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Rehabilitation protocol after microfractures for cartilaginous defects

Article written by: ANDREI BOGDAN, MD, Orthopedics-traumatology doctor

protocol recuperare microfracturi pentru defecte cartilaginoase

Recovery protocol after microfractures for cartilaginous defects

Phase 1: 0-2 postoperative weeks

Objectives:

  • Protecting the cartilaginous area
  • Favoring healing
  • Obtaining and maintaining a complete extension
  • Obtaining a 90-degree flexion
  • Fighting local edema
  • Strengthening the quadriceps muscle
  • Avoidance of thrombus formation in the pelvic limbs

Activities

  • Kinetec: Use the kinetec (a device that will mobilize your knee) as much as possible in the first two weeks. Remove your orthosis during these exercises. You should use the device for at least 10 hours a day. The knee extension should be set at -5 degrees to favor its full extension. You must be able to stretch your knee completely. The device is designed to include a 5-second extension pause. The flexion module should be set at 30-40 degrees and should be gradually increased to 90 degrees as you tolerate more and more knee flexion.
  • Orthosis/crutches: For patellar and trochlear injuries, you will wear a knee orthosis, set to stop the knee from bending more than 30 degrees, and will keep the knee in full extension. You can put your entire body weight on the operated leg, in the limit of pain. In the beginning, you will use crutches on the go and you will give them up once you have regained your confidence in your knees. For condylar defects, the orthosis is not used, but you will use the crutches for a longer period, also the loading on the operated leg is being done progressively, according to the doctor's advice.
  • Apply ice to reduce pain and swelling. Use ice according to the following schedule: 20 minutes ice, 20 minutes without during the first postoperative day. Then apply ice as many times as you feel the need for 15-20 minutes over the next postoperative days. Put a towel between the skin and the ice to prevent frostbite.
  • You can shower and wet the incisions of the portals. However, do not soak them in a tub or Jacuzzi until the threads have been removed.
  • Take an aspirin every morning.
  • You can wear elastic stockings under the knees to prevent swelling of the feet. Also, do at least ten ankle mobility exercises to prevent edema and prevent thrombophlebitis.

Exercise program:

Exercises of the quadriceps muscle - to maintain muscle tone in the thigh and to strengthen the knee.
Sit on your back with your knee at maximum extension as shown. Contract and maintain the contraction of the anterior muscles of the thigh (quadriceps), the knee becoming flattened and straight. If done correctly, the patella will slide proximal to the thigh muscles.
Hold the contraction for 5 seconds. Perform at least 20 repetitions 3 or 4 times a day.

Heel support - to fully stretch your knee, lie on your back with a towel rolled under your heels, or sit on a chair with your heel on a stool, just like in the picture. Allow the knee to relax in extension. If the knee will not stretch completely, you can put a weight (900 g to 2.25 kg) on the thigh, just above the kneecap. Try to maintain this position for 5 minutes, 3 times a day. While maintaining this extension position, work the quadriceps exercises.


Heel slips - to regain your knee flexion.
While lying on your back (figure), slide your heel to bend your knee. Continue to bend the knee until you feel a "stretch" in the anterior region of the knee. Hold the flexion for 5 seconds and then ease the flexion and stretch the knee. While the knee is stretched, you can combine the exercises and repeat the quadriceps. Repeat 20 times, 3 times a day.

Sitting heel slips - to regain your knee flexion.
While sitting on a chair, pull your heel back as if you were trying to put your foot under the chair. Hold for 5 seconds and return to the extended position. You can help the opposite leg if you feel the need. Repeat this exercise 20 times, 3 times a day.


Plantar flexion and dorsiflexion of the foot - mobilize the foot up and down to stimulate circulation in the foot. Perform at least 10 such movements every hour.

Phase 2 - 2 to 6 weeks postoperatively

Objectives:

  • Do not overload the knee, promoting healing
  • Regain complete knee mobility
  • Start muscle strengthening

Exercise program:

Medicinal bicycle
Use a medicinal bicycle to mobilize the knee and increase its flexion. If you cannot perform complete pedals, then keep the operated foot on the pedal and pedal back and forth until the knee bends enough to allow a complete cycle. Most people manage a complete cycle first in the opposite direction, followed by the forward direction. You can use the bike, without resistance, for 10 to 20 minutes a day. Adjust the height of the bicycle saddle so that when you are riding the bike, the knee is fully extended when the pedal is in the lowest position. Pedaling will be done with the help of the forefoot (toe), and not the heel.


Exercises of the quadriceps muscle - to maintain muscle tone in the thigh and to strengthen the knee.
Sit on your back with your knee at maximum extension as shown. Contract and maintain the contraction of the anterior muscles of the thigh (quadriceps), the knee becoming flattened and straight. If done correctly, the patella will slide proximal to the thigh muscles.
Hold the contraction for 5 seconds. Perform at least 20 repetitions 3 or 4 times a day.

Heel support - to fully stretch your knee, lie on your back with a towel rolled under your heels, or sit on a chair with your heel on a stool, just like in the picture. Allow the knee to relax in extension. If the knee will not stretch completely, you can put a weight (900 g to 2.25 kg) on the thigh, just above the kneecap. Try to maintain this position for 5 minutes, 3 times a day. While maintaining this extension position, work the quadriceps exercises.

Heel slips - to regain your knee flexion.
While lying on your back (figure), slide your heel to bend your knee. Continue to bend the knee until you feel a "stretch" in the anterior region of the knee. Hold the flexion for 5 seconds and then ease the flexion and stretch the knee. While the knee is stretched, you can combine the exercises and repeat the quadriceps. Repeat 20 times, 3 times a day.


Short lifts
With your knee bent over a rolled towel or blanket, lift your leg so that your knee is fully extended. Keep your knee locked in extension for 5 seconds, then lower gently. Repeat 20 times.

Standing hamstring curls
Position yourself facing the wall, using it for balance and support. While sitting on the limb without an LIA injury, bend your knee and raise your knee to the bottom. Keep this position flexed for one second. Gently lower your limb back to the floor. Keep your hips aligned as shown. Repeat 20 times.


Peak lifts
Stand facing a table with your hands on it for balance and support. The knees will be in maximum extension. Contract the quadriceps and keep the knee in maximum extension. Get up on your toes while keeping your knees in maximum extension. Hold this position for one second, then return to the starting position. Repeat 20 times.

Hip Abduction
Lie on your healthy side. The knees will be in maximum extension. Raise the operated limb to 45 degrees, as in the figure below. Hold this position for a second, then return gently. Repeat 20 times.

Phase 3: 8-12 weeks postoperatively

Objectives:

  • Walk normal
  • Regain complete knee mobility
  • Regain your muscle strength

Exercises program:

Medicinal bicycle
Use a medicinal bicycle to mobilize the knee and increase its flexion. If you cannot perform complete pedals, then keep the operated foot on the pedal and pedal back and forth until the knee bends enough to allow a complete cycle. Most people manage a complete cycle first in the opposite direction, followed by the forward direction. You can use the bike, without resistance, for 10 to 20 minutes a day. Adjust the height of the bicycle saddle so that when you are riding the bike, the knee is fully extended when the pedal is in the lowest position. Pedaling will be done with the help of the forefoot (toe), and not the heel.

Slips on the wall
Stand up straight with your back and bottom touching the wall. Place your feet 30 cm away from each other and 6 cm away from the wall. Bend your knee and slide along the wall until your knees are bent at 45 degrees. Hold this position for 5 seconds and then return to the starting position. Perform 3 sets of 10-15 repetitions.
In addition, you will continue the exercises started during the second phase.

Phase 4: 12 weeks postoperatively

Objectives:

  • Complete recovery of muscle strength
  • Return to usual activities

Exercises program:

Hamstring stretching
Perform these exercises in the position in the next figure. Bend forward at the hip, keeping the knee fully extended, until you feel a slight stretch in the back of the thigh and knee. Hold the stretching position for 15-20 seconds and repeat 3-5 times.

Stretching the quadriceps
This exercise is performed as in the adjacent position. Perform a movement near the heel. When you feel a stretch in the front of the thigh and knee, hold the position for 15-20 seconds for 3-5 repetitions.

Stretching the leg - In the illustrated position, keep the heel straight on the floor, the knee being in maximum extension. Lean forward at the thighs, with your hands supporting your weight. When you feel a slight stretch in the back of the leg and knee, hold this position for 15-20 seconds for 3-5 repetitions.

Squatting in the chair - In these exercises, lower your bottom towards the chair until you have sat on it. Do not sit in a chair, instead, get up immediately and return slightly to the starting position. Remember to keep your head above your feet and bend your pelvis as you descend. After the first week, you can hold dumbbells while performing these exercises. Start with 1.5 - 2.5 kg in each hand. You can add 1-2 kg per week until you reach 10 kg. Perform 3 sets of 10-15 repetitions.

Sliding on the wall - Stand up straight with your back and bottom touching the wall. Place your feet 30 cm away from each other and 6 cm away from the wall. Bend your knee and slide along the wall until your knees are bent at 30 degrees (DO NOT BEND MORE THAN 30 DEGREES - ESPECIALLY FOR ROTULIAN AND TROCHLEAR MICROFRACTURES). Hold this position for 5 seconds and then return to the starting position. Perform 3 sets of 10-15 repetitions each.


Foot Press (PATIENTS WITH PATELLAR OR TROCHLEAR MICROFRACTURES DO NOT DO THIS EXERCISE)
For the starting weight, use an amount that you feel is light enough to perform 20 repetitions. Use this weight for a week, then you can gradually increase it. The weight will be increased by 2.25 kg every 7-10 days, as long as you can perform 20 repetitions for 3 sets.
In this exercise, avoid allowing your knees to crack or extend rapidly as you reach the full stretch position. Avoid starting exercises with excessively flexed knees. Do not bend your knees so much that your leg and hip come into contact.

Resistant hamstring creases
If you have access to a hamstring creaser (figure), then you can start using it. As with the foot press, start with a reasonable weight with which you will perform the exercises during the first week. You can increase your weight by 2.25-5 kg every 10 days, as long as you can work 3 sets of 20 repetitions. If you do not have access to a hamstring cramp, you can continue with the hamstring cramps in your legs, attaching weights to your ankles. Start with 1.5-2.25 kg and add 0.5 kg each week until you reach 3 sets of 15 repetitions with weights of 4.5 kg.

Step-up exercises - For this exercise, place a small stool, a book, or a piece of wood on the floor, about 60 cm from a wall. Place your injured foot on the stool. Maintain your balance by leaning on the wall (figure). Lift yourself slightly on the stool and allow your knee to stretch slightly. Gently lower your opposite foot to the floor, trying not to rest, instead, immediately returning to the "stepped up" position. Start this exercise with 5 repetitions of 3 sets in the first week. Put add one repetition to each session, until you reach 15 repetitions if you do not feel pain in the knee or at the insertion site of the patellar tendon.

NB: All progressions are approximations and should only be used as guidance. Progression will be based on the individual condition of the patient, which is assessed throughout the treatment process.
    
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