Phys Therapy. 1985;65(2):186-196.

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