悟理治療部落

重建手術需要12周的癒合時間,承重需拿柺杖 第一階段,手術後的4周,需保護骨頭語軟組織的癒合(要防止tibia 往下垂) 一週後接受物理治療passive ROM,如在靜止狀態可在近端tibia下放置枕頭 治療性運動:patellar mobilization,Quadriceps sets,SLR,ankle pump。 第二階段術後4~12週,4~8週仍然需要拐杖 8週之後可以考慮拿掉拐杖,但必須Knee 可以完全的伸直,knee flexion 90~100度 4-8週的治療性運動,mini squats 45*,leg press 60* 8-12週治療性運動,可已開始使用bike。 第三階段術後3~9個月，持續閉鎖練的運動，跑步機，保持quadriceps的力量及靈活性 第四階段9個月後,測試ROM,肌力與耐力要跟好腳相比85% 治療性運動，可以使用，慢跑，衝浪板，彈跳來增強下肢的訓練

悟理治療蔡主任

如何做 mini squat leg press

2010-09-19 21:34

◎ 術後復健分為4階段： PHASE I:0 ~ 4 wks 1.Brace: 1>0-1 wk:brace locked in full extension at all times 2>At 1 wk:brace is unlocked for passive ROM 2.Therapeutic exercises: 1>SLR 2>Patellar mobilization 3>Quadriceps sets 4>Hip abduction and adduction 5>Ankle pumps 6>Hamstring and calf stretching PHASE II:4 ~ 12 wks 1.Brace: 1>4-6 wks: Brace unlocked for gait 2>6-8 wks: Brace unlocked for all activities 3>8 wks: Brace discontinued 2.Therapeutic exercises: 1>4 ~ 8 wks 1)Mini-squats(0-45 degrees) 2)Leg press(0-60 degrees) 3)Standing 4-way hip exercise for flex,exten,ABD,ADD 2>8 ~ 12 wks 1)CKC terminal knee extension 2)Balance and proprioception exercises 3)Leg press(0-90 degrees) PHASE III:3 ~ 9mons 1.Weight-bearing 1>4-8 weeks: WBAT with crutches. 2>8 weeks: May discontinue crutches 2.Therapeutic exercises: 1>Continue CKC exercise progression 2>Treadmill walking PHASE IV:9mons ~ 1.Therapeutic exercises: 1>Sport-specific functional progression i.e)Jog/Run progression;Figure 8,backward running

悟理治療蔡主任

CKC有那些運動

2010-09-19 16:29

Reference: http://www.mdconsult.com.sw.lib.csmu.edu.tw:81/das/article/body/219161304-2/jorg=journal&source=&sp=15128567&sid=0/N/448727/s0095454304000806.pdf?issn=0095-4543 http://www.brighamandwomens.org/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Knee%20-%20PCL%20Reconstruction%20Protocol.pdf

PCL術後復健分四階段 Phase I (0-1 weeks) A.Reduce swelling. B.Proctect the knee in a brace. (locked in extension 除非要exercise) C.Obtain 90度 flexion the end of week 1. D.Obtain 50% weight bearing. E.Regain full passive knee extension. Phase II (2-12 weeks)半個月~三個月 A.Progress quadriceps strengthening.(ex:用腳踩在球上去控制球,站在不同地板上(水床,木板,硬板,軟板)) 從等長>>等張, 肌力>>肌耐力訓練. B.Propriceptive drills. (如果可以PWB則可用close chain) Phase III (13-20 weeks)三個月~五個月 A.Emphasize strengthening, neuromuscular control training(把感覺協調找回來) B.Begin sport or activity training. Phase IV (21+ weeks)五個月以上 A.Begin running. B.Progression of training intensity.

悟理治療蔡主任

Propriceptive drills. (如果可以PWB則可用close chain) 若無法weight bearing ㄋ

2010-09-19 21:31

PHASE I : (1) 0 - 3 weeks BRACE: Locked in full extension THERAPEUTIC EXERCISES : Quad sets, ankle pumps, SLR, hip ABD/ADD, hamstring/calf stretch, calf press with theraband, patellar mobilization(non-weight bearing, ROM:none) (2) 3 - 6 weeks BRACE: Locked in full extension for ambulation- removed for exercise THERAPEUTIC EXERCISES : Add chair slides, passive ROM in prone position(non-weight bearing, ROM: passive only to tolerance 0 to 70 degrees) PHASE II 6 - 12 weeks BRACE : (1) 6-10 weeks: unlocked for all activities (2) 10 weeks: discontinue use THERAPEUTIC EXERCISES : (1) 6-8 weeks: gait training, wall slides, mini-squats, resisted hip exercises in standing (2) 8-12 weeks: stationary bike with light resistance (to begin) and seat higher than normal, closed chain terminal knee extensions, Stairmaster, balance and propriception activities, leg press (limiting knee flexion to 90 ), open chain quad ranging from 0 - 60 degrees (weight bearing : Progress 25% per week until full weight bearing at 10 weeks, ROM : Maintain full extension and progressive flexion) PHASE III BRACE: none (1) 12 weeks - 4 months THERAPEUTIC EXERCISES :Advance closed chain strengthening, progress proprioception and balance activities, maintain flexibility (weight bearing :full , ROM : Gain full and pain-free) (2) 4 mo - 7 mo THERAPEUTIC EXERCISES: Treadmill walking, advance to jog, Add hamstring curls for strengthening (weight bearing :full , ROM :full) PHASE IV 7 months and beyond Maintain strength, endurance, and function, begin sport-specific functional progression (backward running, cutting, grapevine, etc.), progress to running, initiate a plyometric program.Return to sports in PCL brace until 1 year post-op (weight bearing :full , ROM :full and pain free) reference : http://www.orthspec.com/PDFs/PT_protocols/PCL.pdf orthopaedic specialists

悟理治療蔡主任

initiate a plyometric program. 何謂plyometric exercise 7 months會不會太久

2010-09-19 21:33

PCL術後復健運動 術後→ 2週：膝關節護具固定在完全伸直狀態最好近端小腿後側有支撐物更佳，以減少脛骨向後沈，而增加重建的移植物的壓力。股四頭肌可開始訓練。 Quadriceps sets,SLR,ankle pump 2 → 4週：開始增加膝活動度，最好有人托住小腿，避免脛骨向後。股四頭肌繼續加強訓練。 Heel slide 4週→ 8週：穿膝關節護具，膝維持伸直下可開始拐杖走路，可略踏地。mini squats 0-45度 8週→12週：可完全踏地用力。股四頭肌可繼續加強訓練。 12週→關節護具穿到3個月。股四頭肌繼續加強訓練。 9月左右：可回復正常運動。

Reference: 1.學校講義 2.This protocol has been modified from Brotzman and Wilk, which has been published in Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003: 300-302.

Reference: 第2個的網址 http://www.brighamandwomens.org/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Knee%20-%20PCL%20Reconstruction%20Protocol.pdf

四週 完全伸展膝關節固定 可以作一些夾屁股，SLR，腳踝運動，股四頭肌等長收縮，髕骨滑移 控制水腫 教導穿戴固定器，及柺杖走路技巧 四到十二週 增加被動關節活動度 開始閉鎖鍊肌力訓練 主要是共同收縮 而不是單一肌群(股四頭,臀大肌) 肌肉柔軟度 訓練(hip flexion,extension,abd,knee flexion,ankle dorsiflexion) 本體感覺 訓練(平衡板) 三個月到九個月 進階訓練(肌力與神經肌肉控制，ex腳踏車,行走) 九個月後 強度繼續增強(跑步,折返跑,八字跑,單腳跳)

悟理治療蔡主任

行走之強度ㄋ

2010-09-19 21:36

PCL Postoperative Rehabilitation Protocol: [1] Weeks 0 to 4: Protective Phase Brace:full extension Weight bearing: touch down WB Therapeutic Exercise: Quadriceps setting Ankle pumps Straight leg raises Patella and joint mobilization [2] Weeks 5 to 8: Early Strengthening Phase Brace: Open to 30 degrees weeks 5 and 6; open to 60 degrees weeks 7 and 8. Weight Bearing: Progress to full by week 8 Therapeutic Exercise: Mini squats weeks 7 and 8 Step downs weeks 7 and 8 Proprioception:one leg balance [3]Weeks 9 to 12: Advanced Strengthening Phase Therapeutic Exercise: Continue to improve quadriceps strength stationary bike Proprioception: Wobble and BAPS boards [4] 12 Plus Weeks: Functional Training and Return to Sports Phase Sport specific activities:running,cutting Proprioception: Single leg activities reference: http://orthodoc.aaos.org/provencher/PCL%20RECONSTRUCTION%20REHABILITATION%20PROTOCOL.pdf http://nemsi.uchc.edu/clinical_services/orthopaedic/knee/postop/pdfs/rehab_knee_pcl.pdf

悟理治療蔡主任

Single leg activities 請舉例

2010-09-19 21:37

一般手術後的通則： 0~4週：maximum protection phase。主要要保護開刀受傷的組織、防止發炎、減輕疼痛。所以會先用brace固定；運動則採passive或assisted ROM，另外會做像quadriceps setting的運動來預防肌肉萎縮 4~6週：moderate protection phase。此階段主要就是恢復關節活動度，增加對動作的控制及穩定度。 6~12週(~6個月)：minimum protection phase。除了要能做到full range AROM外，須著重於具功能性的活動，來恢復以往的肌力。 PCL重建手術後最先要考慮到固定的問題： 一開始當患者要載重時，可以使用hinged, range-limiting brace將knee固定在full extension，這樣固定的時間需約三周。重建後想恢復knee flexion的角度，最初可以在病患坐著時，讓重力被動的將膝蓋彎曲。 接下來的六週到十二周，開始訓練用open-chain在抗重力姿勢下做主動knee flexion，另外也要特練quadriceps (ex. 上下樓梯，受傷腳先上後下)和hamstring (ex. Knee full extension做hip extension)的強度，來幫助維持膝蓋關節的穩定 之後的半年內的訓練可以加上阻力訓練knee flexor的強度 ex. squatting。 要注意的是PCL injury在做OKC訓練時，knee flexion不可以超過60-90度(會對PCL產生stress)，在後期所做的CKC訓練，蹲下的knee flexion角度則不能超過50-60度。 比起ACL重建手術，PCL的載重能力更要循環漸進，在crutches的使用上，如果要full weight bearing需至少八到十週。 Reference： Kisner C, Colby LA. Therapeutic exercise. 5th ed., Philadelphia, F.A.Davis, 2007: 329-47, 725-42. Pathology and Intervention in Musculoskeletal Rehabilitation. (David J. Magee, James E. Zachazewski, William S. Quillen)

悟理治療蔡主任

阻力訓練knee flexor的強度 ex. squatting 請問squatting真的好嗎 有無其他better exercise

2010-09-19 21:39

0-4weeks (phase I) Goal: Protect healing bony and soft tissue, avoid posterior tibial sagging. (Put pillow under proximal posterior tibia at rest) Use brace locked knee in full extension. (0-1w) Weight bearing as tolerated with crutches and use brace locked in extension. Therapeutic exercise: Patellar mobilization, Quadriceps sets, Ankle pump, Hamstring and calf stretching, SLR. 4-12weks (phase II) Goal: 1. Increase ROM (particularly flexion>60 degree) 2. Normalize gait. 3. Improve quadriceps strength and hamstring flexibility 4-8 weeks: Weight bearing as tolerated with crutches Therapeutic exercise: Wall slides/mini-squats (0-45 degrees), Leg press (0-60 degrees). 8 weeks: Brace discontinued and may discontinue crutches. Therapeutic exercise: Leg press (0-90 degrees), Balance and proprioception exercises, Closed kinetic chain terminal knee extension using weight machine. 3-9 months (phase III) Goal: 1. Full, painfree ROM 2. Normal gait. 3. Good to normal quadriceps control 4. No patellofemoral complaints Therapeutic exercise: treadmill walking, Closed kinetic chain terminal knee extension. 9months until return to full activity (phase IV) Goals: 1. Safe and gradual return to work or athletic participation 2. Maintenance of strength, endurance, and function. Therapeutic exercise: Sport-specific functional progression, jumping (polymeric)

悟理治療蔡主任

reference最好不要用textbook Closed kinetic chain terminal knee extension於phase II & III有何差別

2010-09-19 21:42

Reference: Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. p300-302.

PCL TREATMENT PROTOCOL PHASE ONE(Weeks 1-2) Any weight-bearing exercises should be performed in brace. 1. EXERCISES Manual patella mobs – especially superior/inferior Seated heel slides using towel Supine heel slides at wall if needed Prone hangs if needed to gain full extension 2. STRENGTHING Quad sets (10 X 10sec)– the more the better – at least 100/day SLR – 3 way (avoid extension) SAQ per ROM limitations 3. STRETCHING Hamstring stretch – hold 30 seconds Gastroc stretch with towel – hold 30 seconds PHASE TWO (Weeks 2-6) Brace will gradually be unlocked to 90° around week 4-6 Continue to use ice following exercise 1. EXERCISES ROM Passive ROM 0-90° week 4-6 (depends on stiffness of pt) 0-110° week 6-8 Prone hangs (do not add weight to ankle) Heel slides – seated and/or supine 2. STRENGTHING Quadriceps setting are continued until swelling is gone. SLR (3 way) add ankle weights when ready Active knee flexion – PRONE – 0-30/40° Leg Press Wall squatting 0-30° 3. STRETCHING Continue with Hamstrings and calf stretching 4. BALANCE Weight shifting – med/lat Single leg stance – even and uneven surface – focus on knee flexion GAIT Cone walking – forward Continue to wear brace – unlocked to 90° at week 4 PHASE THREE(Weeks 6-12) Continue to use ice after exercise 1. ROM Goal is 0-140° Post-op brace will be D/C at 6 weeks and pt will be fitted for functional brace. 2. STRENGTH Continue with above exercises, increasing intensity as able Active knee flexion – prone – 0-90° Knee extensions – 0-90° Squats – Smith press or standing (wk 8) Lunges – forward and reverse; add dumbbells or med ball Single leg squats Single leg wall squats PHASE FOUR(Weeks 12-36) Exercises for strengthening should continue with focus on high intensity and low repetitions (6-10) for increased strength. Hamstring and calf stretches should also continue. Light resisted Hamstring work can be initiated at week 12. Initiate lateral movements and sports cord: lunges, forward, backward, or side-step with sports cord, lat step-ups with sports cord, step over hurdles. Initiate jogging for 2 minutes, walking for 1 until this is comfortable for the patient and then progress the time as able. Jogging should first be performed on a treadmill. Swimming – all styles reference: http://www.drlintner.com/

悟理治療蔡主任

Smith press ? please explain more detail Jogging為何要在treadmill

2010-09-19 21:44

Immobilization, Protective Bracing, and Weight Bearing (0-4th week) The immobilizer is worn during the day and even during sleep for the first 4 weeks to prevent posterior displacement of the tibia as the result of gravity or sudden knee flexion. Exercise Maximum Protection Phase (0-4th week) 1. Control pain and swelling: ankle pumping exercise, patellar gliding techniques, quadriceps-setting exercise (augmented by neuromuscular electrical stimulation), and multiplanar SLRs while wearing the protective brace locked in full extension. 2. Begin multiple-angle isometrics of the quadriceps from full extension to 25-30 degrees of flexion. Perform assisted knee extension, progressing to active knee extension while seated. 3. To regain knee flexion: begin with gravity-assisted flexion. Hold the patient’s leg in full knee extension and have the patient control leg lowering as gravity flexes the knee. 4. Trunk and lower extremity stabilization exercise: in a supported standing position (in the parallel bar or with crutches) 5. Bilateral closed-chain quadriceps strengthening (holding on to a stable surface for support when it is permissible to unlock the protective brace) 6. Stretching exercises: hip and ankle musculature, in particular the hamstrings, IT band, and plantarflexors. Moderate and Minimum Protection Phase (4th weeks-24th weeks) *By 9-12 weeks postoperatively the patient should have achieved full knee ROM (0-135 degrees), making it possible to discontinue use of the protective brace if quadriceps control is sufficient. 1. Functional weight-bearing activities. 2. Resistance training for the knee flexors, such as use of a hamstring curl machine (2-3 months postoperatively). 3. Advanced neuromuscular training with plyometrics, balance activities, and agility drills, progressive aerobic conditioning. 4. Vigorous functional activities (9-12 months postoperatively) Reference: Therapeutic Exercise- Foundations and Techniques (5th Edition) p.735-737

悟理治療蔡主任

no special interest. Please re-check your reference. (Time is going by)

2010-09-19 21:46

PHASE I: Immediately post-operatively to week 4 Goals: Protect healing bony and soft tissue structures. supporting proximal tibia/preventing sag Brace: 0-1 week: post-op brace locked in full extension at all times At 1 week post-op, brace is unlocked for passive ROM performed by a physical therapist or PT assistant. Patient supine; therapist maintains anterior pressure on proximal tibia as knee is flexed (force on tibia is from posterior to anterior). Weight-bearing status: Weight-bearing as tolerated (WBAT) with crutches Exercises: Patellar mobilization Quadriceps sets. SLR Hip abduction and adduction Ankle pumps. Hamstring and calf stretching Standing hip extension from neutral. PHASE II: Post-operative weeks 4 to 12 Goals: Increase ROM Normalize gait. Continue to improve quadriceps strength and hamstring flexibility. Brace: 4-6 weeks: Brace unlocked for gait 6-8 weeks: Brace unlocked for all activities 8 weeks: Brace discontinued Weight-bearing status: 8 weeks: May discontinue crutches if patient demonstrates: o No quadriceps lag with SLR. o Full knee extension. o Knee flexion 90-100 degrees. o Normal gait pattern Exercises: 4-8 weeks: o Wall slides/mini-squats (0-45 degrees). o Leg press (0-60 degrees). o Standing 4-way hip exercise for flexion, extension, abduction, adduction o Ambulation in pool (work on restoration of normal heel-toe gait pattern in chest-deep water). 8-12 weeks: o Stationary bike (foot placed forward on pedal without use of toe clips to minimize hamstring activity; seat set slightly higher than normal). o Closed kinetic chain terminal knee extension using resisted band or weight machine o Stairmaster. o Elliptical trainer. o Balance and proprioception exercises. o Seated calf raises. o Leg press (0-90 degrees). PHASE III: Post-operative months 3 to 9 Goals: Restore any residual loss of motion Progress functionally and prevent patellofemoral irritation Improve functional strength and proprioception Continue to maintain quadriceps strength and hamstring flexibility Exercises: Continue closed kinetic chain exercise progression Treadmill walking Jogging in pool with wet vest or belt. Swimming PHASE IV: Post-operative Month 9 until return to full activity Goals: Safe and gradual return to work or athletic participation Maintenance of strength, endurance, and function. Exercises: Continue closed kinetic chain exercise progression Cross-country ski machine. Sport-specific functional progression Reference This protocol has been modified from Brotzman and Wilk, which has been published in Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003: 300-302.

悟理治療蔡主任

Cross-country ski machine? What for?

2010-09-19 21:48

PCL injury treatment 最大保護期(0-6週)：術後使用CPM需在knee joint 0-60度範圍內活動(flexion 超過60度會對移植物造成過多的壓力)、載重比ACL嚴格，部分載重及使用腋下拐走路至少持續到術後4-6週或更久、可於knee extension姿勢下做Quadriceps setting，在0-60度作多重角度等長運動及主動伸直運動(避免膕膀肌強烈收縮，因為會引起脛骨後移) 中度保護和極少保護期(6個禮拜後)：要強調功能性姿勢下做股四頭肌的肌力加強訓練、開放練做knee flexion的阻力式運動會引起脛骨對股骨的向後位移，應於術後6-12週後才可以開始，膕膀肌的訓練可用閉鎖鏈運動和髖關節的阻力式運動、PCL術後回復完整活動要比ACL約晚3個月

悟理治療蔡主任

PCL術後回復完整活動要比ACL約晚3個月??

2010-09-19 21:49

Phase I – Maximum Protection (0-6 weeks): Brace at all times locked at 0°/0° for six to eight weeks Ice and modalities to reduce pain and inflammation Use crutches partial weight bearing for 6 weeks ROM: -Begin aggressive patella mobility -Limit ROM 0-90 with passive prone flexion or seated with anterior tibial translation by the patient or therapist for first 6 weeks Exercises -Quadriceps setting; towel placed behind tibia. Focusing on VMO contraction -SLR in the brace Phase II – Progressive Stretching and Early Strengthening (6-12weeks): Continue with modalities to control inflammation Open brace 0°-90° if patient demonstrates good quadriceps function ROM -Progress to full knee ROM. Minimize posterior tibial translation Exercises -May begin active hamstring contractions -Begin total leg strengthening with SLR program (no resisted hamstrings x 12 wks) -Bilateral closed kinetic chain squatting -Multi-plane open and closed kinetic chain hip strengthening -Unilateral step-up progression -Stationary biking -Pool program; walking and deep water exercise only. No running -Proprioception drills Phase III – Advanced Strengthening and Proprioception Phase (12-24weeks): ROM -Full Exercises -Advance cardiovascular program; stationary bike, treadmill walking, elliptical trainer -Increase intensity of closed kinetic chain exercises -May begin resisted hamstring exercises -Advance proprioception drills -Initiate gym strengthening progressing from bilateral to unilateral as tolerated Leg press, squats, partial lunges, hamstring curls, ab/adduction, calf raises Phase IV – Advance Strengthening and Return to Sport (20-48weeks): Pool running at 20 weeks Dry land running at 24 weeks Multidirectional agility drills at 7-8 months Return to sport 9-12 months Reference: Charles C. Lind, MD PCL Reconstruction Post-Operative Protocol (Rosenberg Cooley Metcalf The Orthopedic Clinic At Park City)

悟理治療蔡主任

Did you really understand all of them? It may not fit the people in here.

2010-09-19 21:50

Preoperative Brace: As needed Weight Bearing: Full, crutches as necessary ROM Goals: Extension: Full, supported Flexion: 135 degrees Therapeutic Exercise: Learn exercises for postoperative regimen Weeks 0 to 4: Protective Phase Brace: Braced in full extension Weight Bearing: Touch down to 40% ROM Goals: Extension: Full with posterior leg supported at all times to protect from tibial sag Flexion: 60 degrees Therapeutic Exercise: Strengthening: Quadriceps setting Three-way leg raises in brace (not flexion) Functional quadriceps electric stimulation **No open chain hamstring strengthening Manual Therapy: Patella and joint mobilization Passive knee flexion to 60 degrees with anterior tibial force Peri-patellar soft tissue mobilization Cryotherapy: Six to eight times a day for 20 minutes Weeks 5 to 8: Early Strengthening Phase Brace: Open to 30 degrees weeks 5 and 6; open to 60 degrees weeks 7 and 8. Weight Bearing: Progress to full by week 8 ROM Goals: Extension: Full Flexion: 90 degrees week 6, progressing to 110 degrees by week 8 Therapeutic Exercise: Strengthening: Quadriceps setting Four-way Straight leg raising in brace Mini squats weeks 7 and 8 Step downs weeks 7 and 8 **No open chain hamstring strengthening Proprioception: One leg balance Core: Abdominal and lumbar exercises Manual Therapy: Patella and joint mobilization Passive knee flexion to 90 degrees **with anterior tibial force Peri-patellar soft tissue mobilization Prone quadriceps stretching to 90 degrees Weeks 9 to 12: Advanced Strengthening Phase Brace: Open Weight Bearing: Full ROM Goals: Extension: Full Flexion: Progress to full Therapeutic Exercise: Strengthening: Quadriceps setting Four-way straight leg raising in brace Half squats weeks Step downs weeks Slow progression of multi-plane closed chain activities **No open chain hamstring strengthening Proprioception: Wobble and BAPS boards Core: Standing trunk activities Conditioning: UBE Manual Therapy: Patellar mobilization Passive knee flexion to 125 degrees with anterior tibial force Peri-patellar soft tissue mobilization Prone quadriceps stretching to 125 degrees Soft tissue flexibility maintenance 12 Plus Weeks: Functional Training and Return to Sports Phase Brace: Functional brace worn Therapeutic Exercise: Strengthening: Sport specific activities begun at 9 months Progression of multi-plane closed chain activities Conditioning: Running straight at 6 months Proprioception: Single leg activities Advanced Core Strengthening: Functional standing trunk activities Note: Return to sport based on provider team input and appropriate testing. All times and exercises are to serve as guidelines. Actual progress may be faster or slower, depending on each individual patient, as agreed upon by the patient and his/her team of providers. Reference: Posterior Cruciate Ligament (PCL) Reconstruction UConn Health Center, New England Musculoskeletal Institute

悟理治療蔡主任

You list a bunch of exercises, then you should know them quite well.

2010-09-19 21:52

PHASE I: Immediately post-operatively to week 4 Goals: 1.Protect healing bony and soft tissue structures. 2.Minimize the effects of immobilization: Brace: 0-1 week: post-op brace locked in full extension at all times. At 1 week post-op, brace is unlocked for passive ROM Weight-bearing status: Weight-bearing as tolerated (WBAT) with crutches, brace locked in extension. Therapeutic exercises: Patellar mobilization,Quadriceps sets,Straight leg raise (SLR),Ankle pumps,Hamstring and calf stretching. PHASE II: Post-operative weeks 4 to 12 Goals: Increase ROM (particularly flexion). Continue to improve quadriceps strength and hamstring flexibility. Brace: 4-6 weeks: Brace unlocked for gait in controlled environment only 6-8weeks: Brace unlocked for all activities. Weight-bearing status: 4-8 weeks: WBAT with crutches. 8 weeks: May discontinue crutches i Therapeutic Exercises: 4-8 weeks: Wall slides/mini-squats (0-45 degrees), Leg press (0-60 degrees) 8-12 weeks: Stationary bike (foot placed forward on pedal without use of toe clips to minimize hamstring activity; seat set slightly higher than normal). PHASE III: Post-operative months 3 to 9 Goals: Restore any residual loss of motion that may prevent functional progression. Progress functionally and prevent patellofemoral irritation. Improve functional strength and proprioception using close kinetic chain exercises. Continue to maintain quadriceps strength and hamstring flexibility. Therapeutic exercises: Continue closed kinetic chain exercise progression, Treadmill walking. PHASE IV: Post-operative Month 9 until return to full activity Goals: Safe and gradual return to work or athletic participation.Maintenance of strength, endurance, and function. Therapeutic exercises: Continue closed kinetic chain exercise progression.Sport functional progression:Jog/Run progression,Jumping (plyometrics).

悟理治療蔡主任

No interest points.

2010-09-19 21:53

Reference:Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003: 300-302.

mini squats 躺在傾斜床上,讓身體傾斜可從45度到90度之高,腳平貼在床面or一腳的高度,在做squats的動作到45度 leg press:; 在牆壁上做即可>可以放球在身體後面,才不會受牆壁阻力影響 腳要離身體更遠一點,flexion 60* (身體不可以整個壓在球上)

Phase 1 ( 0~1 weeks) Ankle pumps, NWB stretch of gastrocnemius / soleus heel prop for extension without overpressure Ice pack ( 15mins/1 day/ 3~5 days) Phase 2 ( 1~6 weeks) Active warm-up: Bike ROM Mobilization : scar tissue massage, patellar mobs, knee extension Flexibility exercises: hamstring and gastroc-soleus Strengthening exercises: Quadriceps: multi-angle quadriceps sets 0, 30, 60; OKC knee ext 0-60 deg, CKC knee extension Total leg: SLR, ankle DF/PF,mini-squats 0-60 Phase 3 ( 6~12 weeks) Active warm-up: Bike, Treadmill Mobilization : Prolonged end-range stretch, knee extension and flexion stretching, Flexibility: Hamstrings, gastroc-soleus, quadriceps Strengthening exercises: Quadriceps: CKC knee extension, wk 8: isotonic knee extension 0-90 Total leg: Hip and ankle strengthening, CKC exercises 0- 90 including leg press, step-up/downs, squats, multidirectional reference http://www.rcmclinic.com/protocols/knee/PCL_rehab_protocol.pdf Knee ligament rehabilitation (Todd S. Ellenbecker )p167~p186

PCL Reconstruction – post-op rehab. Maximum protection phase(0-2wks) Goals: 1. Protection of operated tissues 2. Minimize the effects of immobilization (Early protected range of motion) * Knee is immobilized in a hinged, range-limiting brace locked in full extension. * Weight-bearing as tolerated with crutches. * Position pillow under proximal posterior tibia at rest to prevent posterior tibial sag. * Therapeutic exercises: • Quadriceps sets. • Straight leg raise (SLR). • Hip abduction and adduction. • Ankle pumps. • Hamstring and calf stretching. Moderate protection phase(2-8wks) Goals: 1.Increase ROM (particularly flexion). 2. Continue to improve quadriceps strength and hamstring flexibility * Brace become unlocked for activities. * Therapeutic Exercises: 1.Leg press 2.Stationary bike 3.Balance and proprioception exercises. 4.Closed kinetic chain terminal knee extension using resisted band or weight machine. Minimum protection / return to function phase (8wks-12wks) Goals: 1.Restore any residual loss of motion that may prevent functional progression. 2. Improve functional strength and proprioception using close kinetic chain exercises. 3. Continue to maintain quadriceps strength and hamstring flexibility. * Therapeutic exercises: • Continue closed kinetic chain exercise progression. • Treadmill walking. Return to sport phase (12wks-6months) Goals: 1. Safe and gradual return to work or athletic participation. 2. Maintenance of strength, endurance and function. * Therapeutic exercises: • Continue closed kinetic chain exercise progression. • Sport-specific functional progression (Jog/Run progression, figure 8, backward running and jumping et al.) Reference: 1. Kisner C, Colby LA. Therapeutic Exercise. 5th ed., Philadelphia, F.A.Davis, 2007: 329-47, 725-42. 2. Brotzman SB, Wilk KE, Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby Inc; 2003: 300-302.

Phase 1 (weeks 0-4) -patellar mobilization -prone passive flexion and extension -quadriceps sets -SLR -hip abduction and adduction -ankle pumps -hamstrings and calf stretching 依忍受度在拿cruthes下weight-bearing Pahse 2 (weeks 4-12) -wall slides -mini-squats -leg press -ambulation in pool 第8週開始可以不用繼續使用crutches作weigth-bearing Phase 3 (months 3-6) -持續閉鎖鍊的運動 -treadmill walking Phase 4 (months 6) -持續閉鎖鍊的運動 -jog/run -8字形,向後跑... 閉鎖鍊運動有包含leg press,踩下step-downs,固定式腳踏車,踏步機...

術後→ 2週：膝關節護具固定在完全伸直狀態最好近端小腿後側有支撐物更佳，以減少脛骨向後沈，而增加重建的移植物的壓力。股四頭肌可開始訓練。 2 → 4週：開始增加膝活動度，最好有人托住小腿，避免脛骨向後。股四頭肌繼續加強訓練。 4週→ 8週：穿膝關節護具，膝維持伸直下可開始拐杖走路，可略踏地。 8週→12週：可完全踏地用力。股四頭肌可繼續加強訓練。 12週→關節護具穿到3個月。股四頭肌繼續加強訓練。 運動:quadriceps sets SLR leg press http://www.afasport.com.tw/contentbypermalink/32e3e7534b22268648256d8c002663e7

若為我的病人，我覺得對於PCL，若sprain的程度在grade I~II 是用非手術的保守療法，其程序如下: 1.前兩星期主要為: ---RICE原則 ---輔助其weight bearing，如crutch、brace ---可針對quadriceps做一些簡單的運動，如:quadriceps setting 但禁止做OCK的hamstring運動，避免tibial的post. translation 2.兩星期之後為: ---brace可換成functional knee brace，而crutch可在病人可忍受承重範圍內拿掉 ---運動的項目包括增加其ROM和quadriceps的強化，如騎靜止的Bike， 調整坐墊的前後，可使其knee彎曲角度變化大小不同，而阻力亦可以 以漸進的方式調整訓練其quadriceps。之後病人狀況更好後，可以做 一些更強烈的運動，如running，isokinetic的運動等。 若sprain程度為gradeIII那就要用手術的方式重建了，其術後復建程序如下: 1.前兩星期主要為:(多在bedside遇到) ---brace保護:從0度根據病人stiff情況，漸漸調整到30度。 ---運動方面包括:heel slide在0~30度下做、hamstring和gastronamius的 stretch、quadriceps的setting或是SLR。 ---亦要維持patella的mobility，特別是sup、inf的mobility。防止其在 knee附近產生fibrosis。 2.兩星期到六星期: ---brace的漸漸的到90度 ---運動持續上述的運動，而heel slide可逐漸增加角度，也可開始做平衡 的訓練，如weight shifting、single leg stance、在uneven surface 或是做wall squat:0~30度。 3.六星期之後: ---brace可以換成functional brace ---運動可包含上述的所有運動而逐漸的增加強度，而wall squat 可換成用single leg，而也可以在uneven surfaces練習squat， 而騎bike方面也可以逐漸增加強度。 等病人情況更好後可加入一些更具挑戰性或是關於其ADL的運動 如:running、jumping等運動，但皆要在病人無不適狀況下去做 上述之stretch亦要持續，quadriceps亦不能忽略它。 參考資料: http://xnet.kp.org/socal_rehabspecialists/ptr_library/08KneeRegion/24Knee-PosteriorCruciateLigamentReconstruction.pdf

GENERAL GUIDELINES: 1.No open-chain exercise 2.caution against posterior tibial translation(gravity, muscle action) 3.No CPM 4.Hip progressive resistive exercise (PREs) ................................................................................................................................. weeks 0~4 : 1. Brace locked at 0 degress for 1week 2. weight bearing, as tolerated with crutches 3. patellar mobilzation 4. quadriceps sets 5. SLR (stretch hamstring and calf muscle) 6. standing hip extension from neutral ................................................................................................................................... weeks 4~8 : 1. wall slide (0~45 degrees) 2. mini squats (0~45 degrees) ................................................................................................................................... weeks 8~12 : four-way hip exercises for flexion, abd, add, and extension from neutral with knee fully extended. .................................................................................................................................. moths 3~6 : 1. continue close- chain exercise progression 2. treadmill walking 3. swimming (no frog kick ) .............................................................................................................................. moth 6 : 1. continue close-chain exercise 2. sport-specific function progression, which may include but is not limited to -slide board -jog/run progression -figure-of -eight, backward running, cutting -jumping (plyometrics )

以上內容是我參考此書後的心得 reference : Handbook of Orthopaedic Rehabilitation

0-1 week 1.降低swelling 2.保護knee in a brace (locked in extension) 3.50% weight bearing 4.Full passive knee extension (不可active knee extension) 5.knee flexion 0~30度的阻力運動(勾elastic band) 6.knee flexion 0~60度的範圍內可自由進行承重活動,大於60度不要給阻力 1-2 weeks 1.Prone; knee extension and flexion; agonistic reversals; 利用pulley放在不同位置和高度去訓練,也可以加上lower extremity extension/flexion patterns.(knee extension 讓脛骨做出ER避免IR stretch 到PCL) 2.Progress quadriceps strengthening (坐swiss ball上,腳踩 sitfit, cowboy, perpetual motion ) 2-4 weeks 1.propriceptive drills (跳繩,跳方格往後跳) 2.Begin running(倒退/往前跑) 3.Knee flexion 可達120度(恢復良好+受傷程度第一級者) 結合主任交的機制和自己找的journal訊息 Reference: Matsuda Y, Ishii Y, Noguchi H, Ishii R. Varus-valgus balance and range of movement after total knee arthroplasty. 2005 Jun;87(6):804-8. http://www.ncbi.nlm.nih.gov/pubmed/20134223

PCL reconstruction 1.quadriceps setting 2.Lateral step(先把肌肉練起來,來穩定關節,保護韌帶) 3.OCK 作 knee extension 100~45 degrees (漸增PCL受力強度) 4.CKC 作 leg press(low feet position),先0~50 degrees(安全範圍),而後 0~90 degrees,最後合併兩膝靠近 5.CKC 作 squat ,先0~50 degrees(安全範圍),而後 0~90 degrees,最後合併兩膝靠近 6.腳踏車(肌肉力量) 7.單腳站合併手摸地板(平衡) 謝謝 主任 學長姐 教導 教師節 快樂!! 2010/9/28

剛動完手術首先要促進消腫並且維持ROM，所以一開始可教導病人一些AROM. ankle pumping. Quadriceps set等以幫助消腫，和一些stretch的運動幫助病人維持flexibility，patella mobility也是需要維持的重點之一。 接著慢慢加入一些肌力訓練，從OKC knee extension 40° - 0°開始練起，利用quadriceps的肌力減輕PCL的負擔，並在PCL load較小的情況下開始練起。 然後再加入一些weight bearing及walking的練習，並在CKC的情況下再加入terminal knee extension40° - 0°的訓練，進而再訓練squat 0° - 50°，最後再加入leg press 0° - 30° 去誘發hamstring和quadriceps的co-contraction。

在PCL手術之後，第一周開始要先以維持病人的ROM為主，passive exercise(flexion)角度約落在0-45度之間，因為45度之後PCL會開始受力，並以慢慢的增加角度讓PCL去承受loading。並且可以開始做quadriceps setting，如果病人腫脹問題很嚴重可以在加上ankle pumping。 接下來第二周開始，可以開始做OKC的運動heel slide，角度從0開始到45度再慢慢向上增加，然後開始試著讓病人去weight bearing。 第三周後開始讓病人去做CKC(squat)，一開始在0-50度之間去做蹲下來的動作，雙腳的knee要微微的打開(mini-squat)，避免讓PCL去承受太多的剪力。等適應之後，開始慢慢的增加loading量，50度開始增加到90度(squat exercise)，這時候是PCL受拉力最大的時候。 第四週之後，開始對knee周邊的肌肉做強化的訓練，如terminal knee extension或lateral stepping去增強VMO、VL。

在了解knee的muscle和ligment的受力機制後，我覺得對於重建PCL的復健流程如下:(about exercise) 早期(first week): 由於還處於比較acute的stage故還是在病床上做一些簡單的運動，如:quadriceps的setting、hamstring和gastronamius的stretch...等運動。 中期(2~4 weeks): 病人已經可以下床了，但是PCL還是處在脆弱的階段，因此在此階段要避免 PCL受到較大力量拉扯，並且強調加強quadriceps的運動，如lateral step up、 或是做CKC的squat exercise 但是角度應該在0~30度之間，因為在此角度PCL幾乎 不會受力，而且Knee 受compression的力量也很小。 後期(4 weeks 之後): 在後期PCL已逐漸堅固，因此漸漸的可以給他loading使其更加的強韌!! 因此在exercise上，練squat角度可以漸漸變大，約0~50度，但不超過50度，因為過50度後knee comperssion force會急遽增加。或是練leg press，但是要注意以下兩點 1.要在low feet position，這樣可減少knee的compression force。2.兩腳要打開，這樣可以稍微使PCL受力增加，同時又可以加強quadriceps的訓練。之後如要加強quadriceps 和 hamstrings 的co-contraction可以在0~30度下練leg press.

<術後第一週> 主要利用brace給予一個良好的固定(full extension)，使骨質及軟組織能進行癒合作用。 <術後第二週> 可將固定適度地減少，開始帶入一些partial range的AROM及PROM,達到消除水腫及增加ROM (SLR, stretching exercise, quadriceps sets, patella movements, ankle pumping, hip add&abd) <術後兩週~四週> 1. OKC運動:knee extension (100-45 degrees的range下去做) 2. CKC運動:squatting-mini squat(0-45 degrees)==>squatting(45-80 degrees)==>leg press-low feet position 腳微開 (0-60 degrees) <術後四週後> 1.Functional: walking on treadmill, lateral step up, stairclimber exercise 2.Proprioception: Quadriceps,hamstrings co-contraction on cusion

手術之後首先要注意到的是傷口及其周邊發炎腫脹及疼痛的問題，所以可先利用冰敷等方式來消腫及減輕疼痛，待情況好一些後，即可開始進行運動方面的復健治療。 Week1~2: 增加及維持ROM--訓練順序: PROMAAROMAROM，包括knee flexion & extension，依情況漸增角度。Tibiofemoral joint 及 patellofemoral joint 的mobility皆要注意。 Week3~4: *肌力訓練--active hamstring and quadriceps contraction *Walking訓練--利用crutches從NWB到PWB *OKC訓練--角度從0~40度開始，此時主要受力者為ACL，漸增角度(45~100度)以訓練到PCL。 Week5~6: *CKC訓練--(1)bil. squatting，從小角度開始，knee flexion超過30度後開始訓練到PCL，PCL最大受力在knee flexion 90度 (0-50度為訓練安全範圍)。(2)leg press，0-30度可誘發quadriceps和hamstring的co-contraction，但做leg press可能會對PCL產生過多的loading，所以要注意其角度。 *Walking 訓練--漸增WB能力 Week7~8: *增加CKC的訓練強度 *Resisted exercises (hamstring & quadriceps) *腳踏車及跑步機的訓練

術後教導病人做Bed E'x：ankle pumping,heel slide,quadriceps set,維持ROM與協助減輕術後的腫脹。 第二週以lateral step up訓練quadriceps strength與0-20、30度的range內開始做squat，避免PCL loading過大。 第三週squat角度漸增至0-50度給予PCL適度的loading做為訓練，做squat時雙腳應雙腳打開。 第四週加入週邊肌肉的訓練，做terminal knee extension(40-0度)增加VMO/Vastus recruitment；Leg press(0-30度)促進hamstring和quadriceps的co-contraction。

PCL reconstruction 手術完第一週: 病人應該要穿穿戴膝關節固定支架,運動最好以在床上的訓練為主像是減少水腫的ankle pumping,isometric quadriceps contraction以及一些AROM以病人能達到的角度為主避免造成傷害角度在大約0-45度之間 第二週: 1.讓病人WB可減少水腫 2.利用CPM可被動的增加knee flexion角度,之後也要讓病人自己AROM(如果病人無法flexion可能要看是因為psoas太緊所影響或者是quadriceps太緊造成) 3.在開刀的傷口地方可以用USD增加組織修復速度 4.在對於PCL還是比較脆弱時運動一開始要以CKC為主,因為CKC 運動會促進關節穩定度比較不會破壞healing graft.所以採用squating 0-50度(但是一開始病人可能無法在FWB下執行我們可以先讓病人躺在tilting table以40%WB先開始再慢慢增加). 第三週: 除了上述的CKC運動還有erminal knee extension40° - 0°外可以在加上一些OKC運動增加quadriceps肌力,另外要注意是否有knee extension limitation要適時的給hamstring & gastrocnemous stretch 第四週: 此時PCL應該復原的差不多運動主要以quadriceps,hamstrings co-contraction為主

0-2週 Brace固定在full extension 冰敷 OR USD 簡單的床上運動，如:ankle pumping.quadriceps setting 3-4周 CPM增加角度 WB差不多到40% 漸進式肌力訓練 OKC之knee extension 0-40開始 5-8周後 WB慢慢增加到100% CKC之squat knee flexion 0-50開始 terminal knee extension quadriceps和hamstring的co-contraction

<<術後第一週>> 首先著重在傷口的復原及肢體腫脹和疼痛的問題, 可先利用ice pack等方法來降低疼痛. 一開始brace把knee固定在full extension幫助骨質癒合, 穿戴brace這段期間做ankle pumping去改善腫脹問題. <<第二週>> 在Knee extension -30~0度的OCK運動(PCL受力最小的角度), 先NWB訓練Quadriceps, 去降低PCL的負荷. 例如:quadriceps setting, seated knee extension…等. <<第三週>> 在WB下做訓練, 但要以PCL受力較小情況下訓練為主.　　1.squat運動,雙腳打開,做knee flexion 0~50度的訓練.(此姿勢可增加10-30%的Hamstring/ gluteus maximus recruitment,且在knee flexion 0~50度時,對knee joint的compression也比較小)　　2.leg press運動,雙腳打開,在High feet position下做訓練.(此姿勢對PCL的受力較少,但compression相對較多,不在雙腳靠近時訓練leg press,是因為此姿勢會增加5-10%PCL之剪力)　　3. Lateral step up & stairclimber增強Quad recruitment　　 <<第四週>> 增加PCL的負荷,加強訓練PCL的強度.　　1. squat運動,雙腳打開, Squat ascend from 88-102 degrees(訓練更多Hamstring,但對PCL受力反劇增(最大受力knee flexion 90度CKC))　　2. leg press運動,雙腳打開,在Low feet position(knee flexion 30度)下做訓練.(此姿勢會使Quadriceps出力多20%, 而PCL之受力多10~15%, 但對joint compression相對少20%, 也可加強Quadriceps和hamstrings的co-contraction)　　3. squat運動,雙腳靠近.(此姿勢可增加5-20%的gastroc/quadriceps recruitment)　

week 1: (1)消腫:冰敷、ankle pumping (2)維持ROM:PROM、AAROM week 2~4: 依進步情形逐漸由(1)做到(4) (1) OKC knee flexion:45~100 degrees(此時PCL受力) (2) terminal knee extension:40~90 degrees (3) CKC squat:0~50 degrees(safe range:0~50 degrees,PCL 在30度後受力逐步增加) (4) leg press: 0~30 degrees (low feet position) week 5~6: plyometric training:連續性的OKC-CKC gait concept(開始gait training)

剛開始手術完時我們可以先讓病人做一個降低水腫以及止痛的動作,穿上brace將病人的knee flexion的10度的位置 之後第二周我們可以讓病人利用crutch 或cane行走訓練,並配合一些squat 第三周,假理論上病人knee flex的角度應該可以拉到120度,這時可以配合一些manipulation以及叫病人踩腳踏車去加大的flexion角度 ,也可以配合一些水療增進她的循環 一開始時先做 CKC的運動 之後再做OKC的運動 第四週已經可以將brace拆除主要是第三周運動的進階版

1st week: 可教導ankle pumping,quadriceps setting,和heel slide.等運動,目的是維持ROM增進循環漸少腫脹情形 2nd week: 針對quadriceps加強訓練,在此階段可做 OKC: knee extension :100-45度 3rd week: 可以下床站立,PWB,針對quadriceps加強訓練,在此階段可做 CKC e'x:squat 0-30 度,PCL不過度受到拉力 CKC e'x:leg press (low feet):減少對關節的compression lateral step up 4th week: 增加PCL loading squat:0-50度 Leg press:0-30 (雙腳打開):hamstrings/quadriceps co-contraction treadmill walking

在術後一週主要是要讓病人維持角度，所以我們要先做PROM並且可以教導病人做ankle pumping and 股四頭肌的等長收縮，接下來就可以做出OKC CKC的動作!最後角度回覆正常可以教導病人做肌力訓練的運動

在第0-2'週的時候，要先消除patient的swlling並維持knee的角度， 可以用PROM和AAROM。 2-4週時，開始增加knee的角度，並訓練Quadriceps CKC squat:0-50 degress leg press:0-30 degress 4週後 CKC squat進步到OKC squat 去增加對於PCL的load

PCL reconstruction 術後復健 第一週：固定(full extension) 1.消腫、止痛、抗發炎：ankle pumpimg、冰敷 2.重新建立quadriceps control：quadriceps setting 3.維持ROM：PROM or AROM e’x 第二~三週： 1.行走：可以開始PWB，甚至在可忍受的範圍內FWB 2.OKC e’x：從terminal knee extension 40-0 開始訓練， 逐漸將角度增大，提高PCL的loading 第四~五週：(循序漸進) 1.CKC e’x：Squat訓練，在knee flexion 0-50內實行 2.CKC e’x：Leg press 訓練，在knee flexion 0-30內實行，low feet position 第六週開始： 連續性的OKC and CKC e’x：plyometric training

初期 術後1週 - 術後1-3天要整天穿著hinged knee brace使knee joint卡在knee extension，以避免CL受力，此時可做床上的運動quadriceps settings，以避免肌力退化過多。 - 術後3-7天可開始做OKC的knee extension的運動 * 病人坐在mat邊緣，在小腿下墊球使knee flexion角度小於45°﹝在OKC做knee extension若膝關節大於45°，PCL會到stress﹞，請病人坐抬腳膝蓋伸直的動作 * 病人站在扶手前，knee total extension下做hip extension的運動﹝一開始先避免用 knee flexion方式訓練hamstrings，以免stress PCL﹞ 中期 術後2-3週 - 第2週，開始訓練leg press，knee joint角度一樣控制在0-45° * 病人靠牆坐著，膝彎曲45°，將球放在腳下，讓病人做膝伸直的動作，來初部訓練 quadriceps and hamstrings的co-contraction - 第3週 * 練雙腳squat。一開始可以先背貼著牆垂直地面，腳與肩同寬做knee flexion，角度 不要大於60°避免stress PCL。 * 訓練對quadriceps較functional movement：forward step-ups和lateral step-ups。病 人的訓練腳為先上後下。 後期 術後4-6週 - 加強quadriceps and hamstrings的co-contraction * 練雙腳squat。訓練1-2天後可在背部墊大球，3-4天後墊小球，之後再進階到背完全 無支撐物做squatting，注意訓練時背要挺直，腳與肩同寬，膝彎去角度小於90°來 減少對PCL的stress。 * 訓練lunge。病人訓練腳在前做knee flexion + weight-bearing再伸直。Knee flexion的 角度一樣小於90°來減少對PCL的stress。 - 術後六週以後的訓練可將knee flexion的角度，以病人可以忍受疼痛範圍內慢慢增加即可。

術後第一、二週主要以消腫以及維持ROM為原則 可以作ankle pumping或是PROM 接下來第三到四週可以開始訓練Quadriceps squat在0度到50度之間,並且雙腳要打開避免剪力產生 或是Leg press在0-30度內 五到六週可以開始進行更多OKC及CKC運動

0-2weeks Goal: Protect healing bony and soft tissue, avoid posterior tibial sagging. 1. Use brace locked knee in full extension. (0-1w) 2. Weight bearing as tolerated with crutches and use brace locked in extension. 3. 利用IR幫助傷口乾燥癒合，CPM恢復ROM(0-30) Therapeutic exercise: Patellar mobilization, Quadriceps sets, Ankle pump, Hamstring and calf stretching, SLR. 2-6weks Goal: 1. Increase ROM (use CPM 0-90 degree) 2. Improve quadriceps strength and hamstring flexibility: mini squat (0-50 degrees) 膝蓋與肩同寬，Leg press (0-50 degrees) 3. Weight bearing as tolerated with crutches 6-10 weeks: Brace discontinued and may discontinue crutches. Goal: 1. Full, painfree ROM 2. Normalize gait. 3. Good to normal quadriceps control: lateral step up 4. No patellofemoral complaints Therapeutic exercise: bicycle (低強度), balance and proprioception exercises, leg press(0-50 degrees). 10-12weeks Goals: 1. Normal gait: treadmill. 2. Maintenance of strength, endurance, and function: bicycle, swim (frog kick). Therapeutic exercise: up/down stairs, full squat, running, jumping. ※主任不好意思，這幾天感冒回到家不是在昏睡，腦袋也不清不楚的沒有辦法好好想作業，所以才這麼晚交。