CHARLES UNIVERSITY IN PRAGUE FACULTY OF PHYSICAL EDUCATION AND SPORT DEPARTMENT OF PHYSIOTHERAPY BACHELOR DEGREE OF PHYSIOTHERAPY BACHELOR THESIS CASE STUDY OF PHYSIOTHERAPEUTIC TREATMENT OF A PATIENT AFTER RECONSTRUCTION OF ANTERIOR CRUCIATE LIGAMENT Author: RafaelAlexandros Vasiliou Supervisor: Mgr. Ivana Vláčilová Prague, Czech Republic 2015 Abstract Title: Case study of diagnosis of anterior cruciate ligament reconstruction Author: RafaelAlexandros Vasiliou In this Bachelor Thesis I analyzed the anatomy of the knee joint including bones, ligaments, muscles and nerves, kinesiology and biomechanics, ACL rupture and its mechanism. I also included some chapters which are related to the ACL rupture like risk factors, prevention and rehabilitation. During the clinical work placement I applied individual therapy to my patient for eight times during two weeks including individual exercise program to the gym. The therapeutic plan was based according to my findings during the first day of meeting when I performed the initial kinesiologic examination. Detailed description of the initial kinesiologic examination and day to day therapy are included in the special part of this Bachelor Thesis. After eight therapy sessions the result was positive with the objective findings to confirm it. The strength of the muscles of the right lower extremity of the patient was improved and the range of motion of the right knee which is the most important was also improved for 20 degrees. More details about the final kinesiologic examination and results are also included in the special part of this Bachelor Thesis. KEY WORDS: Anterior Cruciate Ligament, balance exercises, m.quadriceps femoris, m.vastus medialis, Range of Motion, Proprioceptive Neuromuscular Facilitation, Post Isometric Relaxation. Abstrakt Název: Kazuistika fyzioterapeutické péče o pacienta po rekonstrukci předního zkříženého vazu Autor: RafaelAlexandros Vasiliou V této bakalářské práci uvádím anatomii kolenního kloubu včetně popisu kostí, ligament, svalů a nervů. Uvádím i kinesiologii, biomechaniku a popis mechanismu vzniku ruptury ACL. V kapitolách vztahujících se k problematice ruptury ACL popisuji i rizikové faktory, prevenci a rehabilitaci. Během klinické praxe jsem v době dvou týdnu aplikoval 8x individuální terapii včetně cvičebního programu v tělocvičně. Fyzioterapeutický plán byl sestaven na podkladě vstupního kineziologického vyšetření, které bylo provedeno v první den seznámení s pacientem. Detailní popis tohoto vyšetření a jednotlivých terapeutických jednotek je uveden ve speciální části této bakalářské práce. Po osmé terapii bylo dosaženo pozitivního objektivního výsledku. Svaly pravé dolní končetiny byly posíleny a o 20 stupňů se zlepšil i rozsah pohybu pravého kolenního kloubu. Více informací z výstupního kineziologického vyšetření a výsledky jsou popsány opět ve speciální části této bakalářské práce. Klíčová slova: přední zkřížený vaz, balanční cvičení, m.quadriceps femoris, m.vastus medialis, rozsah pohybu, proprioceptivní neuromuskulární facilitace, postizometrické relaxace Acknowledgement I would like to thank all my teachers who helped me a lot and for the knowledge I gained from them during my studies in the Faculty of Physical Education and Sport in Prague. Special thanks to my supervisor Mgr. Ivana Vláčilová who helped me by giving me instructions and advice for the development of my Bachelor Thesis. I also want to express my thanks to my supervisor PhDr. Mahr – Edwin to the C.L.P.A. (Centrum léčby pohybového aparátu) where my clinical practice took place for the special knowledge I gained from him. I would also like to thank my patient who was very understandable and cooperative with me during the two weeks of my clinical practice. Finally, many thanks to my family and my girlfriend who were supporting and encouraging me during my whole studies in Czech Republic. Declaration I declare that this Bachelor Thesis has been based on my own individual work. The clinical work placement took place at the C.L.P.A. (Centrum léčby pohybového aparátu) from 05.01.2015 until 16.01.2015. During my clinical practice I was supervised by PhDr. Mahr – Edwin and by Mgr. Ivana Vláčilová from the department of physiotherapy of Faculty of Physical Education and Sport in Prague. I was responsible for a patient with diagnosis of reconstruction of anterior cruciate ligament of the right knee. All examinations I used and treatment methods I applied are based on my knowledge I gained during my studies. All the information I used for the development of my Bachelor Thesis has been taken from a list of literature which is included at the end of this project. RafaelAlexandros Vasiliou April 2015, Prague Contents 1. PREFACE ..................................................................................................................... 1 2. GENERAL PART......................................................................................................... 2 2.1. Anatomy of the knee joint ......................................................................................... 2 2.1.1. Bones of the knee joint ........................................................................................... 3 2.1.2. Patella...................................................................................................................... 3 2.1.3. Menisci.................................................................................................................... 3 2.1.4. Joint capsule ............................................................................................................ 4 2.1.5. Ligaments of the knee joint .................................................................................... 4 2.1.6. Muscles and innervation of the knee joint .............................................................. 5 2.1.7. Nerve supply of joints ........................................................................................... 10 2.1.8. Vascular supply and lymph supply of the knee joint ............................................ 10 2.2. Kinesiology and Biomechanics of the knee joint .................................................... 10 2.3. Movements of the knee joint ................................................................................... 12 2.4. Instability of the knee joint ...................................................................................... 12 2.5. Sports injuries - Ligament injuries........................................................................... 12 2.5.1. Anterior cruciate ligament rupture ........................................................................ 14 2.5.2. Epidemiology for ACL ruptures ........................................................................... 15 2.5.3. Mechanism of ACL ruptures ................................................................................ 15 2.5.4. Risk factors of ACL injury ................................................................................... 16 2.5.5. Prevention of the ACL injury ............................................................................... 17 2.6. Biomechanical changes during level walking following ACL surgery ................... 17 2.7. Alterations in joint kinematics during walking after ACL surgery ......................... 18 2.8. Examination by the physiotherapist ......................................................................... 18 2.8.1. Specific examination of the knee joint ................................................................. 20 2.8.1.1. Lachman’s test ................................................................................................... 20 2.8.1.2. Anterior drawer test ........................................................................................... 20 2.8.1.3. Pivot shift test .................................................................................................... 21 2.8.1.4. Assessment of other structures of the knee ........................................................ 21 2.8.1.5. Further investigations ........................................................................................ 21 2.8.1.6. Magnetic Resonance Imaging ............................................................................ 22 2.9. Rehabilitation of the ACL rupture ........................................................................... 22 2.9.1. Phases of rehabilitation of the ACL rupture ......................................................... 23 3. SPECIAL PART (case study) ..................................................................................... 25 3.1. Methodology ............................................................................................................ 25 3.2. Anamnesis ................................................................................................................ 26 3.2.1. Doctor’s report ...................................................................................................... 28 3.3. Initial kinesiologic examination............................................................................... 29 3.3.1. Postural Examination ............................................................................................ 29 3.3.2. Foot arch ............................................................................................................... 30 3.3.3. Special Tests ......................................................................................................... 31 3.3.4. Anthropometric Measurements............................................................................. 32 3.3.5. Palpation (according to Lewit) ............................................................................. 33 3.3.6. Soft tissue Examination (according to Lewit) ...................................................... 33 3.3.7. Muscle Strength Tests (according to Kendall) ..................................................... 34 3.3.8. Muscle Length Tests (according to Janda) ........................................................... 35 3.3.9. Joint Play Examination (according to Lewit) ....................................................... 35 3.3.10. Examination of Movement Patterns (according to Janda) .................................. 36 3.3.11. Gait Examination (according to Janda) .............................................................. 36 3.3.12. Pelvis examination (according to Lewit) ............................................................ 37 3.3.13. R.O.M. Examination (according to Kendall) ...................................................... 37 3.3.14. Examination of deep stabilization system of the trunk (according to Kolář) ..... 38 3.3.15. Neurologic Examination ..................................................................................... 38 3.3.16. Conclusion of initial kinesiologic examination: ................................................. 39 3.4. Short-term rehabilitation plan: ................................................................................. 40 3.5. Day to day therapy ................................................................................................... 40 3.5.1. Treatment methods that used during daily therapies ............................................ 60 3.5.2. Exercises used in the gym improving patient’s condition .................................... 66 3.6. Final kinesiologic examination: ............................................................................... 71 3.6.1. Postural Examination ............................................................................................ 71 3.6.2. Foot arch ............................................................................................................... 72 3.6.3. Special Tests ......................................................................................................... 73 3.6.4. Anthropometric Measurements............................................................................. 74 3.6.5. Palpation (Soft tissue Examination) according to Lewit ...................................... 75 3.6.6. Soft tissue Examination (according to Lewit) ...................................................... 75 3.6.7. Muscle Strength Tests (according to Kendall) ..................................................... 76 3.6.8. Muscle Length Tests (according to Janda) ........................................................... 77 3.6.9. Joint Play Examination (according to Lewit) ....................................................... 77 3.6.10. Examination of Movement Patterns (according to Janda) .................................. 78 3.6.11. Gait Examination (according to Janda) .............................................................. 78 3.6.12. Pelvis examination (according to Lewit) ............................................................ 78 3.6.13. R.O.M. Examination (according to Kendall) ...................................................... 79 3.6.14. Examination of deep stabilization system of the trunk (according to Kolář) ..... 80 3.6.15. Neurologic Examination ..................................................................................... 80 3.7. Conclusion of the final examination and evaluation of the effect of the therapy .... 81 3.7.1. Prognosis ............................................................................................................... 82 3.8. Long-term rehabilitation plan: ................................................................................. 83 4. CONCLUSION ........................................................................................................... 83 5. BIBLIOGRAPHY (List of literature) ......................................................................... 84 6. SUPPLEMENTS ........................................................................................................ 87 6.1. List of figures ........................................................................................................... 87 6.2. List of tables............................................................................................................. 88 6.3. Abbreviations ........................................................................................................... 89 6.4. Approval by the Ethics Committee .......................................................................... 90 1. PREFACE Anterior cruciate ligament often occurs during sports. This type of injury is common in football, basketball, skiing and other sports with lot of stop-and-go movements, jumping or weaving. Without treatment, the injured ACL is less able to control the knee movements and keep it stable and almost every time abnormal changes are presented. My Bachelor Thesis is divided in two parts. In the first part apart from the anatomy including bones, ligaments, muscles and innervation, kinesiology and biomechanics of the knee joint which are important to be understandable for the reader, I also included special chapters explaining the mechanism of the ACL injury, specific examination of the knee joint and anterior instability, the risk factors of the ACL injury, the changes during walking after operation, the prevention and rehabilitation after an operation. These topics and some others are explained during the first part. The second and the most important part of my Bachelor Thesis includes concretely the therapeutic plan which I followed to a patient after reconstruction of anterior cruciate ligament and also specific results after the final kinesiologic examination. The reader of this Bachelor Thesis should be able to understand the general principles of ACL injury and the importance of an effective therapeutic approach during the short rehabilitation plan. 1 2. GENERAL PART 2.1. Anatomy of the knee joint The knee is a major weight – bearing joint and it is located between two of the body’s longest bones. These two facts make the knee highly susceptible to soft injury due to shear and torsion loads. The knee is a uniaxial and synovial joint. It consists of two articulations [5], [24]. One is between the femur and tibia and one between the femur and patella which permits flexion and extension as well as slight internal and external rotation [27]. The joint is bathed in synovial fluid which is contained inside the synovial membrane called the joint capsule. It plays an important role in movement related to carrying the body weight in horizontal (walking and running) and vertical (jumping) directions. Around the knee joint are present the ligaments which offer stability by limiting movements together with several menisci and bursae and protect the articular capsule (Fig.1) [5],[12]. Figure 1: Anatomy of the knee joint [1] 2