Quadriceps and Patella Tendon Repair Progression (2-6 weeks) | OEP371 - Ortho Eval Pal: Optimizing Orthopedic Evaluations and Management Skills

Episode Transcript
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Speaker 1 (00:00):
Hello everyone and welcome to episode 371 of the
OrthoEvalPal podcast.
I'm your host, paul Marquis,and today we're going to be
doing part two of our quadricepsand patella tendon repair
progression, which is going tobe the two to six week time
frame.
We're going to be talking aboutsome of the precautions we need
to pay attention to at thispoint.
We'll go over some weightbearing considerations, range of

(00:21):
motion progression, and we'lltalk about some of the exercise
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Welcome back everyone.

(01:53):
So we're working on part two ofour patella or quad tendon
repair rehab segment.
If you didn't listen to ourfirst episode, which was 370,
you may want to go back and dothat first.
It's just going to make a nicesteady progression in regards to
how we manage these patients.
I talk about some of theprecautions and things we have
to really be careful with, andthen it's going to kind of slide
into today's section, whichshouldn't take too long because
it's similar to our firstsection, just with a nice steady

(02:15):
progression.
So now we're at the two to sixweek post-op period.
Six-week post-op period we needto remember that protocols are
guides, okay, so every patientresponds differently to surgery
or to certain injuries, or maybethere are other complications

(02:36):
that happen during the time ofthis injury, but they may
respond a little differently.
They may sense pain differentlythan others.
Maybe some are stiffer thanothers.
Some really like to hold on totheir swelling and others, you
know, really get rid of itquickly.
And sometimes we have patientswho can start to fire up that
quad, which is very difficultafter a quad tendon or patella

(02:59):
tendon repair.
But some of them can fire it ona little bit sooner than others
and then others might struggle.
So you may need to pivot andadjust and that's okay, all
right.
I've always had really goodsuccess treating these diagnoses
and the key here is to justprogress nice and steady.
It's better to be a littleconservative and to deal with a

(03:23):
little bit of stiffness or maybea little bit of quad shutdown
or whatever it might be, than topush too aggressively and
re-tear them, because thenyou're in trouble, then you're
into a second surgery, thesuccess rates are not as great
after that and it makes it justso much more challenging for the
patient.
So we need to remember herethat we still have these
precautions for re-tear.

(03:44):
We can't be pushing these folksreally aggressively into
flexion of the knee.
We can't have them activelyextending the knee in the open
chain or doing things likesquatting activities or trying
to go up steps.
They're still in their brace.
So they're still locked intofull extension pretty much all
the time when they're sleeping,when they're walking.
The only time they're not inthe brace um or uh, it's

(04:08):
unlocked would be in rehab.
You know when or when they'redoing exercises at home, such as
, you know, doing something likea heel slide or something like
that.
Um, that's the only time youwould really unlock or remove
the brace, and I typically havepeople take the brace off.
They're usually sick and tiredof it.
So when they're in the clinic Ihave them take it off.
But I also tell them right upfront what they need to be
cautious with that they can'tjust do a straight leg raise

(04:30):
without assistance or sit offthe edge of the table and let
the leg hang off the end, allright.
So something you want to thinkabout here is starting to regain
this range of motion.
Now.
Remember we weren't pushing ittoo much at first.
Between that three to six weekrange we need to start getting
up to about 90 degrees offlexion.
We shouldn't get it in thethird week.

(04:51):
It should be something that isvery progressive a couple, two,
three, four degrees, fivedegrees maybe every time they
come into the clinic.
All right, this is the toughestperiod in regards to getting
range of motion back.
The knee is naturally stiff andtight because it's been in full
extension and in the brace allthe time, but they're also very
apprehensive, so they want tofight you.

(05:12):
So you're trying to flex them alittle bit, um and, and they're
trying to kind of push backbecause they're afraid, um.
One thing I do is I have themdo a lot of heel slides on their
own because again they get thatreciprocal inhibition when
their hamstrings are contracting, their quads are relaxing.
So they can kind of get thatnaturally and sometimes I'll do
a little active, assistive andtry to help them a little bit.

(05:33):
But it's very tough to get that90 degrees.
And what I have found from myexperience is that once we get
to that 90 degree mark whichshould happen, you know, around
the five to the six week periodyou don't want to push on this
hard, you want to just let themget it kind of naturally with a
little bit of assistance.
Once you get to that 90 degreeposition, it seems like they

(05:55):
they go over a hump and thengetting past that gets easier.
Okay, uh, and so again, we'restill not doing any active open
chain knee extension.
So I like to have these folksdo plenty of heel slides.
This is a time frame when youcan start using blood flow
restriction training.
You can do it on bothextremities.
After the two-week mark we canstart it on the affected side

(06:18):
where they had the surgery,maybe starting with the BFR on
there while they're doing somegravity-assisted extensions, you
know, trying to get that kneeto zero.
Now if they don't have zero,we've got a problem on our hands
, because they should have beenin this brace locked at zero
right from the get-go andthere's really nothing like a
cyclops lesion or anything likethat that could cause them to

(06:39):
lose their extension, except formaybe some swelling which would
cause them to stay in a flexposition.
But if they're in their kneeextension brace they shouldn't
have a problem getting to fullextension.
But if so, you do need to getthem doing some gravity assisted
knee extension so they can getto zero without any issues.

(07:00):
Now, straight leg raises.
You should be able to have themdo straight leg raises in the
side lying position, in theprone position, and when I do
side lying I take them out ofthe brace.
Now I know many protocols willsay leave them in the brace.
I've never had an issue withthis.
When I have them on their sideto do that straight leg raise, I
have them turn like a quarter,turn forward just a little bit
more, so they're more likealmost in a more prone position,

(07:22):
but they're extending the hipand extending the leg and
abducting it at the same time,so the knee can't fall into
flexion, it can only fall intoextension.
So that's how I like to do thestraight leg raises.
If they're doing it on the side, then I have them roll onto
their stomach.
They do some prone ones andthen they'll also roll on to the
affected side and do someadduction.

(07:44):
Sometimes I prefer to doadduction in other positions
than side lying.
I just don't find it to be avery effective way to do it.
I might have them do somebolster squeezes or something
like that.
Now, if you're going to do somesupine straight leg raises,
which you should start at aboutthe three you know two to three
week period, I would do themwith the brace in full extension

(08:06):
on the leg and then I startthem active, assistively.
I go at these really easily, Igauge how much they work and how
high we go, and I might startwith three sets of five and over
the course of three to sixweeks, you know, get them doing
about three sets of tenindependently, with no extra
weight on that leg and justdeveloping good leg control.

(08:26):
Now again, like I said lasttime, I love doing ball bridges.
I'm not really curling the ballunder.
I mean, if they're super fitand they're doing fine and
they're gaining that range ofmotion nicely, you might start
with some bridges and thenhamstring curls at the same time
I'm supporting that foot on theball just to make sure it
doesn't slide off.
I might have them do somestanding heel raises.

(08:48):
I'll also put them in the proneposition, have them do some
active knee flexion to the endrange and then I also have them
do some upper body ergometry.
And if I didn't do some BFR onthe legs, I might throw some on
the arms at this point and justget, you know, a really nice
pump and get some physiologicresponse and some human growth
hormone release to help promotesome healing here.

(09:08):
So these folks I might be, youknow, seeing them, you know,
once to twice a week, just kindof monitoring them a little bit,
giving them some home exercises.
I want to check on that scar.
Maybe I want to do some scartissue massage and teach them
how to do that once the incisionis closed and healed up well.
Also, you want to make surethat they still have some good
patella mobility.

(09:29):
Again, you don't want to reaminto superior gliding, but good
medial lateral motion isimportant, and you want to start
to see that patella start tomigrate superiorly with a quad
set as they're progressing, andthat should come along nicely.
So there you have it, folks,Second stage of the rehab for
quad and patella tendon rehab.

(09:50):
If you haven't already done so,head over to our new website.
Check it out.
I'd love to know what you think.
Send me any feedback that youwould good or bad, or if there's
anything you want to see thatyou might want on there.
I had somebody the other daysay hey, I just grabbed one of
your eBooks wondering if you hadan eBook on this particular
topic and, as a matter of fact,I'm going to be coming out with
some new ones soon and it'sgoing to be fulfilling that need

(10:12):
, and so be sure to check it out.
Um, hope you all have a greatday, be kind to each other and
take care.

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Quadriceps and Patella Tendon Repair Progression (2-6 weeks) | OEP371

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