John Nyland

OBJECTIVE: The purpose of this study was to examine the effect of a preoperative exercise intervention on knee pain, functional ability, and quadriceps strength among patients with knee osteoarthritis before and after total knee arthroplasty (TKA) surgery. DESIGN: A repeated-measures design was used to compare 2 groups over 4 data collection points. SETTING AND PATIENTS: Community-dwelling subjects with osteoarthritis of the knee who were scheduled for a unilateral TKA were recruited from a single orthopedic surgeon's office and were randomized into control (n = 28) or prehab groups (n = 26). INTERVENTIONS: The control patients maintained usual care before their TKA. The exercisers performed prehabilitation exercises, which included resistance training, flexibility, and step training, 3 times per week before their TKA. OUTCOME MEASURES: Knee pain, functional ability, quadriceps strength, and strength asymmetry were assessed at baseline (T1), at 1 week before the patients' TKA (T2), and again at 1 (T3) and 3 (T4) months after TKA. RESULTS: The exercisers improved their sit-to-stand performance at T2, whereas the control group did not change their performance of functional tasks and had increased pain at T2. At T3 the exercisers demonstrated improved sit-to-stand performance. The control patients at T3 exhibited decreases in pain, their 6-minute walk, surgical leg strength and an increase in their nonsurgical leg strength and leg strength asymmetry. At T4 the exercisers improved in their performance of 3 of the 4 functional tasks, decreased all of their pain measures, and increased their surgical and nonsurgical quadriceps strength. At T4 the control group improved their performance on 2 of the 4 functional tasks, decreased all of their pain measures, increased their nonsurgical leg strength, and exhibited greater leg strength asymmetry. CONCLUSION: These findings appear to indicate the efficacy of prehabilitation among TKA patients and support the theory of prehabilitation.

PURPOSE: We systematically reviewed the evaluated efficacy of medial patellofemoral ligament (MPFL) reconstruction, rehabilitation, and patient outcomes for safely returning patients to sports. METHODS: We performed a literature search using the Ovid Medline database from 1950 to present, as well as the SportDiscus and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Only English-language studies that described MPFL reconstruction or repair, rehabilitation, and patient outcome information were included. Search terms were combinations of "MPFL repair," "MPFL reconstruction," "patellofemoral ligament," "patellar dislocation," "patient outcome," and "rehabilitation." Coleman Methodology Scores were used to evaluate research quality. RESULTS: A total of 21 studies (11 prospective and 10 retrospective) met our inclusion criteria, with a total of 488 patients (184 male and 304 female patients) and 510 knees contributing to this review. Most patients were female (62.3%), and the mean age at surgery was 23.4 years (range, 6 to 52 years). Semitendinosus autografts were most commonly used (n = 145 [28.4%]). Of all reported complications at follow-up (n = 155), quadriceps dysfunction (n = 48 [31.0%]), positive apprehension (n = 32 [20.6%]), and decreased knee range of motion (n = 28 [18.1%]) were most common. Although inclusion criteria required rehabilitation information, the level of description was generally limited to acute care rehabilitation, with insufficient progressive exercise descriptions. Coleman Methodology Scores (58.76 ± 8.6) indicated generally poor study methodologies. CONCLUSIONS: MPFL reconstruction and rehabilitation are likely to improve a patient's ability to perform activities of daily living. Poor study methodology including outcome surveys that lack either sensitivity or validity to measure the influence of patellofemoral joint dysfunction on sports participation, as well as limited exercise rehabilitation information, make it difficult to determine efficacy. Recommendations for improved outcome measurements and more comprehensive functional rehabilitation are provided. LEVEL OF EVIDENCE: Level IV, systematic review.

OBJECTIVE: To review basic meniscal anatomy, histology, and biomechanical principles as they apply to surgery and rehabilitation. DATA SOURCES: We searched MEDLINE and CINAHL for the years 1960-1999 using the terms meniscus,surgery,rehabilitation,meniscal repair, and arthroscopy. DATA SYNTHESIS: Injuries to a healthy meniscus are usually produced by a compressive force coupled with transverse-plane tibiofemoral rotation as the knee moves from flexion to extension during rapid cutting or pivoting. The goal of meniscal surgery is to restore a functional meniscus to prevent the development of degenerative osteoarthritis in the involved knee. The goal of rehabilitation is to restore patient function based on individual needs, considering the type of surgical procedure, which meniscus was repaired, the presence of coexisting knee pathology (particularly ligamentous laxity or articular cartilage degeneration), the type of meniscal tear, the patient's age, preoperative knee status (including time between injury and surgery), decreased range of motion or strength, and the patient's athletic expectations and motivations. Progressive weight bearing and joint stress are necessary to enhance the functionality of the meniscal repair; however, excessive shear forces may be disruptive. Prolonged knee immobilization after surgery can result in the rapid development of muscular atrophy and greater delays in functional recovery. CONCLUSIONS/RECOMMENDATIONS: Accelerated joint mobility and weight-bearing components of rehabilitation protocols represent the confidence placed in innovative surgical fixation methods. After wound healing, an aquatic therapy environment may be ideal during all phases of rehabilitation after meniscal surgery (regardless of the exact procedure), providing the advantages of controlled weight bearing and mobility progressions. Well-designed, controlled, longitudinal outcome studies for patients who have undergone meniscectomy, meniscal repair, or meniscal reconstruction are lacking.

This review summarises the existing knowledge about pathogenesis, differential diagnosis, conservative treatment, surgery and post-surgical rehabilitation of sports hernias. Sports hernias occur more often in men, usually during athletic activities that involve cutting, pivoting, kicking and sharp turns, such as those that occur during soccer, ice hockey or football. Sports hernias generally present an insidious onset, but with focused questioning a specific inciting incident may be identified. The likely causative factor is posterior inguinal wall weakening from excessive or high repetition shear forces applied through the pelvic attachments of poorly balanced hip adductor and abdominal muscle activation. There is currently no consensus as to what specifically constitutes this diagnosis. As it can be difficult to make a definitive diagnosis based on conventional physical examination, other methods, such as MRI and diagnostic ultrasonography are often used, primarily to exclude other conditions. Surgery seems to be more effective than conservative treatment, and laparoscopic techniques generally enable a quicker recovery time than open repair. However, in addition to better descriptions of surgical anatomy and procedures and conservative and post-surgical rehabilitation, well-designed research studies are needed, which include more detailed serial patient outcome measurements in addition to basing success solely on return to sports activity timing. Only with this information will we better understand sports hernia pathogenesis, verify superior surgical approaches, develop evidence-based screening and prevention strategies, and more effectively direct both conservative and post-surgical rehabilitation.

Preparing for the stress of total knee arthroplasty (TKA) surgery by exercise training (prehabilitation) may improve strength and function before surgery and, if effective, has the potential to contribute to postoperative recovery. Subjects with severe osteoarthritis (OA), pain intractable to medicine and scheduled for TKA were randomized into a usual care (UC) group (n = 36) or usual care and exercise (UC + EX) group (n = 35). The UC group maintained normal daily activities before their TKA. The UC + EX group performed a comprehensive prehabilitation program that included resistance training using bands, flexibility, and step training at least 3 times per week for 4-8 weeks before their TKA in addition to UC. Leg strength (isokinetic peak torque for knee extension and flexion) and ability to perform functional tasks (6-minute walk, 30 second sit-to-stand repetitions, and the time to ascend and descend 2 flights of stairs) were assessed before randomization at baseline (T1) and 1 week before the subject's TKA (T2). Repeated-measures analysis of variance indicated a significant group by time interaction (p < 0.05) for the 30-second sit-to-stand repetitions, time to ascend the first flight of stairs, and peak torque for knee extension in the surgical knee. Prehabilitation increased leg strength and the ability to perform functional tasks for UC + EX when compared to UC before TKA. Short term (4-8 weeks) of prehabilitation was effective for increasing strength and function for individuals with severe OA. The program studied is easily transferred to a home environment, and clinicians working with this population should consider prehabilitation before TKA.