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Jan 12th, 2014

Rosalind asked The Guru for the following Physiotherapy Advice:

micro# to med fem condyle to an approx 1x2cm defect in weight bearing area ( defect apparent at previous ant med- menisectomy Dec ;2011) performed 1/2/13.

Vague instructions from surgeon and physios re weight bearing protocol Post-op. ! Was walked FWB in recovery.

Surgeon said on 1/3/13 he hoped I would get back to tennis , likely will need TKR in 10 years, stay on crutches another 3/52s.

Physios today when pushed for guidance gradual return to FWB next few weeks and estimate back to sport in 6/12s.

Please if you have knowledge to clarify my rehab I should be so grateful.

NB with micro#s also post med -menisectomy, and ACL graft too vertical So loss of full ext… Since reconstruction 2007.

The Guru Responded:

Hi Rosalind

That’s a fairly large OCD that’s been filled. The microfracture forms a blood clot to fill the OCD, which the over time forms fibrocartilage – a dim and distant cousin to the articular cartilage that used to be there. The load bearing properties are much worse….and here lies the issue.

You want to do what ever you can do to make sure that the clot takes and stays, and doesn’t get sloughed off. If it does the OCD returns and the outer rim of the defect takes all of the load.

Rehab therefore needs to allow for enough time to get good adherence of the clot and the very start of FC being formed, which like a degree of weight bearing loading to stimulate the type I and II collagen. So the location of where on the medial femoral condyle is key – the more nearer the midline the more patella grind, the lower the lesser the knee flexion before the patella enter the trochlea…..

Rule of thumb is 6/52 on crutches – final 2 weeks on increasing to PWB. No loaded flexion for 6/52+, and nothing near 90 degrees due to the PFJRF. Free active stuff, on a reformer with low springs from 6/52. Minimal pain, but no boggy swelling allowed! Ice daily. Compression (via a sleeve) is controversial. initially but OK later on. Return to (full) function really depends on pain and swelling. If you do too much too soon, it will delay you later. If you don’t do enough then the FC doesn’t lay well enough and will have altered load bearing properties allowing it to stay painful.

The pain you feel is all (mostly) subchondral and is pretty instannt ie you’ll know if you’re doing something wrong. Get in the pool, work hard to everything else around the knee then slowly at 6/52 increase load and movement – controlled by pain and swelling. You potential cloud on the horizon is the ACL and lack of extension, not allowing “normal” movement.

I wouldn’t put a set 6/12 before your back on court, as it depends on what you do between now and then……

The Guru

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