This protocol serves as a guide for post-surgical or post-injury rehabilitation exercises and goals. These guidelines may be interpreted to ensure a uniquely tailored plan to your needs. We confer with you, your doctors and your surgical team.
Overview of Tibial Plateau Fractures
Tibial plateau fractures involve a break in the upper portion of the tibia (shinbone) at the knee joint. These fractures account for approximately 1% of all fractures and often result from high-energy mechanisms, such as motor vehicle accidents, or low-energy trauma, particularly in individuals with diminished bone quality. These injuries may be associated with damage to surrounding structures, including vasculature, nerves, ligaments (like the ACL), menisci, and adjacent compartments.
Schatzker classification is frequently used to categorize these fractures. Treatment options range from non-operative management to surgical intervention, often involving ORIF (open reduction internal fixation). The primary goals of treatment are to restore joint stability, alignment, and range of motion, while minimizing the risk of complications like arthrofibrosis. Early rehabilitation is crucial for a faster recovery and preventing secondary complications. Rehabilitation is similar to ACL tear protocols and incorporates various exercises tailored to the fracture type and surgical approach.
A successful recovery and return to work and exercise is possible with proper rehabilitation;
Initial Assessment and Goals
The initial assessment following a tibial plateau fracture is crucial for establishing a baseline and guiding the rehabilitation process. This involves a thorough evaluation by the medical team, including physicians and physical therapists. The assessment typically includes a review of the patient’s medical history, mechanism of injury, and surgical details, if applicable. A physical examination is conducted to assess pain levels, swelling, range of motion (ROM), and neurovascular status.
Specific measurements of knee flexion and extension are recorded, along with any limitations or restrictions. The assessment also identifies any associated injuries, such as ligament tears or meniscal damage, which may impact the rehabilitation plan. Based on the initial assessment findings, individualized goals are established in collaboration with the patient. These goals typically focus on reducing pain and swelling, restoring ROM, improving muscle strength and stability, and ultimately, returning to pre-injury activity levels.
Short-term goals in the early phases may include achieving full knee extension and a specific range of flexion, while long-term goals may involve returning to sports or work.
Phase 1: Early Post-operative (Weeks 0-6)
Phase 1 of rehabilitation following a tibial plateau fracture focuses on protecting the healing bone and soft tissues. During this early post-operative period, which typically spans from weeks 0 to 6, the primary goals are to control pain and swelling, prevent complications, and initiate gentle range of motion (ROM) exercises. Weight-bearing is usually restricted, often with the patient remaining non-weight-bearing (NWB) or toe-touch weight-bearing (TTWB) using crutches or a walker.
A hinged knee brace is often utilized to provide stability and control ROM. The brace may be locked in full extension initially and gradually unlocked to allow for increasing flexion as healing progresses. Therapeutic exercises in Phase 1 are primarily focused on gentle ankle pumps, quadriceps sets, and hamstring sets to maintain muscle activation without stressing the fracture site.
Range of motion exercises are performed passively or active-assisted, within the limits prescribed by the surgeon, to prevent stiffness and promote joint lubrication. It’s crucial to monitor for signs of infection or deep vein thrombosis (DVT) and to adhere closely to the surgeon’s instructions during this phase.
Weight-Bearing Restrictions
Following a tibial plateau fracture, weight-bearing restrictions are a critical component of the early post-operative phase. The specific weight-bearing protocol is determined by the surgeon based on the fracture’s severity, stability of the fixation, and individual patient factors. Commonly, patients are prescribed non-weight-bearing (NWB) for up to 6-12 weeks to allow adequate bone healing. This means no weight is placed on the affected leg while standing or walking, requiring the use of crutches or a walker for mobility.
In some cases, toe-touch weight-bearing (TTWB) may be permitted, where the patient can lightly touch their toes to the ground for balance but not bear any significant weight. Partial weight-bearing (PWB) may be gradually introduced as healing progresses, allowing a limited percentage of body weight to be applied to the leg. Adhering to the prescribed weight-bearing restrictions is crucial to prevent displacement of the fracture fragments and ensure optimal healing.
Regular follow-up appointments with the surgeon and physical therapist are necessary to monitor healing progress and adjust weight-bearing status accordingly. Premature weight-bearing can lead to complications, while appropriate adherence promotes bone union and a successful recovery.
Range of Motion Limitations
During the initial post-operative period (Phase 1), range of motion (ROM) is carefully controlled to protect the healing fracture and any repaired soft tissues. Limitations are implemented to prevent excessive stress on the surgical site and promote optimal healing. Often, a hinged knee brace is utilized, initially locked in full extension to maintain stability. As healing progresses, the brace’s hinges are gradually unlocked to allow controlled flexion and extension within a specified range, such as 0-60 or 0-90 degrees, depending on the surgeon’s recommendations and the presence of any meniscus repairs.
Early ROM exercises are typically passive or active-assisted, performed with the help of a physical therapist or using external devices. The focus is on gentle movements to prevent stiffness and promote circulation without stressing the fracture site; Forced or aggressive ROM exercises are strictly avoided to minimize the risk of complications; As bone healing advances and soft tissues recover, the ROM limitations are progressively relaxed, allowing for a greater range of motion in flexion and extension. The physical therapist guides the patient through a series of exercises to gradually improve knee mobility while ensuring continued stability and protection of the healing fracture.
Therapeutic Exercises in Phase 1
Phase 1 therapeutic exercises following a tibial plateau fracture focus on minimizing swelling, pain management, and gentle restoration of muscle activation without stressing the healing bone. Exercises are primarily non-weight-bearing and emphasize regaining quadriceps control. Isometric quadriceps sets, where the patient tightens the thigh muscles without moving the knee, are crucial for preventing muscle atrophy. Ankle pumps are performed frequently to promote circulation and reduce the risk of deep vein thrombosis (DVT).
Straight leg raises (SLRs) in the brace, locked in full extension, help strengthen the quadriceps while protecting the knee joint. Hamstring sets, similar to quad sets, activate the posterior thigh muscles. Active-assisted range of motion (AAROM) exercises, guided by a physical therapist, gently move the knee within the prescribed limits, often using heel slides or a towel to assist with flexion and extension. Patellar mobilization exercises help prevent stiffness and maintain proper patellar tracking. These early exercises lay the foundation for subsequent rehabilitation phases, promoting healing and preparing the knee for increased weight-bearing and more demanding activities. Emphasis is placed on proper form and controlled movements to avoid complications.
Phase 2: Intermediate Rehabilitation (Weeks 6-12)
Phase 2 of tibial plateau fracture rehabilitation, spanning weeks 6-12, focuses on gradually increasing weight-bearing, improving range of motion, and initiating more aggressive strengthening exercises. Progression is dictated by bone healing and patient tolerance, monitored closely by the surgeon and physical therapist; Partial weight-bearing is introduced, often starting with toe-touch weight-bearing and progressing to full weight-bearing as tolerated.
Range of motion exercises become more active, with the goal of achieving full knee flexion and extension. Strengthening exercises advance from isometric to isotonic exercises, including leg presses, stationary cycling with minimal resistance, and hamstring curls. Closed kinetic chain exercises, such as mini-squats and step-ups, are introduced to improve stability and proprioception. Balance exercises, like single-leg stance, are incorporated to enhance neuromuscular control. Throughout this phase, it’s crucial to monitor for any signs of pain or swelling, adjusting the exercise program accordingly. The emphasis remains on controlled movements and proper form to protect the healing fracture site.
Progression of Weight-Bearing
During the intermediate rehabilitation phase (weeks 6-12) following a tibial plateau fracture, the progression of weight-bearing is a critical component. Initially, patients are typically non-weight-bearing to allow for adequate bone healing. The transition to weight-bearing is gradual and carefully monitored by the physical therapist and surgeon. This progression usually begins with toe-touch weight-bearing, where only the toes make contact with the ground, allowing for minimal load on the injured leg;
As healing progresses and pain decreases, partial weight-bearing is introduced, typically starting at around 25% of body weight and gradually increasing to 50% and then 75%. Full weight-bearing is typically achieved once radiographic evidence confirms sufficient bone healing and the patient demonstrates adequate strength and control. Throughout this process, assistive devices such as crutches or a walker are used to provide support and stability. It’s crucial to listen to your body and avoid pushing too hard, as excessive weight-bearing too early can compromise healing and lead to complications.
Increasing Range of Motion
During the intermediate rehabilitation phase (weeks 6-12) after a tibial plateau fracture, a primary goal is to progressively increase the knee’s range of motion (ROM). Initially, motion may be limited to protect the healing bone and soft tissues. As pain and swelling subside, exercises are introduced to gently restore flexion and extension. Active-assisted range of motion (AAROM) exercises are often used, where the patient uses their own muscles with some assistance from a therapist or external device to move the knee.
The focus is on achieving full extension first, as this is crucial for normal gait and function. Flexion is then gradually increased, with the goal of reaching at least 90 degrees of flexion by the end of this phase. Exercises may include heel slides, stationary cycling (with low resistance), and gentle stretching. It’s important to perform these exercises regularly and consistently, but without pushing through excessive pain. The physical therapist will monitor progress and adjust the exercises as needed to optimize ROM gains while minimizing the risk of complications.
Strengthening Exercises
In the intermediate rehabilitation phase (weeks 6-12) following a tibial plateau fracture, strengthening exercises play a vital role in restoring stability and function to the knee joint. These exercises aim to rebuild the strength of the muscles surrounding the knee, including the quadriceps, hamstrings, and calf muscles. Initial exercises focus on isometric contractions, where the muscles are activated without joint movement, to minimize stress on the healing fracture. As healing progresses, isotonic exercises are introduced, involving controlled movements through a range of motion.
Examples of strengthening exercises include quadriceps sets, hamstring curls, calf raises, and leg presses with light resistance. The intensity and difficulty of these exercises are gradually increased as tolerated, based on pain levels and muscle strength. Closed kinetic chain exercises, such as mini-squats and step-ups, are also incorporated to improve functional strength and stability. It is crucial to maintain proper form and technique during all exercises to prevent re-injury. The physical therapist will guide the patient through a progressive strengthening program, ensuring that exercises are performed safely and effectively to achieve optimal outcomes.
Phase 3: Advanced Rehabilitation (Weeks 12+)
Phase 3 of rehabilitation, typically beginning around week 12 post-fracture, focuses on advanced strengthening and functional exercises to prepare the patient for a return to higher-level activities. This phase emphasizes restoring full strength, power, and endurance in the affected leg. Exercises become more challenging and may include activities like plyometrics, agility drills, and sport-specific training.
Advanced strengthening exercises involve heavier weights and increased repetitions in exercises like leg presses, squats, and lunges. Plyometric exercises, such as jump squats and box jumps, help improve explosive power and prepare the knee for impact activities. Agility drills, including cone drills and shuttle runs, enhance coordination and proprioception. For athletes, sport-specific training is incorporated to simulate the demands of their chosen sport. Throughout this phase, close monitoring of pain and swelling is essential to avoid overstressing the healing bone. Progression is based on achieving specific milestones in strength, stability, and function, guided by the physical therapist and surgeon. The ultimate goal is a safe and successful return to pre-injury activity levels.
Advanced Strengthening Exercises
In the advanced rehabilitation phase, typically starting around week 12 post-surgery, advanced strengthening exercises play a crucial role in regaining full function after a tibial plateau fracture. These exercises aim to restore strength, power, and endurance in the affected leg, preparing it for higher-level activities and a return to sport or work. Progressing from basic strengthening, this phase incorporates exercises with increased resistance and complexity.
Examples include weighted squats, leg presses, hamstring curls, and calf raises, performed with heavier loads and higher repetitions. Single-leg exercises, such as single-leg squats and lunges, challenge balance and stability while further strengthening the leg muscles. Core strengthening exercises are also important to improve overall stability and control. It is important to gradually increase the intensity and volume of these exercises based on individual progress and tolerance, with careful monitoring for pain or swelling. The focus remains on achieving symmetrical strength between the injured and uninjured legs, ensuring optimal function and minimizing the risk of re-injury.
Return to Activity and Sports
The final stage of rehabilitation following a tibial plateau fracture focuses on a safe and gradual return to desired activities and sports. This phase typically begins around week 12 and beyond, contingent on achieving adequate strength, range of motion, and functional stability. A comprehensive assessment is crucial, evaluating not only the injured leg but also overall physical conditioning. Specific drills and exercises are implemented to mimic the demands of the intended activity or sport.
For athletes, this involves sport-specific training, agility exercises, plyometrics, and gradual increases in running or jumping volume. For individuals returning to work, the focus shifts to simulating job-related tasks, such as lifting, carrying, or prolonged standing. Throughout this process, close monitoring for pain, swelling, or instability is essential. A graded return to activity is recommended, gradually increasing the intensity and duration of exercise while allowing adequate recovery time. The goal is to restore confidence and functional capacity, enabling a successful and sustainable return to pre-injury levels of activity.
Potential Complications and Considerations
Rehabilitation following a tibial plateau fracture aims for optimal recovery, various complications can arise and warrant careful consideration. One significant concern is arthrofibrosis, characterized by excessive scar tissue formation within the knee joint, limiting range of motion. Early and consistent rehabilitation is crucial to minimize this risk. Another potential complication is nonunion or delayed union of the fracture, requiring further intervention.
Malalignment of the healed fracture can also lead to long-term issues, such as post-traumatic arthritis. Additionally, soft tissue injuries, including ligament or meniscal tears, can complicate the recovery process. Neurovascular injuries, although less common, necessitate prompt recognition and management. Patient-specific factors, such as age, overall health, and adherence to the rehabilitation protocol, significantly influence the outcome. Close communication between the patient, surgeon, and physical therapist is essential to address any emerging complications and adjust the rehabilitation plan accordingly. Ultimately, a proactive and individualized approach is crucial for optimizing recovery and minimizing long-term sequelae following a tibial plateau fracture.