Indication, contraindication, cost-effectiveness of acquatic therapy and water rehabilitation in athletic knee injuries

1. Nicola Taddio, Physical Therapist, BPT, OMTP, ATC
Masters Degree in Science of Health and Rehabilitation Professions
First Level Master IFOMT in Manual Therapy and Musculo-Skeletal Rehabilitation, University of Padua, Italy
Lecturer a.c. Master in “Sports Physioterapy”, University of Siena, Italy
Lecturer a.c. Master in “Sports Physiotherapy and Performing Arts”, University of Genoa, Savona pole, Italy
www.fisioterapiafkt.com nicola.taddio@gmail.com

2. Acknowledgements
to my collegues and friends
A. Cacchio MD PhD
A. Foglia OMPT F. Musarra OMPT
F. Borra PT ATC N. Taddio OMPT ATC
www.hrrgroup.org
hrrgroup.org

3. SESSION
Physiotherapy for the knee injuries
TITLE
Knee rehabilitation in the pool
AIM
The objective of this presentation was to summarize
findings about aquatic exercise after knee injury,
surgery or degenerative disease, from scientific
literature to clinical practice, guided from the
authors, to discover the indication, contraindication,
benefits and cost effectiveness of this treatment

4. Swimming Pool vs Acquatic Gym

5. Table of
contents

6. Introduction
From evidence to expert opinion
Overview (evidence)
Epidemiology of knee injuries
Risk factors of knee injuries
ACL cascade and natural history
ACL injury and surgery: light and shadows
Why, when and how in water (opinion)
Complex knee injuries
Cartilage and meniscal problems
Revision surgery
Degenerative knee in young active patient
Knee osteoarthritis
Multimodal approach (take home message)
The custom made program
Accellerated vs accomodating rehabilitation
2012 Physiotherapist goals

7. Introduction
from evidence to expert opinion

8. Evidence Pyramid
Cohort studies
Case-control
Case series
Case-report
Preliminar studies(animals, in vitro)
Expert opinion
SRs of
RCTs
Systematic
Reviews of RCTs
RCTs
Randomized
Controlled Trials
Courtesy www.gimbe.org 2006, (modified NT 2009)
Clinical Guidelines
Recommendation for clinical
practice
Scientific field
(research)
Clinical field
(application)
Meta-analysis

9. Research evidencePatient preference
E.VIDENCE B.ASED C.LINICAL P.RACTICE
….evidence does not makes decision, people do…..
Clinical state and circumstances
Haynes RB, Devereaux PJ, Guyatt GH.
Physicians' and patients' choices in evidence based practice
BMJ. 2002 Jun 8;324(7350):135
(Haynes RB 2002)
Clinical expertise
Knowledge
Experience
Skill
Competence

10. Overview
through the evidence

11. 17,397 patients
19,530 sport injuries
Over a 10-year period of time;
6434 patients (37%) had 7769 injuries (39.8%) related to the knee joint.
68.1% male 31.6% female
39.8% related to the knee joint
Age at time of injury from 20 to 29 (43.1%) in the almost 50% of cases
 The injuries documented were:
ACL (20.3%), Meniscus M. (10.8%), Meniscus L.
(3.7%), MCL (7.9%), LCL (1.1%), PCL (0.65%).
The activities leading to most injuries were soccer (35%) and skiing (26%).
 LCL injury was associated with tennis and gymnastics;
MCL with judo and skiing;
ACL with handball and volleyball;
PCL with handball, lateral meniscus with gymnastics and dancing;
Medial meniscus with tennis and jogging.
Majewski M, Susanne H, Klaus S.
Epidemiology of athletic knee injuries: A 10-year study.
Knee. 2006 Jun;13(3):184-8. Epub 2006 Apr 17
Athletic knee injuries

12. Dvořák J Br J Sports Med 2009;43:317-322
©2009 by BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine
Epidemiology of soccer injuries
Knee 15%
Knee 12%
Lower extremity
The main region injuried in soccer is the lower limb:
ankle, knee, thigh, lower leg: 56% women, 61% males

13. Bone
Fracture???
Cartilage
fracture???
Isolated ACL
tear ???
Complex
ligaments injury
???
Meniscus
tear ???
Patella
dislocation
???
Patellar
tendon acute
tear ???
Contusion ???
Bone bruise ???
Risk factors for injuries in football.
Arnason A, Sigurdsson SB, Gudmundsson A, Holme I, Engebretsen L, Bahr R.
Am J Sports Med. 2004 Jan-Feb;32(1 Suppl):5S-16S.

14. ……….. we know some ACL injuries occur under circumstances
that seem innocuous doing simple maneuvres that the
athlete has done hundred or thousands of times before, such
as coming down from a rebound or making a cut. All of us
suspect complex neurologic function like proprioception and
fine neuromuscolar control play a key role here
(foreword by Douglas W. Brown AOSSM President , 22 March 1999)
70% of ACL injuries
occur without
contact.......

15. M. M. Murray, S. D. Martin, T. L. Martin, and M. Spector
Histological Changes in the Human Anterior Cruciate Ligament After Rupture
J. Bone Joint Surg. Am. 2000; 82: 1387
Unlike extra-articular ligaments that healafter injury, the human intra-articular anterior cruciate ligament
1) formsa layer of synovial tissue
over the ruptured surface, which mayimpede repair of the ligament. Moreover, a large number of cells in
this synovial layer and in the epiligamentous tissue
2) express the gene for a contractile
actin isoform, a-smooth muscle actin, thus differentiating into myofibroblasts.
These events may play a role in the
A) retraction and B) lack of healing
of the ruptured anterior cruciate ligament

16. The ACL cascade
• The ACL disruption never heal
• The outcome of ACL injury is
a ACL deficient knee
• ACL insufficiency = ACL instability
• ACL instability = pathological joint kinematics
• Alteration of rolling-gliding knee mechanism =
• Shear forces friction wear
Fate of the ACL-injured patient. A prospective outcome study.
Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR.
Am J Sports Med. 1994 Sep-Oct;22(5):632-44.

17. • Pathologycal biomechanics
• Secondary damage
• Medial meniscus
• Articular cartilage
• Release the secondary restraints
• Joint involvement = OA ???
• The crucial role of meniscus = save the meniscus
The ACL cascade
Fate of the ACL-injured patient: a prospective outcome study.
Snyder-Mackler L.
Am J Sports Med. 1995 May-Jun;23(3):372-3

18. COPERS
• Reduce the risk of
sport activities
• No knee abusers
NON-COPERS
ACL Recontruction in
the young active
patient and potential
knee abusers
Conservative treatment
ACL INJURY
L. Herrington, E. Fowler
A systematic literature review to investigate if we identify
those patients who can cope with anterior cruciate ligament deficiency
The Knee, Volume 13, 2006 Aug.,Issue 4, Pages 260-265

19. Geographic mapping of meniscus and cartilage lesions associated
with anterior cruciate ligament injuries.
Slauterbeck JR, Kousa P, Clifton BC, Naud S, Tourville TW, Johnson RJ, Beynnon BD.
J Bone Joint Surg Am. 2009 Sep;91(9):2094-103.
ACL INJURY
• 1209 subjects have sustained an ACL injury and next ACLR from 1998 to 2002
• 1104 patients who met inclusion criteria
MENISCUS
• Meniscus injuries = 722 (65%)
• Meniscus isolated = female (56%) vs male (71%)
• Bimeniscal tears (M+L) = female (11%) vs male (20%)
• Surgical delay = less than three months medial meniscus injury 8%
• Surgical delay = more then three month medial meniscus injury 19%
CARTILAGE
• Femoral articular cartilage injuries = 472 patients (43%)
• Multiple cartilage lesions = 7.7% 25 y.o. or older, 1.3% younger
• Isolated medial femoral condyle lesions = 24.2% compared with 13.3%
• Surgical delay one year = 60% compared with 47% for all others
• Surgical delay of more than one year = large and grade-3 lesions of the LFC
• 29% of female pts have a grade-1 lesions of the MFC vs male have 16%
• 49% of male pts have grade-3 and 4 lesions of the MFC vs female have 35%
• 35 y.o pts or older, meniscus and femoral cartilage lesions were more frequent and on the medial side.
When we
have ACL
Injury:
Meniscus 65%
Cartilage 43%

20. ACL & Meniscus injury vs OA
•At 10 to 20 years after the diagnosis, on average, 50% of those with a diagnosed ACL or
meniscus tear have simptomatic osteoarthritis (with associated pain and functional
impairment): the young patient with an old knee.
•There is a lack of evidence to support a protective role of repair or reconstructive
surgery of the ACL or meniscus against osteoarthritis development.
•Osteoarthritis development in the injured joints is caused by intra-articular pathogenic
processes initiated at the time of injury, combined with long-term changes in dynamic
joint loading.
•Variation in outcome is reinforced by additional variables associated with the individual
such as age, sex, genetics, obesity, muscle strength, activity, and reinjury.
•A better understanding of these variables may improve future prevention and
treatment strategies.
The long-term consequence of anterior cruciate ligament and meniscus injuries:
osteoarthritis.
Lohmander LS, Englund PM, Dahl LL, Roos EM.
Am J Sports Med. 2007 Oct;35(10):1756-69. Epub 2007 Aug 29. Review
1. At 10 to 20 years after the diagnosis, on average,
50% of those with a diagnosed ACL or meniscus
tear have simptomatic osteoarthritis (with
associated pain and functional impairment):
the young patient with an old knee.
1. There is a lack of evidence to support a
protective role of repair or reconstructive
surgery of the ACL or meniscus against
osteoarthritis development.

21. Courtesy Prof. Paolo Aglietti
“ACL Study Group”
Biannual Meeting, Sardinia,
Italy, 2004
Metanalysis about
laxity/instability results

22. Early follow-up vs late follow-up after ACLR
• Study design: case series
• Follow-up: 2 years
• 743 patients 760 surgical procedure
• 316 BPTB 427 QSTGR
• Esclusion criteria: contralateral ACLR and bilateral ACLR
• Current study: 675 knee/patients
• 612 interview by phone 5 years after (90%)
• REINJURY, same knee, in 39 patients (6%)
• CONTRALATERAL INJURY 35 pz (6%)
• 3 patients both(reinjury+contralateral injury)
• Contact injury 3 time frequent
• Contralateral injury risk 10 time in IKDC 1 e 2 Sports
• Higher injury risk in the first 12 month after ACLR
• No difference between gender (M vs F) and graft (TR vs STGR)
Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate
ligament reconstruction.
Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K.
Arthroscopy. 2005 Aug;21(8):948-57.

23. Return to Sport after ACLR:
a 2011 meta-analysis
Return to sport following anterior cruciate ligament reconstruction surgery:
a systematic review and meta-analysis of the state of play.
Ardern CL, Webster KE, Taylor NF, Feller JA.
Br J Sports Med. 2011 Jun;45(7):596-606. Epub 2011 Mar 11.
• 48 studies
• 5770 participants
• Mean follow-up of 41.5 months (3,45 years)
• 82% of participants had returned to some kind of sports
• 63% had returned to their preinjury level of participation
• 44% had returned to competitive sport at final follow-up
• 90% of participants normal or nearly normal knee function when assessed
postoperatively using impairment-based outcomes such as laxity and strength
• 85% when using activity-based outcomes such as the International Knee
Documentation Committee knee evaluation form.
• Fear of reinjury was the most common reason cited for a postoperative reduction
in or cessation of sports participation
• The relatively low rate of return to competitive sport despite the high rates of
successful outcome in terms of knee impairment-based function suggests that other
factors such as psychological factors may be contributing to return-to-sport outcomes.

24. Take Home
First
Message
1

25. Take Home message 1
Soccer is a high risk sport for knee injuries,
particulary for ACL, meniscus and cartilage
The ACL injury never heal an than is the main
cause for disability for young active patients
Non surgical treatment with a specific exercise regimen
is not guarantee to have a stable knee without
long term degenerative changes
The ACLR is not a guarantee of return to sport at the
same level and long term functional good results
However a knee injury start up an alteration of joint homeostasis with
possible acceleration of long term degenerative changes

26. Accelerated vs
Accomodating
Rehabilitation

27. Knee Rehab = variables
• Patient: coper vs non coper
• Age: children vs adolescent vs adults
• Sports: professionel vs amatorial vs sedentary
• Injury: isolated vs associated (men. cart. leg/per.)
• Timing: acute vs sub-acute vs chronic
• Reconstruction: primary vs revision
• Graft: biological vs artificial ACI, MACI, YALOGRAFT
• autograft vs allograft bptb vs dstg vs quad
• Fixation: rigid vs not rigid (bone vs soft-tissue)
• Concomitant surgery: meniscus, cartilage, bone, other lig.
• Preview surgery: meniscus, cartilage vs osteotomy
• Surgeon: learning curve vs espertise
• Physiotherapist: learning curve vs espertise
• Rehabilitation: accelerated vs delayed vs accomodating

28. Accelerated
Delayed
Accomodating
Rehabilitation
Knee Rehab = variables
When ? Why ? How ?

29. Systematic, stepwise rehabilitation with
criteria-based progression is recommended for an
individualized rehabilitation of each athlete not only to
achieve initial return to sport at the preinjury level but
also to continue sports participation and reduce risk
for reinjury or joint degeneration under the high
mechanical demands of athletic activity.
Current concepts for rehabilitation and return to sport after
knee articular cartilage repair in the athlete.
Mithoefer K, Hambly K, Logerstedt DS, Ricci M, Silvers H, Della Villa S.
J Orthop Sports Phys Ther. 2012;42(3):254-73. Epub 2012 Feb 29.
Knee Rehab and return to sport

30. Surgeon
Physical Therapist
GOALS of TREATMENT
Patient

31. PATIENT GOALS
1. Have a stable knee
2. Asimptomatic joint
3. Return to ADL, work and sports
activities like before injury
and/or surgery
4. The results and outcome don’t
deteriorates in time
Carol A. Mancuso, Thomas P. Sculco, Thomas L. Wickiewicz,
Edward C. Jones, Laura Robbins, Russell F. Warren, and
Pamela Williams-Russo
Patients’ Expectations of Knee Surgery
J. Bone Joint Surg. Am. 2001; 83: 1005-1012

32. 1. Restore the normal
arthrokinematics
2. Anatomical reconstruction
3. Stable primary ligament fixation
4. Treat the concomitant lesions
(meniscus, cartilage, other
ligaments and structures)
5. Early ROM passive and active
6. Immediate weigth bearing, if
tolerated
7. Fast gait readaptation and
functional rehabilitation for ADL
SURGEON GOALS

33. PHYSIOTHERAPIST GOALS
1. Prevent the complication
2. Educate the patient an active
approach
3. Help to get through surgical trauma
minimizing the joint reactivity
4. Remove the symptoms (pain,
sweeling, oedema, hemathoma,
stiffness, arthrogenic muscle
inibition….…)
5. Normal gait and function of ADL
6. Safe and fast return of ADL, work
and sports
7. No recurrence of functional
instability
8. The result don’ t deteriorate in time
1
2
3
Arthrofibrosis
Loss of motion
Hemarthrosis
Septic arthritis Cartilage injuries
Associate injuries

34. Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn
WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott
M, Wolf BR, Williams GN.
A systematic review of anterior cruciate ligament
reconstruction rehabilitation:
part I:
continuous passive motion,
early weight bearing,
postoperative bracing,
and home-based rehabilitation.
part II:
open versus closed kinetic chain exercises,
neuromuscular electrical stimulation,
accelerated rehabilitation,
and miscellaneous topics.
J Knee Surg. 2008 Jul;21(3):225-34-217-24. Review.

35. ITEM RECOMMENDED NON RECOMMENDED
EARLY WEIGHT
BEARING
X
IMMEDIATE ROM X
CPM X
POST-OP. BRACE X
CCC EXERCISE first 6 weeks 0°-60°
CCA EXERCISE after 6 weeks 90°-40°
Synopsis
ITEM RECOMMENDED NON RECOMMENDED
NMES In the early phase
MANUAL THERAPY ? In the stiff knee
MODALITIES ? If needed
ISOKINETIC ? In the late phase
PREV. BRACE ? If instability
Evidence-based rehabilitation following anterior cruciate ligament reconstruction.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ.
Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1128-44. Epub 2010 Jan 13. Review

36. Accelerated Rehabilitation in 2012
Phase 1 (1° week)
• Inflammation and pain control with cryotherapy
• Restore the PROM and AROM 0°-90°
• Remove the arthrogenic muscular inibition
• Isometricis ASRL 4 quadrants, CCC 0-60°
• Correct gait patterns, stance phase in full extension
• Remove the crutchies only when the gait is normal
Phase 2 (2°-9° week)
Cryotherapy if pain and inflammation
Restore complete P/A ROM 10° degrees by week 8° week > 120°/130°
Increase the gait training with and without crutchies
Increase the load with exercise in CCC,
Exercise in CCA only 90°-40° from 5°-6° week
Begin the neuromuscular training, only static stability
Evidence-based rehabilitation following anterior cruciate ligament reconstruction.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ.
Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1128-44. Epub 2010 Jan 13. Review

37. Accelerated Rehabilitation in 2012
LOSS OF MOTION
AFTER
ACLR+MENISCAL
SUTURE+BRACE FOR
30 GG =>
ARTHROLISIS

38. Accelerated Rehabilitation in 2012
Phase 3 (9° -16° week)
Full PROM and AROM
Muscle strenght, endurance and power from 9° week in CCC+CCA
FULL ROM
Increase the neuromuscular training with dynamic stability and
pliometrics, jogging 13°sett.
Phase 4 (16° - 22° week)
Sport SpecificTraining
Evidence-based rehabilitation following anterior cruciate ligament reconstruction.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ.
Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1128-44. Epub 2010 Jan 13. Review

39. Take Home
Second
Message
2

40. WHAT HAPPENS BEFORE AND AFTER ACLR ???
• Direct contact injuries
• Indirect contact injuries
• Non conctact injuries> 70%
• Successful > 85%-95%
• Insuccessful> 5%-15%
• Complication >
• Revision >
30%
3%-5%
Prevention
Outcome
B
E
F
O
R
E
A
F
T
E
R
Primary
vs
Secondary
Early
vs
Late
Complications following anterior cruciate ligament reconstruction in the English NHS.
Jameson SS, Dowen D, James P, Serrano-Pedraza I, Reed MR, Deehan D.
Knee. 2011 Jan 7

41. Why, when and
how in water
(authors opinion)
Pool
Rehabilitation

42. Knee athletes injuries
in my clinical practice
Acute Injury
and/or Re-injury
POST SURGICAL REHABILITATION
PRIMARY
•ACL isolated
•ACL with associated men/cart injuries
•ACL with other ligaments injuries
•MENISCUS isolated and/or REPAIR
•CARTILAGE isolated
REVISION
•ACL, PCL
•MENISCUS, CARTILAGE
•ARTHROLISYS
•OSTEOTOMY
COMPLEX KNEE PROCEDURE
•OSTEOTOMY with ACLR and MENISCUS
/CARTILAGE TRANSPLANTATION
PROBLEM KNEE
•MULTI LIGAMENT knee surgery
•FAILED knee surgery
CONSERVATIVE REHABILITATION
TRAUMATIC ISOLATED
•ACL, MCL , PCL, LCL, Meniscus, Cartilage
•Patella dislocation and instability
•Fracture (patella, tibial spine or plateau)
TRAUMATIC ASSOCIATED
•ACL with other ligaments injuries
•ACL with associated meniscal injuries
•ACL with associated cartilage injuries
•PCL and PLC
DEGENERATIVE
•Meniscal isolated
•Cartilage isolated
•KNEE ABUSER: young patient with old knee
OVERUSE
•Patellar and quad. tendon
•Patello Femoral Pain Sindrome
•Osgood-Shlatter disease

43. • Immediate passive/active motion
• Early weight bearing and correct gait patterns
• No postoperative bracing
• Home-based rehabilitation
• Open versus closed kinetic chain exercises
• Neuromuscular electrical stimulation
• Accelerated rehabilitation in isolate ACLR
• Delayed rehabilitation in the complex or revision ACLR
• Preventive bracing if necessary
• Prevent the post-operative complication
• Safe (no only fast) return to activities and sports
• Prevention of failure and re-injury
• Prevention of degenerative changes
My 2012 Rehabilitation Goals
Evidence-based rehabilitation following anterior cruciate ligament reconstruction.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ.
Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1128-44. Epub 2010 Jan 13. Review
Past & Present
Rehabilitation
Goals

44. Pool Rehabilitation: why ?
Control the inflammatory response
Respect the surgical procedure
Reduce the nociceptive and neuropathic pain
Assist the healing process
Wait the return to tissue homeostasis
Physiological response to water immersion: a method for sport recovery?
Wilcock IM, Cronin JB, Hing WA.
Sports Med. 2006;36(9):747-65. Review.

45. Pool Rehabilitation: why ?
Control the inflammatory response
The local inflammatory
response is more
important than the
systemic response for
early postoperative
functional recovery
Which is more important after total knee arthroplasty:
local inflammatory response or systemic inflammatory response?
Ugraş AA, Kural C, Kural A, Demirez F, Koldaş M, Cetinus E.
Knee. 2011 Mar;18(2):113-6. Epub 2010 May 14.

46. Pool Rehabilitation: why ?
Hydrotherapy is effective in
reducing the physiological
and functional deficits
associated with DOMS,
including improved recovery
of isometric force and
dynamic power and a
reduction in localised
oedema.
Effect of hydrotherapy on the signs and symptoms of delayed onset muscle soreness.
Vaile J, Halson S, Gill N, Dawson B.
Eur J Appl Physiol. 2008 Mar;102(4):447-55. Epub 2007 Nov 3.

47. Pool Rehabilitation: why ?
Respect the surgical procedure
The effect of accelerated, brace free, rehabilitation on bone tunnel enlargement
after ACL reconstruction using hamstring tendons: a CT study.
Vadalà A, Iorio R, De Carli A, Argento G, Di Sanzo V, Conteduca F, Ferretti A.
Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15(4):365-71. Epub 2006 Dec 6.
The over-load
and cyclic motion
could be cause of
failure in the first
phase (3/6
weeks) of
rehabilitation
•Tunnel widening
•Slippage
•Bungee effect
•Graft migration
•Graft stretch out
•Pull-out strenght

48. Pool Rehabilitation: why ?
Reduce the nociceptive and neuropathic pain
Inflamed synovial lining and fat pad tissues
increased intraosseous pressure
increased osseous metabolic activity
loss of tissue homeostasis
PainThe pathophysiology of patellofemoral pain: a tissue homeostasis perspective.
Dye SF.
Clin Orthop Relat Res. 2005 Jul;(436):100-10. Review.
chronicacute
Biological Perspective
OVERLOAD

49. Trauma or Surgery
Aemarthrosis
Inflammation (peak 48 hours)
Fagocitosis-Neoangiogenesis
Repair-Regeneration (7 days)
Reinnervation
Ligamentisation
Remodeling
Maturation
P.
R.
I.
C.
E.
PHYSICAL
THERAPY
POOL REHAB.
Pool Rehabilitation: why ?
Assist the healing process

50. Pool Rehabilitation: why ?
Wait and increase the return to tissue homeostasis
Bone remodeling and cartilage maintenance are strongly influenced by biomechanical signals
generated by mechanical loading. Although moderate loading is required to maintain bone
mass and cartilage homeostasis, loading can cause deleterious effects such as bone fracture and
cartilage degradation. Because a tight coupling exists between cartilage and bone, alterations in
one tissue can affect the other. Bone marrow lesions are often associated with an increased risk
of developing cartilage defects, and changes in the articular cartilage integrity are linked to
remodeling responses in the underlying bone. Although mechanisms regulating the
maintenance of these two tissues are different, compelling evidence indicates that the signal
pathways crosstalk, particularly with the Wnt pathway. A better understanding of the complex
tempero-spatial interplay between bone remodeling and cartilage degeneration will help
develop a therapeutic loading strategy that prevents bone loss and cartilage degeneration.
Mechanical loading: bone remodeling and cartilage maintenance.
Yokota H, Leong DJ, Sun HB.
Curr Osteoporos Rep. 2011 Dec;9(4):237-42. Review.

51. Pool Rehabilitation: when ?
Conservative and post surgical:
• Complex knee injuries
• Cartilage and meniscal problems
• Revision surgery
• Degenerative knee in young active
patient
• Knee osteoarthritis

52. LOSS OF MOTION
AFTER
ACLR+MENISCAL
SUTURE+BRACE FOR
30 GG =>
ARTHROLISIS
Pool Rehabilitation: how ?
Case report:

53. Take Home
Message
3

54. Take Home message 3
The main arms of Physical Therapist to
manage knee injuries are manual therapy,
therapeutic exercise and if needed modalities
The advantages of pool rehabilitation, a particular kind of therapeutic
exercise, are that is possible at the same time:
control the inflammatory response, respect the surgical procedure,
control pain response, assist the healing process,
wait the return to tissue homeostasis
The absolute indications of pool rehabilitation are:
complex knee injuries, cartilage damage with reconstruction, meniscal
repair or transplantation, fracture, osteotomies, prosthesis (Total-Uni )

55. Take Home message 4
Despite recommendations for the use of water
exercise programs in patients with knee injuries,
very few randomized clinical studies were conducted
The structure of the exercise programs (content, duration,
frequency and duration of the session) is very heterogeneous
and in literature there is not consensus
On overall, exercise programs based on hydrotherapy only vs mixed exercise
programs (land and water exercise), give better results in early phase than but
without clear differences
Another important finding, particularly from authors experience, is that in
selected cases in elite or top level athlete and in particularly surgical procedure
(meniscus suture, cartilage transplantation or complex knee procedure) the water
exercise is a great chance to use an accelerated protocol for an accommodating
rehabilitation program to building a safe custom made return to sports.

56. Thanks for your
kind attention
science explain what is possible to make
ethics tell us what is right (Socrates)
la scienza spiega cio’ che e’ possibile fare,
l’etica dice cio’ che e’ giusto fare (Socrate)