• THE FOLLOWING PROTOCOL HAS BEEN ESTABLISHED AS A REFERENCE FOR REHABILITATION FOLLOWING AUTOLOGOUS CHONDROCYTE IMPLANTATION OF THE TROCHLEA. THE REHABILITATION PROGRESSION IS SIGNFICANTLY SLOWER THAN THAT OF A FEMORAL CONDYLE LESION.

• THIS IS TO SERVE ONLY AS A GUIDELINE. INDIVIDUAL CASES WILL VARY. THE EMPHASIS OF THIS PROTOCOL IS TO PRESERVE THE STABILITY OF THE SURGICAL PROCEDURE AND RETURN THE PATIENT TO AN OPTIMAL LEVEL OF FUNCTION.
• ALTHOUGH TIME FRAMES HAVE BEEN ESTABLISHED, IT IS MORE IMPORTANT THAT GOALS ARE REACHED AT THE END OF EACH PHASE PRIOR TO PROGRESSION TO THE NEXT.
• IT IS IMPORTANT TO AVOID EXCESSIVE LOADING THROUGH THE GRAFT SITE TO ENSURE PROPER HEALING. INFORMATION REGARDING THE LOCATION OF THE IMPLANTATION SITE SHOULD BE OBTAINED FROM THE SURGEON.
• PAIN AND SWELLING NEED TO BE CAREFULLY MONITORED THROUGHOUT THE REHABILITATION PROCESS. IF EITHER OCCUR, THE CAUSATIVE ACTIVITY NEEDS TO BE IDENTIFIED AND APPROPRIATELY ADJUSTED TO LESSEN THE IRRITATION. IGNORING THESE SYMPTOMS MAY COMPROMISE THE SUCCESS OF THE SURGERY AND THE PATIENT'S OUTCOME.

Weeks 0 - 2

• Non weight bearing for 2 weeks
• Hinge brace locked at 0^o. Unlock for CPM and exercise only

Weeks 2 - 4

• Partial weight bearing (30 - 40 lbs.) with bilateral crutches (If the patient is extremely small or large, this may vary.)
• Important to avoid twisting/pivoting on involved knee while weight bearing.
• Brace locked at 0^o with weight bearing

Weeks 4 - 8

• Continue PWB status. May progress to one crutch if gait pattern is normal and pain free with 2 crutches
• Important to avoid twisting/pivoting on implanted knee
• Begin to open hinge brace from 20 to 3^o with ambulation, if quadriceps control is adequate to obtain normal gait pattern

Weeks 8 - 12

• Progress to full weight bearing (FWB) and discard crutches if pain free with minimal edema. Gait pattern should be normal

CPM

• Begin 6 - 24 hours after surgery
• Use in 2 hour increments for 8 - 10 hours/day
• May use CPM for up to 6 weeks. Important to use it for the first 4 weeks
• From weeks 0 - 3, start with settings of 0 - 30^o, depending upon the location of the defect. Allow leg to dangle over the edge of the bed to increase bending motion.
• Increase by 5^o per day per patient comfort and edema
• By week 6, settings from 0 - 90 to 110^o should be attained

ROM Exercise

• During weeks 0-4, do active-assisted flexion ROM exercises within pain limits; passive knee extension ROM techniques
• Patella mobilization - start 1-2 weeks post op
• Hamstring, gastroc/soleus, and hip stretching
• Goal: 0-40^o by 4 weeks, 90^o by 6 weeks, 120^o by 8 weeks post op.

Edema Control

• Ice, elevation, edema modalities and edema massage as needed (no non-steroidal anti inflammatory medication)

Strengthening

• Isometrics-quad sets, straight leg raises and hamstring isometrics, straight leg raises in four directions (hip flexion, extension, abduction, adduction). Do exercises in the brace if quadriceps control is inadequate. Knee must be kept straight. Can add resistance above the knee
• Consider use of biofeedback or electrical stimulation for muscle reeducation

Weeks 4-10

• Progress QS, SLR, hip strengthening as tolerated, can add resistance below the knee if quadriceps control is adequate
• Begin isometric closed chain exercise (foot in fixed position) starting with light resistance. For example, sitting in chair and lightly pushing on floor or on wall at varying angles
• At weeks 6-10, begin weight shifting activities with involved leg extended if FWB

Weeks 10-12

• Light open chain isometrics with knee in fixed position at multiple angles of flexion
• Theraband resistance exercises from 0-30^o only
• Continue SLR strengthening
• Begin hamstring strengthening - manual resistance, progressive resistance exercises (PRE's), machines, etc.
• Progressive resistive exercises (PRE's) for gastroc/soleus, hips and upper quadrant
• Consider multi-hip for involved side unilateral weight bearing/balance/stabilization training

Cardiovascular/Walking Activities

• Choose at least one activity for 25 - 40 minutes, 3 times/week: cycle with uninvolved extremity; upper body ergometer
• Weeks 8-12: stationary bike with light resistance only; stair master in limited arcs of motion from 0-30^o; swimming with straight leg kick only, upper body ergometer

Functional/Balance Activities

• Weeks 8-12: balance training on involved leg - eyes open, eyes closed if motor control adequate; consider balance/tilt board, Baps, ball throws, etc.

Goals to be met at the end of Early Phase

• Full ROM
• Minimal/slight edema level
• Pain free tolerance to Early Phase exercise with adequate stability, motor control
• Minimal occasional pain only

• Maintain full active/passive ROM, patella mobility and surrounding muscular flexibility (quads, hamstrings, gastroc/soleus, abductors and adductors)

Strengthening/Cardiovascular/Walking Activities

• Continue cardiovascular training (Stair master - limited arc of motion from 0-45^o, bicycling, upper body ergometer, swimming)
• May begin treadmill at slow to moderate pace and may begin walking backwards after the 12^th week post op

Balance/Functional Training

• Progress balance/proprioceptive training (i.e., ball throws or T Band resistance in unilateral stance, etc.)
• Consider slide board
• Consider sport cord lateral drills

Goals to be met at the end of Transitional Phase

• Minimal pain ROM
• >60% quadriceps and hamstring strength
• Pain free status with Transitional Phase exercise, no edema
• Minimal, occasional pain

Strengthening

• Advance closed chain strength training - increase resistance and decrease reps. Progress to 90^o flexion with closed chain exercises if patient is pain free.
• Initiate unilateral closed chain strengthening

Cardiovascular Training/Walking

• Continue per Transitional Phase endurance training
• Treadmill - progress to fast walking and backward walking
• Initiate slight incline 2-3^o at 8-10 months post op

Functional/Balance Training

• Initiate light plyometric activity at 9 months (vertical, horizontal jumping, bilateral lateral jumping etc.); emphasis on eccentric control with landing. Progress as tolerated and per motor control to diagonal and unilateral plyometric training

• Initiate impact training
• Initiate light jog on treadmill utilizing slight incline; start with 2 minute walk, 2 minute jog, etc.

Strengthening

• Advance training with heavier weights and fewer repetitions to increase size/mass of muscles
• Emphasize single leg loading and loading in full weight bearing

Function/Cardiovascular Training

• Per physician guidelines, a progressive running and agility program should be incorporated beginning with straight plane running with increasing speeds
• Cutting drills should begin with slow "S" cutting with progressive speeds; if stable, sharper "V" cutting may be incorporated with sport specific drills
• High impact activities (basketball, tennis, etc.) may begin at 16 months if pain free
• Return to sports may vary according to individual MD guidelines

For specific questions on the rehab protocols, please contact Lisa Giannone, P.T.

San Francisco, California

Phone: 415-387-6564

Fax: 415-387-2013

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THIS MATERIAL DOES NOT CONSTITUTE MEDICAL ADVICE. IT IS INTENDED FOR INFORMATIONAL PURPOSES ONLY. PLEASE CONSULT A PHYSICIAN OR PHYSICAL THERAPIST FOR SPECIFIC TREATMENT RECOMMENDATIONS.

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