SPORTS MEDICINE CARTILAGE REPAIR

rehabilitation is that of adapting the rehabilitation to optimise loading, and this requires consideration of: n Exercise programming n Stages and timescales of tissue healing n Clinical biomechanics n Chondrocyte maturation.

The rehabilitation programme,

including progression rates, should be individualised for each athlete based on the following factors, all of which have the potential to influence outcome: n Lesion size n Lesion location: tibiofemoral joint or patellofemoral joint n Concomitant procedures n Preoperative duration of symptoms n Preoperative baseline condition n Age n Athlete motivation and individual goals.

Rehabilitation should ideally mirror the state of the repair tissue and its ability to accept load. Despite the fact that the three main categories of cartilage repair have different timescales for the acceptance of loading (Fig. 4), any athlete undergoing cartilage repair will progress through the three rehabilitative phases of protection, function and activity. These are not discrete phases, and at any one point therapy may be split between more than one of these phases. There has been great progress over the past few years in the development of magnetic resonance imaging (MRI) protocols for the evaluation of cartilage repair tissue, but this is still work in progress and there are accessibility issues even for elite athletes. From a practical rehabilitative perspective, the status of the repair tissue is usually assessed indirectly through the patient’s clinical signs and symptoms during and after therapy sessions. Consequently, adapting the content of the rehabilitation programme to match the status of the repair requires vigilance in monitoring the patient’s condition.

Early mobilisation is essential, as

stiffness is the ‘kiss of death’ for the knee. If cartilage is not exposed to sufficient loading within a matter of a few weeks, then the cartilage thickness and stiffness reduce (27). Some of the main adverse events reported after ACI procedures between 1996 and

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CARTILAGE REPAIR

microfracture OATS/

mosaicplasty

autologous chondrocyte implantation

REPAIR TISSUE & RETURN TO SPORTS super clot

fibrocartilage return to sport 8-10 months

immediate defect fill with plugs fibrocartilage infill around plugs return to sport 6-9 months

0–6wks

7 weeks – 6months 6 months – 3 years

2003 included adhesions, arthrofibrosis and mechanical complications (28), which could potentially be attributed to the conservative rehabilitation that was adopted during this time. Later research has indicated that it may now be possible to accelerate cartilage repair rehabilitation without any detrimental effects to the repair tissue (26). In order to minimise the risk of scar tissue formation, it is critical to teach the athlete mobilisations for the patella, especially the quadriceps tendon and patellar tendon. Exercise selection should be focused on achieving specific functional rehabilitation goals (eg. range of movement, strength, endurance, proprioception) while minimising the risk of exposure of the repair site to excessive stress (especially shear, as this creates tensile stress on the repair site). The early postoperative stages of rehabilitation will have a strong focus on protection of the repair site and generally involve restrictions in weight- bearing and range of movement, as determined by the repair location. However, it is important that these restrictions are not seen as barriers to progressing towards the rehabilitation goals. It is possible to select exercises and adapt them so that the athlete can work on a particular rehabilitation goal while adhering to the postoperative guidelines. See practical example 1. When an athlete is restricted

to partial weight-bearing there are a couple of areas that are a good investment of the therapist’s time within the preoperative and early postoperative phases of rehabilitation (29). Checking and reinforcing proficiency in judgement of the amount

soft primitive gelatinous tissue “wave-like”

putty-like” increased tissue stiffness return to sport 12 – 18 months

Figure 5: ‘Clam’ exercise

Figure 4: Cartilage repair procedures and return to sport

Figure 6: ‘Hip Hike’ starting position

Figure 7: ‘Hip Hike’ end position

of weight the athlete is putting through the repaired leg can be implemented using a simple method with two sets of bathroom scales (Fig. 8). Athletes should be advised not to ‘toe-touch’ weight-bear, as this has the potential

PRACTICAL EXAMPLE 1 The athlete is in the early stages of post-cartilage repair surgery. One of the rehabilitation goals is to retrain and strengthen the gluteus medius.

Patient 1: medial femoral condyle repair and has weight-bearing restrictions. Solution: use ‘clam’ exercise (Fig. 5).

Patient 2: patella repair and has range-of-movement restrictions. Solution: use hip hike with leg in full extension (Figs 6 and 7).

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