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Anyone willing to share or know the most current stuff about protocols for Patellar and/or Quad tendon repairs?
We are in the process of redesigning ours, I haven't yet done a search, but wondered if anyone would want to share?
I think I'm primarily interested in how much flexion to allow, how soon to progress the flexion, and using what methods. I don't think anyone would dispute gait training, patellar mobs, quad setting, etc. Thanks everyone...
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Jason,
This condition falls into one of those "can't be really protocoled" conditions.
So much depends on where the tear occurred, complete or partial, viability of the remaining tissue, and how soon after the tear the repair was made (older tears retract, and therefore need reinforcement via fascia, mesh, etc)
Sometimes the surgeon will permit PROM, others only AAROM, sometimes limite are set around 90 degrees. This is one of those conditions that requires a conversation with the surgeon to develop the safest program.
I do usually have to reinforce use of the brace with flexion locks to the patient. They often try and sneak without it, especially at night when going to the bathroom. I just remind them that if they suffer a reflexive quad shut-down, they will most likely over flex the knee and re-tear.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Jason, The protocol that I sent you was partially developed at a "certain" possibly military orthopaedic surgery residency in a "certain" warmer climate state located down near Mexico. Possibly.
Anyway this protocl was agreed upon by several of the attending orthopaedic surgeons in this residency along with the PTs there and takes into account some of the stuff that Duffy mentions above.
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Thanks, alex, it looks good. It is my understanding that most of these protocols are pretty similar, but wanted to start a dialogue amongst others who see this about what we're doing and why.
While I agree with John D above, the same argument (about not being protocol-able) could be made for just about any postoperative repair.
Protocols just keep everyone on the same page and keep the treatment in an agreed-upon ballpark. As other threads indicate, this sort of thing is desperately needed in our profession. John D's skill, experience and good contact with his surgeons probably gives him an advantage in this area.
Alex's protocol he forwarded (which may or may not be from a military location, and may or may not be developed at a major teaching institution's Orthopedic Surgery residency program) calls for: 1. AROM only to 45 immediately 2. AAROM up to 70 in weeks 2-4 3. AAROM up to 90 in weeks 4-6 4. AAROM to 120 in weeks 6-8 5. No active quad ROM or light PRE until week 4
This is a bit more aggressive than what I have typically seen in the past, but as a PT, I like more aggressive protocols anyway. Anyone else care to share?
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Those guidelines seem pretty close to the recommendations the surgeons use in this area for tibial tubercle transfers. Any guidelines on bracing, WB status and when non-assisted ambulation can occur?
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Sure. From this protocol mentioned above... Bracing in full extension x4 wks Open 0-30 for ambulation from 4-6 wks. Afterward opened to patients ROM measure
WB is PWB until 2 wks, then WBAT, wean crutches if NL gait.
The bracing guidelines are about right on what I have seen elsewhere, but I have usually seen WBAT from day one... J
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Hi Jason, I am currently treating a quad tendon repair (DOS: 12/10/04. I saw her 1/28/05 for the first time. She wore a brace locked in extension for 7 weeks. You can imagine how she presented! I did not receive a protocol just "ROM, gentle stretching". She actually had the brace removed when she saw me. Regaining flexion has been torture, but she is almost there. Pain meds do not seem ro work well with her. I took a Kevin Wilk course awhile ago and happened to come by a protocol in his course book. But since she was referred to PT so late after the surgery, she started off very slowly and really wasn't the protocol type. Good luck! Erica
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Hi Jason, Chris- The course I took was called "the complicated patient". Frankly, I pulled it out when I had this patient just to use as a guideline. I am not a big believer in "protocols" as everybody is different. I can fax it to you when I get into work tomorrow. Send me an email with your fax numbers. This particular patient came in on Fri and the day before in her apt building she tried to walk down the stairs with a reciprocal gait pattern, she practically fell and had to hold on to the handrails. Talk about quad shutdown, that set her back let me tell you. I will try and send you an email Good luck. Erica
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Just curious, how exactly does one tear the patellar tendon? What type of injury did these patients have exactly? (if you can reveal that sort of information) Sarah
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The two most common that I see are a direct fall onto the knee, causing a compression rupture. The other is a fall with concomitant flexion and severe quad contraction, causing the tear. Can't say I have ever seen any "regular" predisposing factors in these people...they seem to be regular folks in the 50-70 year age range. Probably that same degenerative processes that occur in the Achilles happen in the quad. These people may have "made it through" that Achilles tear age range, and now end up with the quad tear during an accident.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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My patient is a 43 y/o (female) and fell on a slippery step into full knee flexion. Went to the ER and they told her she was fine! The next day she went to here orthopaedist and needless to say the rest is history. She is also very overweight, which I doubt played a factor here but it is playing a factor in the rehab. Her knee flexion on her uninvolved side is 110 on a good day due to all the soft tissue. Erica
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Younger patients tend to tear their patellar tendons, usually with a fall on the knee like John mentioned or a sudden quad contraction. Often in the chronic tendonosis people, seen some from jumping in basketball or volleyball or with olympic/explosive lifters with histories of patellar tendon problems.
Over 40, the quad tendon tends to rupture, and it is usually from falling backward on a fully flexed knee. Overweight people seem to be more predisposed, in my experience. I once saw a lady in her late 30s with bilateral quad tendon ruptures. The usual story: overweight/deconditioned, fell suddenly on her heels with flexed knees, heard a pop and couldn't walk.
With patellar tendon ruptures in athletes, these often have the "stop and pop" type of mechanism, and the immediate effusion leads some people to prematurely declare an ACL rupture. Inability to do a SLR (at all) is the biggest thing that makes you suspicious. And prompt Ortho referral.
John, I had to laugh at your comment about "making it through" the achilles tear age range. So true!
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