Treatment and Rehabilitation Options for ACL Strain and Tibial Plateau Fracture
For a 41-year-old active male with an ACL strain and tibial plateau fracture, a comprehensive rehabilitation program without surgical reconstruction is the most appropriate initial approach, focusing on strength training, neuromuscular control, and gradual return to activity.
Initial Management
- Weight bearing status: Immediate weight bearing is safe as long as there is correct gait pattern (with crutches if needed) and no pain, effusion, or increase in temperature when walking 1
- Pain management: Cryotherapy can be applied in the first postoperative week to reduce pain 1
- Immobilization: Use of knee brace may be appropriate (rated 5/9 for appropriateness by AAOS) 1, 2
Rehabilitation Protocol
Phase 1 (Early Phase)
- Isometric quadriceps exercises: Start in first week for muscle reactivation when pain-free 1
- Electrostimulation: Can be useful for re-educating voluntary contraction of quadriceps muscles 1
- Range of motion exercises: Focus on achieving full extension and progressive flexion
- Swelling management: Cryotherapy and elevation
Phase 2 (Intermediate Phase)
Strength training progression:
Neuromuscular training: Must be added to strength training to optimize outcomes and prevent reinjuries 1
Phase 3 (Advanced Phase)
Return to running criteria 1:
- 95% knee flexion ROM
- Full extension ROM
- No effusion/trace of effusion
- Limb symmetry index (LSI) >80% for quadriceps strength
- LSI >80% eccentric impulse during countermovement jump
- Pain-free aqua jogging
- Pain-free repeated single-leg hopping
Return to sport/activity criteria 1:
- No pain or swelling
- Full knee ROM
- Stable knee (clinical tests)
- Normalized subjective knee function and psychological readiness
- Isokinetic quadriceps and hamstring peak torque at 60°/s showing 100% symmetry
90% symmetry in jump height and impulse measurements
- Completion of sport-specific training program
Special Considerations for Tibial Plateau Fracture
For posterolateral tibial plateau fractures with ACL injury, surgical fixation may be indicated if:
- Depression is >2mm and/or
- Width outreaches more than half of the posterior horn of lateral meniscus 3
For less severe fractures, conservative management with the rehabilitation protocol above is appropriate 1, 2
Age-Specific Considerations
For a 41-year-old patient, non-surgical management is often appropriate as:
- The risk and consequence of subsequent meniscal tears are reduced compared to younger patients 1
- Activity levels typically decrease with age 1
- Non-surgical treatment with physical therapy and activity modification allows patients to minimize functional instability while avoiding surgical risks 1, 2
Monitoring Progress
- Regularly assess psychological factors using validated instruments (Self-Efficacy Scale) 1
- Monitor for signs of instability that may indicate need for surgical intervention
- Evaluate quality of movement throughout rehabilitation, not just strength metrics 1
Return to Driving
- For right knee injuries: approximately 4-6 weeks
- For left knee injuries: approximately 2-3 weeks
- Patient should be able to safely activate the brake in a simulated emergency 1
Common Pitfalls to Avoid
- Neglecting neuromuscular training in favor of strength training alone
- Progressing too quickly through rehabilitation phases without meeting objective criteria
- Failing to address psychological factors that influence rehabilitation outcomes
- Not monitoring for signs of instability that may indicate need for surgical intervention
- Overlooking quality of movement in favor of focusing solely on strength metrics