Journal of Orthopaedic & Sports Physical Therapy - Frank R. Noyes, MD

The Use of Thermography for the Diagnosis and Management of Patellar Tendinitis

Robert E. Mangine, Karen A. Siqueland, Frank R. Noyes
Computerized thermography was used to evaluate 17 patients diagnosed with patellar tendinitis. The intent of this study was to determine if a specific patellar tendinitis thermal pattern could be distinguished using infrared thermography. A specific thermal abnormality was found over the patellar tendon in 14 subjects (78%). Twelve subjects showed focal "hot" spots, while two showed focal "cold" spots. The thermal abnormalities appeared as specific focal areas directly overlaying the patellar tendon, without disruption to the thermal pattern of the remaining peripatellar regions. The thermal gradient slope over the patellar tendon was greater in symptomatic knees. Five subjects returned 2-4 weeks later for follow-up thermographic examination. Among the follow-up subject group, changes in thermal asymmetry correlated with changes in symptoms 80% of the time. Computerized thermography appears useful as a noninvasive, objective method of detecting inflammation of the soft tissues about the patellar tendon, and also helps to differentiate this disorder from other knee pathologies.

J Orthop Sports Phys Ther 1987;9(4):132-140.

A Physiological Profile of the Elite Soccer Athlete

Robert E. Mangine, Frank R. Noyes, Mary Pat Mullen, Sue D. Barber-Westin
From the Cincinnati Sportsmedicine and Orthopaedic Center and The Deaconess Hospital, Cincinnati, OH. Research Funded by the Cincinnati Sportsmedicine Research and Education Foundation and the United States Olympic Committee.

The purpose of this study was to develop a physiological profile of the elite soccer athlete. Protocols were developed to assess flexibility, knee ligament translation, body composition, anaerobic power, lower extremity functional performance, and muscle strength. Eighty-three male U.S. National Team players provided data for this study. Different protocols were used over the years the data was gathered. Each area was tested, using a subset of the total group. The physiological profile of the elite soccer player was compiled from results in each area tested. The players were flexible, on the whole, although 17% of the players demonstrated hamstring tightness. All but one player tested had less than 2.5 mm anterior/posterior (A/P) knee ligament translation. The average body fat was 9.5%, and all athletes performed normally on the function tests. The mean power output on Wingate testing was 8.1 Watts per kilogram body weight. The average hamstring-to-quadricep torque ratio (H/Q) at 60°/sec was 56% (right) and 56.6% (left), and at 450°/sec, was 67.1% and 70.1 %. Identification and measurement of these key physiological qualities for the elite soccer athlete will provide standards and a baseline for trainers, coaches, players, and future investigators.

J Orthop Sports Phys Ther 1990;12(4):147-152.

Knee Rehabilitation After Anterior Cruciate Ligament Reconstruction and Repair

Lonnie Paulos, Frank R. Noyes, Edward Grood, David L. Butler
Reprinted with permission from The American Journal of Sports Medicine 9:3 140-147, 1981.

Presented at the Interim Conference of the American Orthopaedic Society for Sports Medicine, February 8, 1980, Atlanta, GA.

Address correspondence to: Lonnie Paulos, MD, 2350 Auburn Ave., Cincinnati, OH 45219.

The purpose of this paper is to present the specifics and rationale of our postoperative rehabilitation program after anterior cruciate ligament (ACL) reconstruction and compare it with an international survey of 50 knee experts. It is important to stress that what we present is opinion. This opinion, however, is based on principles, guidelines, and specifics which we believe are important.

The early phases of our program are based upon time and control of forces, both of which are necessary for ligament healing. The classic parameters of return to play do not indicate healing of ligament tissue and must not be substituted for time restraints.

After ACL repair and reconstruction, there are five phases of rehabilitation: maximum protection (12 weeks), moderate protection (24 weeks), minimum protection (48 weeks), return to activity (60 weeks), and activity and maintenance.

The maximum protection phase consists of the early healing period and controlled motion period. The early healing period is governed by a principle which requires the absolute control of forces to prevent disruption of the suture line or attachment site. This time will vary according to the surgical technique. We do not allow motion during this period. During the controlled motion period, we allow motion but control external forces to protect ligament healing.

The moderate protection phase consists of the crutch-weaning and walking periods. The major goal of the moderate protection phase is to prepare the patient for walking. The principles which govern Phase 2 are that walking activities create large anterior cruciate ligament forces and healing strength is still low. A balance of quadriceps and hamstring forces is necessary for proper knee kinematics. De-emphasis of quadriceps exercises and emphasis of hamstring muscles is appropriate; however, both muscle groups must be strengthened. The crutch-weaning period is designed to allow the gradual increase of motion and strength to sustain walking activities.

A paradox of exercise exists for strength building. To push weight from 30° of flexion into full extension will protect the patellofemoral joint but will create large forces on the ACL. Our compromise is to push low weight through a full range of motion. We begin full weightbearing no sooner than the 16th week.

The final three phases of our program are designed to develop dynamic stability through strength, coordination, and endurance. Phase 3, the maximum protection phase, consists of the protected activity period from the 24th through the 36th week, and the light activity period from the 37th through the 48th week. Restrictions include no running, no jumping, and the use of a brace full-time. The light activity period allows further time to protect the slow healer. This may be shortened or lengthened, depending upon the patient's condition and goals.

Phase 4, the return to activity phase, begins nine to 12 months after surgery. It consists of the advanced rehabilitation period and the running period. The advanced rehabilitation period is designed to achieve maximum strength and further enhance neuromuscular coordination and endurance. The running period begins when the operated leg has at least 75 percent of the strength and power of the normal leg.

The activity and maintenance phase consists of the return to sport and maintenance periods. On return to sport, the patient must gradually resume full activity by advancing from skill drills. The maintenance program consists of triweekly strength-building sessions, brace protection during sporting, and avoidance of high-risk activities.

J Orthop Sports Phys Ther 1991; 13(2):60-70.

Rehabilitation of the Allograft Reconstruction

Robert E. Mangine, Frank R. Noyes
A series of prospective studies have been performed using allograft tissue for anterior cruciate ligament (ACL) reconstruction. This type of procedure has been shown to effectively control joint displacement and increase overall patient function in a specific patient population. In considering the use of allograft tissue, the surgeon must take into account the indications and contraindications as well as graft preparation and possible immune response. The current clinical trend is utilization of allograft tissue for patients who have previously failed autograft surgery, have patellofemoral arthrosis, or have a long-standing chronic ACL deficiency. The rehabilitation process for these types of patients is very similar to our approach in the autograft patient. It is important for the clinician to facilitate an early motion program after surgery, early exercise protocols, and early weight bearing. However, as in any protocol, careful evaluation is critical. Three different studies reported by our group have shown the allograft to be successful in controlling joint displacement. On testing with the KT-1000 arthrometer, 69 percent of acute repairs had less than 3 mm of anterior posterior displacement; 26 percent of these patients had only 3-5 mm of anterior displacement compared to the contralateral knee. A second study of chronic anterior cruciate ligament patients showed 54 percent had under 2.5 mm of anterior displacement and 34 percent had 3-5 mm of anterior displacement when compared to the contralateral knee. With effective implementation of a rehabilitation program, only 5 percent of our acute and chronic patients developed a motion complication, and only 9 percent had patellofemoral complaints. Using a strict rating system, the overall rating of these patients showed that 89 percent were in the excellent to good range, which allowed them to once again participate in recreational or competitive sports. Only 11 percent had a fair to poor result; 50 percent of that group chose not to return to sporting activity for nonknee related causes. These studies have shown that allograft ligament reconstructive techniques are effective and improve functional ability in the chronic anterior cruciate ligament patient. Use of these tissues should, however, be on a selective basis. Caution must be used by the physician when using these tissues, and the physical therapist must recognize that the protocol for postoperative management is essentially the same as for the autograft techniques.

J Orthop Sports Phys Ther 1992;15(6):294-302.

Key Words: anterior cruciate ligament, allograft, rehabilitation, clinical outcome

Physical and Arthroscopic Examination Techniques of the Patellofemoral Joint

Carl W. Nissen, Mark C. Cullen, Timothy E. Hewett, Frank R. Noyes

A systematic approach to the clinical history, physical, and arthroscopic examination of patellofemoral disorders will lead to improved diagnostic accuracy and clinical treatment success. We review important aspects of physical and arthroscopic examination of patellofemoral disorders. Basic and advanced physical examination techniques are presented, and their clinical significance is reviewed. Arthroscopic examination of the patellofemoral joint is used as an adjunct to physical examination to evaluate chondral lesions of the patella and femoral sulcus and to visualize patellar tracking. Techniques to assess patellar tracking and the integrity of patellar restraints and to grade chondral lesions are outlined. Utilization of these techniques will improve clinical studies on the treatment of patellofemoral disorders.

J Orthop Sports Phys Ther. 1998;28(5):277-285.

Key Words: knee pain, physical examination, extensor mechanism, malalignment

Meniscal Repair and Transplantation: Indications, Techniques, Rehabilitation, and Clinical Outcome

Timothy P. Heckmann, Sue D. Barber-Westin, Frank R. Noyes

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique.

The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present.

Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.

J Orthop Sports Phys Ther. 2006; 36(10):795-814. doi:10.2519/jospt.2006.2177

Key Words: knee rehabilitation, meniscus repair, meniscus transplant