4. What should an Orthopedic surgeon
know about rehabilitation?
When ?
Where? Why?
How?
What?
5. Why The Knee????????
Although the knee joint may look simple ,
it is one of the most complex.
Moreover, the knee is more likely to be injured than
is any other joint in the body.
We tend to ignore our knees until something happens
to them that causes pain.
As the saying goes, however, "an ounce of prevention
is worth a pound of cure."
In addition, if some problems with the knees
develop, an exercise program can be extremely
beneficial.
6. KNEE JOINT - ANATOMY & FUNCTION
Figure 1: Right Knee
7. KNEE JOINT - ANATOMY & FUNCTION ( CONT.)
To function well, a person needs to
have strong and flexible muscles.
In addition, the meniscal cartilage,
articular cartilage and ligaments
must be smooth and strong.
Problems occur when any of these
parts of the knee joint are
damaged or irritated.
I - Bones:
The knee is essentially made up of
four bones:.
femur,tibia,fibula&patella
Figure 2: Right Knee
8. II) Muscles:
When the knee moves, it does not just bend
and straighten, or, as it is medically termed,
flex and extend.
There is also a slight rotational component
in this motion.
The knee muscles which go across the knee
joint are the quadriceps and the
hamstrings.
The quadriceps muscles are on the front of
the knee, and the hamstrings are on the
back of the knee.
KNEE JOINT - ANATOMY & FUNCTION ( Cont.)
9. III) MENISCUS :
The meniscus is a C-shaped
piece of tissue which fits into
the joint between the tibia and
the femur.
The meniscus has several
functions:
A)Stability .
B)Lubrication & nutrition.
C)Shock absorption.
10. IV)Ligaments: (Cruciate Ligaments)
•There are two cruciate ligaments located in the center
of the knee joint
•. The anterior cruciate ligament (ACL) and the
posterior cruciate ligament (PCL) are the major
stabilizing ligaments of the knee.
Figure : Right Knee
12. Types of Knee injury
• Arthritis
• Bursitis
• Meniscus
• Ligaments
• Sprains
• Bone tumours
• Other causes of
knee pain.
13. A)TORN CARTILAGE (MENISCUS)
•The majority of the meniscus has no blood supply.
•The two most common causes of a meniscus tear
are traumatic injury and degenerative
•Meniscus tears can occur in all age groups.
•Traumatic tears are most common in active people
from age 10-45.
• Individuals who experience a meniscus tear
usually experience pain and swelling as their
primary symptoms.
•.
14. DIAGNOSIS AND TREATMENT Of MENISCAL
TEARS
•History
•Physical examination
• x-rays
• MRI
•Arthroscopic
15. Figure 5: Side view of knee.
Circled area contains an area of normal meniscus.
Figure 6
Side view of knee. Circled area contains
an image of a portion of the meniscus.
The light center area represents the tear.
16. • Meniscus tear symptoms are classified as small, moderate or a large tear.
• On the basis of the blood supply, these menisci are grouped as red-red
(within 3mm of meniscosynovial juntion) , red-white(3mm-5mm) and white-
white(>5mm).
• According to site and direction of tear : Longitudinal , transverse ,bucket
handle, complex……
Types of injury
17. DIAGNOSIS AND TREATMENT Of MENISCAL TEARS
(Cont.)
•The recovery from meniscus tear depends on the aspects like
your type of injury & repair, movement intensity, age, and
repairing tendency of your body.
•Guidelines must be individualized and may change during the
recovery phase.
•Arthroscopy is much less traumatic to the muscles, ligaments and
the tissues than the traditional method of opening the knee.
•Occasionally, it is possible to repair a torn meniscus. While this
may be done arthroscopically, because of the slow healing process
of the meniscus, the recovery time is longer then simply removing
the torn piece of meniscus (meniscectomy).
19. Treating a Torn Meniscus Conservatively
RICE—Ultrasound—TENS or D.D.
•Simple stretches to increase the flexibility of the quadriceps
muscles, the hamstrings, and the calves.
•Simple strengthening exercises
20. Meniscal repair rehabilitation program:
Post-Op. : Day of surgery at home.
1.RICE
2. Do not allow incisions to get wet while bathing.
3. ROM exercises:
a. Ankle range of motion
b. Heel Slides (Do Not Flex Past 90° for 4 weeks)
4. Begin strengthening exercises as tolerated:
a. Quadriceps and hamstring sets,
b. Straight Leg Raises (SLR
c. Seated knee extension, hip flexion, standing
knee flexion.
5. Non-weight bearing with crutches for 4 weeks.
Pre-Op. Instructions
21.
22. Meniscal repair rehabilitation program
(Cont.)
Post-Op: Day 1
1. Continue ice, elevation, and compression
wrap.
2. Continue range of motion exercises 2 - 3
times per day and add:
a. Stationary bike riding with seat height as
low as tolerable with low resistance.
3. Continue strengthening exercises.
4. Ice before and after exercises and 20
minutes every two hours while awake
23.
24. Meniscal repair rehabilitation program
(Cont.)
Post-Op: Day 2 – 7
1. Continue ice and elevation.
2. Continue range of motion exercises.
3. Continue strengthening exercises and add: . Weight
to all SLR’s, Knee Extension, Knee Flexion, Hip
Flexion exercises.
4. Ice before and after exercise and continue use of
compression wrap.
5. Physician examination 6 - 8 days post-op for
evaluation and suture removal.
25. Wall Squats - Stand with back leaning against wall. Walk feet 12 inches in front of body. Keep
abdominal muscles tight while slowly bending both knees 45 degrees. Hold 5 seconds. Slowly
return to upright position. Repeat 10 times.
Heel Raises - Stand with weight even on both
feet. Slowly raise heels up and down. Repeat
10 times.
Straight Leg Raises - Lie on your back with one leg straight and
one knee bent. Tighten abdominal muscles to stabilize low back.
Slowly lift leg straight up about 6 to 12 inches and hold 1 to 5
seconds. Lower leg slowly. Repeat
Heel Slides - Lie on your back. Slowly bend and
straighten knee.
Repeat 10 times
26. Meniscal repair rehabilitation program (Cont.)
Post-Op: Week 1 - 3
1. Continue ice and elevation as needed.
2. Continue range of motion exercises to
90° of flexion limitation.
3. Continue strengthening exercises.
4. Ice before, if indicated, and after
exercise.
27. Meniscal repair rehabilitation program (Cont.)
Post-Op: Week 4 – 8
1.Continue ROM exercises progressing past 90° to
achieve full motion.
2. Continue strengthening exercises, and add:
. Heel raises with balance assistance,.
Progressing to elevated or one-leg heel raises..
Partial squats with balance assistance,
. Progressing to single leg squats. Side Step-Ups,
. Stair Climber exercises .
.Begin Walk-Jog program on smooth, flat surface,
walking curves as tolerated at 6 weeks
28.
29. Meniscal repair rehabilitation program (Cont.)
Return to full activities when:
a. Range of motion and girth measurements are
bilaterally equal,
b. Bilateral strength measurements are 85% or
better, and
c. Clearance by treating physician.
Patients heal at different rates, possess various pre-
operative deficiencies, and require specific attributes
to perform normal function. Due to these factors,
this protocol must be individualized to each patient
to allow for optimal return to desired activities.
30. WE ARE TIRED! WE NEED A BREAK!
LET US DO
SOME
STRETCHING
EXERCISES
32. There is generally some bleeding in the internal
areas surrounding the ACL and is manifested by a
swelling in the knee area.
The pain itself is not so severe and therefore
many patients go for non-surgical ACL physical
therapy options that surgical ones.
33. Diagnosis
• History of the trauma
• Clinically :anterior drawer test.
• MSU
• MRI
• Arthroscope
34. Treatment (ACL)
Non surgical:
ACL physical therapy can be adopted if the cartilage of
the knee is not worn out or damaged.
It is a possibility only if the patient is fine with not
indulging in high risk activities and serious sports.
You may also have to wear a knee brace and some
exercises.
35. • ACL reconstruction surgery uses a graft to
replace the ligament. The most common grafts
are autografts using part of your own body, such
as the tendon of the kneecap (patellar tendon) or
one of the hamstring tendons. Another choice is
allograft tissue, which is taken from a deceased
donor.
Surgical options :
• For treatment are recommended when the
knee totally collapses during the injury and
looses functionality.
36. ACL reconstructionRepair rehabilitation program:
THE HIGHEST INCIDENCE OF KNEE STIFFNESS OCCURS IF ACL
SURGERY IS PERFORMED WHEN THE KNEE IS SWOLLEN, PAINFUL,
AND HAS A LIMITED RANGE OF MOTION.
Knee pain
Stiffness
Limping
Quadriceps
wasting
Knee
effusion
Malalignment
37. ACL reconstruction rehabilitation program (Cont.)
Preoperative Rehabilitation Phase
Goals:
•Control pain and swelling
• Restore normal range of motion
• Develop muscle strength sufficient for
normal gait and ADL
38. Reconstruction rehabilitation program (Cont.) Pre-operative ACL
Immobilize the knee
Extended use of the knee immobilizer should be limited to avoid
quadriceps atrophy. You are encouraged to bear as much weight
on the leg as is comfortable.
Control Pain and Swelling
Crushed ice- PT
Restore normal range of motion
ASAP:
Quadriceps isometrics exercises, straight leg raises, and
range of motion exercises should be started immediately.
39. Pre-operative -ACL reconstruction rehabilitation program
(Cont.)
Full extension is obtained by doing the following exercises:
1) Passive knee extension.
• Sit in a chair and place your heel on the edge of a stool or chair.
• Relax the thigh muscles.
• Let the knee sag under it's own weight until maximum extension is
achieved.
2) Heel Props:
• Place the heel on a rolled towel making sure the heel is propped high
enough to lift the thigh off the table.
• Allow the leg to relax into extension.
• 3 - 4 times a day for 10 - 15 minutes at a time.
3) Prone hang exercise.
• Lie face down on a table with the legs hanging off the edge of the
table.
• Allow the legs to sag into full extension.
41. Pre-operativeACL reconstruction rehabilitation program
(Cont.)
Bending (Flexion) is obtained by doing the following
exercises:
1) Passive knee bend
• Sit on the edge of a table and let the knee bend under the influence of
gravity.
2) Wall slides are used to further increase bending.
• Lie on the back with the involved foot on the wall and allow the foot to slide
down
the wall by bending the knee. Use other leg to apply pressure downward.
Wall Slide: Allow the knee to gently slide down
3) Heel slides are used to gain final degrees of flexion.
• Pull the heel toward the buttocks, flexing the knee. Hold for 5 seconds.
• Straighten the leg by sliding the heel downward and hold for 5 seconds.
43. • In later stages of rehabilitation, do heel slides by grasping the leg with
both hands and pulling the heel toward the buttocks.
Heel slides in later stages of rehabilitation
44. Develop muscle strength
1) Stationary Bicycle. Use a stationary bicycle two times a day for 10 - 20
minutes to help increase muscular strength, endurance, and maintain range of
motion.
2) Swimming
3) Low impact exercise machines such as an elliptical cross-trainer, leg press
machine, leg curl machine, and treadmill can also be used.
Till a full range of motion and good muscular control of the leg (you should be able
to walk without a limp).
Pre-operativeACLreconstruction rehabilitation program
(Cont.)
45.
46. ACL reconstruction rehabilitation program
After Surgery
Prior to leaving the operating room a knee immobilizer will
be applied to the knee.
• A Cryocuff or ice packs will provide cold and compression,
reducing pain and swelling.
• The postoperative knee brace helps to maintain extension
and is to be worn at all times while walking and during
sleeping, otherwise it can be removed.
• The drainage tubes will be removed before leaving the
hospital.
47. ACL Reconstruction Rehabilitation Protocol cont.
Early Range of Motion and Extension
1) Passive extension of the knee by using a
rolled towel. Note the towel must be high
enough to raise the calf and thigh off the table.
2) Active-assisted extension is performed by
using the opposite leg and your quadriceps
muscles to straighten the knee from the 90
degree position to 0 degrees.
Hyperextension should be avoided during this
exercise.
Use the non-injured leg to straighten the knee
3) Passive flexion (bending) of the knee to 90
degrees.
• Sit on the edge of a bed or table and letting
gravity gently bend the knee.
48. ACL Reconstruction Rehabilitation.
Postoperative Days 1 - 7
WORK ON EXTENSION IMMEDIATELY.
* Control pain and swelling
* Care for the knee and dressing
* Early range of motion exercises
* Achieve and maintain full passive extension
* Prevent shutdown of the quadriceps muscles
•Gait training
•DO NOT SIT FOR LONG PERIODS OF TIME WITH FOOT IN A
DEPENDENT POSITION (LOWER THAN THE REST OF YOUR BODY),
AS THIS WILL CAUSE INCREASED SWELLING IN the KNEE AND LEG.
WHEN SITTING FOR ANY SIGNIFICANT PERIOD OF TIME, ELEVATE
LEG AND FOOT.
IT IS IMPORTANT TO KEEP THE INCISIONS DRY FOR THE FIRST 7-10 DAYS.
49. ACL Reconstruction Rehabilitation
Exercising Quadriceps
1)You should start quadriceps isometric contractions with the
knee in the fully extended position as soon as possible.
2) Begin straight leg raises (SLR) with the knee immobilizer
on 8 sets of 10 repetitions 3 times a day. Start by doing
these exercises while lying down.
REMEMBER TO RELAX THE MUSCLES EACH TIME THE LEG TOUCHES
DOWN
Straight leg raises – lying (left) and seated (right)
50. ACL Reconstruction Rehabilitation
Exercising Hamstrings
1) For patients who have had ACL reconstruction using
the hamstring tendons it is important to avoid
excessive stretching of the hamstring muscles
during the first 6 weeks after surgery.
2) The hamstring muscles are exercised by pulling
your heel back producing a hamstring contraction.
• If a hamstring tendon graft from your knee was
used to reconstruct the ACL, this exercise should
be avoided for the first 4 - 6 weeks.
51. ACL Reconstruction Rehabilitation
Postoperative Days 8 – 10
Goals: Physical therapy
Maintain full extension
REMEMBER THAT IT IS EXTREMELY
IMPORTANT TO CONTINUE TO REMOVE the
LEG FROM THE KNEE IMMOBILIZER 4 TO 6
TIMES A DAY FOR 10 - 15 MINUTES AT A TIME
TO MAINTAIN FULL EXTENSION.
52. ACL Reconstruction Rehabilitation
PostoperativeWeek 3
Goals: * Maintain full extension
* Achieve 100 – 120 degrees of flexion
* Develop enough muscular control to wean off knee
immobilizer
* Control swelling in the knee
MAINTAINING FULL EXTENSION AND DEVELOPING
MUSCULAR CONTROLARE IMPORTANT
Maintain Full Extension
1) Continue with full passive extension (straightening), gravity
assisted and active flexion, active-assisted extension, quadriceps
isometrics, and straight leg raises.
2) Work toward 90-100 degrees of flexion (bending)
54. ACL Reconstruction Rehabilitation cont.
3) Continue to use the knee brace for walking even if
you have good muscle control of the leg.
4) Wean from crutches when you can put full weight
on the leg and walk with a normal heal-toe gait and
no limp.
5) You can continue using a stationary bike. Cycling
is an excellent conditioning and building exercise for
the quadriceps.
THE BIKE IS ONE OF THE SAFEST MACHINES YOU CAN USE TO
REHABILITATE YOUR KNEE, AND THERE IS NO LIMITATION ON
HOW MUCH YOU USE IT.
55. ACL Reconstruction Rehabilitation cont.
Postoperative Weeks 3 - 4
Goals: * Full range of motion
•Strength through exercise
1) Expected range of motion is from full extension to 100 – 120 degrees of flexion.
(Add wall slides) and hand assisted heel drags to increase your range of motion.
2) Continue quadriceps isometrics and straight leg raises
3) Continue partial squats and toe raises
4) If you belong to a health club or gym you may start to work on the following
machines:
• Stationary bike.
• Elliptical cross-trainer 15 - 20 minutes a day.
• Inclined leg-press machine for the quadriceps muscles. 70 - 0 degree range.
• Seated leg curls machine
• Upper body exercise machines.
• Swimming: pool walking, flutter kick (from the hip), water bicycle, water jogging.
No diving, or whip kicks.
57. ACL Reconstruction Rehabilitation cont.
Postoperative Weeks 4 - 6
Goals:
* 125 degrees of flexion pushing toward full flexion
* Continued strength building
1) Expected ROM should be full extension to 125
degrees. Start to push for full flexion. Walls slides added
if your flexion range of motion is less than desired.
2) Continue quad sets, straight leg raises, partial squats,
toe raises, stationary bike, elliptical machine, leg presses,
and leg curls.
3) Tilt board or balance board exercises. This helps with
your balance and proprioception.
59. ACL Reconstruction Rehabilitation cot.
Postoperative Weeks 6 – 12
Now ROM should be full extension to at least 135 degrees of
flexion.
Goals:
•135 degree of flexion-* Continued strength-* Introduce
treadmill
1) Continue quad sets, straight leg raises, partial squats, toe
raises, stationary bike, elliptical machine, leg presses, and leg
curls.
2) Hamstring reconstruction patients can start leg curls in a
sitting position. If you develop hamstring pain then decrease
the amount of weight that you are lifting, otherwise you can
increase the weight as tolerated.
.
60. IT IS IMPORTANT TO AVOID USE OF A LEG
CURL MACHINE THAT REQUIRES YOU TO LIE
ON YOUR STOMACH. THIS MACHINE PUTS TOO
MUCH STRAIN ON THE HEALING HAMSTRING
MUSCLES, AND CAN RESULT IN YOU
"PULLING" THE HAMSTRING MUSCLE
61. ACL Reconstruction Rehabilitation cont.
NO MOUNTAIN BIKING OR HILL CLIMBING!
3) Continue tilt board and balance board for balance
training.
4) Continue swimming program.
5) Start treadmill (flat only).
6) You may begin outdoor bike riding on flat roads.
62. ACL Reconstruction Rehabilitationcont.
Postoperative Weeks 12 – 20
Goals:
* Continued strength
* Introduce jogging and light running
* Introduce agility drills
* Determine need for ACL functional brace
1) Continue all previous strengthening exercises.
2) Start straight, forward and backward jogging
and light running program.
3) Start functional running
program after jogging program
is completed.
63. Cross over drills
Agility drills
4) Optional fitting for ACL functional brace.
5) Start agility drills & zig-zags
Definition: Agility is the ability to move and
change direction and position of the body
quickly and effectively while under control.
64. ACL Reconstruction Rehabilitationcont.
24 Weeks Postoperative (6 months)
This is the earliest you should plan on returning to full
sports.
Goals:* Return to sports
To return to sports you should have:
• Quadriceps strength at least 80% of the normal
leg
• Hamstring strength at least 80% of the normal leg
• Full motion
• No swelling
• Good stability
• Ability to complete a running program
65. WE ARE TIRED! WE NEED A BREAK!
LET US DO
SOME
STRETCHING
EXERCISES
66. ACL reconstruction with simple meniscal repair
•General Considerations:
-PROM as tolerated. Early emphasis on achieving full
extension.
-Patients will be in a knee immobilizer for weight
bearing for 3 weeks post-op.
-Touchdown weight bearing for 3-5 days, progressing to
full weight bearing in extension until 3 weeks post-op.
-Important to watch for lower leg rotation or heel whip
with ambulation.
-Closed chain activities initiate at 2-3 weeks post-op and
beginning between 20°-70° OR in full extension to avoid
stress onto the repair.
67. -Active hamstring exercises can be initiated at 4 weeks
and resistive at 6 weeks.
-No lateral exercises for 6-8 weeks and nor ballistic
activities for at least 4 months post-op.
-No resisted leg extension machines (isotonic or isokinetic)
at any point in the rehab process.
-Patients are given a functional assessment test at 14
weeks, 6 months and 1 year post-op.
ACL reconstruction with simple meniscal repair
cont.
68. Week 1:
-Straight leg raise exercises (lying, seated, and standing),
quadricep/adduction/gluteal sets, gait training.
-Well-leg stationary cycling, abdominal exercises and upper body
conditioning.
• Weeks 2-4:
-Continue with pain control, gait training, and soft tissue treatments. -
Aerobic exercises.
• Weeks 4-6:
-Discontinue use of knee immobilizer if able to demonstrate adequate quad
control.
-Incorporate closed-chain exercises (i.e. mini-squats, modified lunges,
short step-ups) .
-Add hamstring curls without resistance*.
-Patients should have full extension and 110 degrees of flexion by the end
of this period.
• Weeks 6-8:
-Leg weight machines
-Stationary cycling initially for ROM, increasing as tolerated. -Increase the
intensity of functional exercises (i.e. add a stretch cord for resistance, add
weight, increasing resistance of aerobic machines).
69. • Weeks 8 - 12:
-Introduce resistive hamstring curls*.
-Add lateral training exercises (i.e. lateral stepping, lateral step-ups,
step overs).
• Weeks 12-16:
-Progress to running as able to demonstrate good mechanics and
appropriate strength.
-Begin to incorporate sport-specific training (i.e. volleyball
bumping, light soccer kicks and ball skills on contralateral side).
-Patients should be weaned into a home program with emphasis on
their particular activity.
• Weeks 16-24:
-Incorporate bilateral jumping and bounding exercises, making
sure to watch for compensatory patterns and any signs of increased
load onto the knee with take-offs or landings.
-cautiously introduce hamstring resisted exercises, watching for
signs of joint line/meniscus irritation
71. ACL reconstruction with complex meniscal repair-
rehabilitation program
General Considerations:
-PROM as tolerated. Early emphasis on achieving full
extension.
-Patients will be in a knee immobilizer for 4 weeks post-op.
-Non weightbearing for 3-4 weeks.
-Closed chain activities initiate at 3-5 weeks post-op and
beginning between 20°-70° OR in full extension to avoid
stress onto the repair.
72. Active hamstring exercises can be initiated at 6 weeks
and resistive at 8 weeks
-No lateral exercises for 10 weeks and no pivoting or
ballistic activities for at least 4 months postop.
-No resisted leg extension machines (isotonic or
isokinetic) at any point in the rehab process.
-Patients are given a functional assessment test at 14
weeks, 6 months and 1 year postop.
73. • Week 1
-Straight leg raise exercises quadricep/adduction/gluteal sets, gait training.
Well-leg stationary cycling, abdominal exercises and upper body conditioning.
-Soft tissue treatments to posterior musculature, retropatella and surgical
incisions.
• Weeks 2-4:
-Continue with pain control, gait training, and soft tissue treatments.
mini-squjits, modified lunges,
^Avoiding going into the last 15°-20° of extension avoids stress onto the repair.
Aerobic exercises consisting of well-leg stationary cycling, and upper body
weight training.
Weeks 4 - 6:
-Discontinue use of knee immobilizer if able to demonstrate adequate quad
control.
-Add hamstring curls without resistance.
-Stationary cycling initially for ROM, increasing as tolerated.
-Patients should have full extension and 110 degrees of flexion by the end
of this period.
74. • Weeks 6 - 8:
-Leg weight machines
-Stationary cycling initially for ROM, increasing as tolerated. -Increase
the intensity of functional exercises (i.e. add a stretch cord for resistance,
add weight, increasing resistance of aerobic machines).
• Weeks 8 - 12:
-Introduce resistive hamstring curls*.
-Add lateral training exercises (i.e. lateral stepping, lateral step-ups,
step overs).
• Weeks 12-16:
-Progress to running as able to demonstrate good mechanics and
appropriate strength.
-Begin to incorporate sport-specific training (i.e. volleyball bumping,
light soccer kicks and ball skills on contralateral side).
-Patients should be weaned into a home program with emphasis on their
particular activity.
75.
76. C) Total knee replacement
Considerations
· Knee replacement surgery is considered a last
resort in many cases, as it involves various risks.
However, knee replacement is commonly
suggested for people who have constant pain in
the knee joint that is severe enough to affect their
daily life. Anyone experiencing significant
stiffness, instability or deformity of the knee
joint is also considered a candidate for knee
replacement surgery.
77. Causes
.
Osteoarthritis-Rheumatoid Arthritis-Post-traumatic
Arthritis
·
Technique
•During a total knee replacement, the end of the femur bone is removed and
replaced with a metal shell. The end of the lower leg bone (tibia) is also
removed and replaced with a channeled plastic piece with a metal stem.
Depending on the condition of the kneecap portion of the knee joint, a plastic
"button" may also be added under the kneecap surface
78. Proposed Rehab Protocol for Total Knee
Replacement.
.
Extension:
o Place a rolled towel under your ankle to help with extension.
.
o Getting the knee fully straight (fully extended) is one of the most
important things for a successful total knee replacement.
o Put nothing under the knee.
--------------------------------------------------------------------------------
Ice the knee as needed for 20 minute intervals on/off as needed.
Be sure to ice it after your physical therapy sessions.
N.B. The knee is going to be warm and swollen for a long time (9 months
to 1 year).
80. (Proposed Rehab Protocol for Total Knee Replacement cont).
Phase I
Immediate Postoperative Phase (Day 0 – 10)
Goals:
Active quad contraction
Safe independent ambulation with walker or crutches
as needed
Passive knee extension to 0 degrees
Knee flexion to 90 degrees or greater
Control of swelling, inflammation, bleeding
81. (Proposed Rehab Protocol for Total Knee Replacement
cont).
Day 0-2:
Weight bearing as tolerated with walker/2 crutches as needed
starting on Day 0-1
Cryotherapy immediately and continuously unless ambulating
ROM of knee to begin immediately post op
Exercises
• Ankle pumps
• Passive knee extension to 0 degrees
• SLR
• Quad sets
• Knee flexion to 90 degrees
• Knee extension to 0 degrees
• Instruct in gait training - safe transfers
82. (Proposed Rehab Protocol for Total Knee Replacement
cont).
Day 3-10:
Weight bearing as tolerated with walker/2 crutches as
needed
Cryotherapy
Exercises
Ankle pumps
Passive knee extension to 0 degrees
SLR
Quad sets
AAROM - Knee flexion to at least 90 degrees
Hip adduction/abduction
Instruct in gait training – safe transfers
Start stationary bike, low resistance
83. (Proposed Rehab Protocol for Total Knee Replacement
cont).
Phase II: Motion Phase (Week 2-6)
Goals:
Improve ROM
Enhance muscular strength, endurance
Dynamic joint stability
Diminish swelling/inflammation
Establish return to functional activities
Criteria to enter Phase II:
Leg control, able to perform SLR
AROM 0-90 degrees
Minimal pain/swelling
Independent ambulation/transfers
84. (Proposed Rehab Protocol for Total Knee Replacement cont).
Weeks 2 -4:
WBAT with assistive device as needed. Wean from walker to cane or from 2
crutches to 1 by 2 weeks. Wean off all assistive devices by no later than 4 weeks.
Exercises:
Quad sets
SLR
Knee extension 90-0 degrees
Terminal knee extension 45-0 degrees
Hip abduction/adduction
Hamstring curls
Knee flexion to at least 115 degrees
Stretching:
Hamstrings- Gastroc/soleus- Q-uads
Passive knee extension stretch
Continue stationary bike and advance resistance as tolerated
Continue cryotherapy
Patellofemoral mobilization
Incision mobilization
Patients may begin to drive if they are no longer using assistive devices
for ambulation (about 2 weeks post op)
85. (Proposed Rehab Protocol for Total Knee
Replacement cont).
Weeks 4-6:
Exercises:
Continue previous exercises +
o Initiate front and lateral step ups
o Advance resistance on stationary bike
Initiate progressive walking program
Initiate endurance pool program, swimming with flutter kick
Return to functional activities
Continue compression, ice, elevation as needed for swelling
Patients should be walking and driving independently
at this point
86. (Proposed Rehab Protocol for Total Knee Replacement cont).
Phase III: Intermediate Phase (Weeks 7-12)
Goals: Progression of ROM to greater than 115 degrees
Enhancement of strength and endurance
Eccentric/concentric control of limb
Cardiovascular fitness
Functional activity performance
Criteria to enter Phase III:
ROM 0-115 degrees
Voluntary quad control
Independent ambulation
Minimal pain
87. (Proposed Rehab Protocol for Total Knee Replacement cont).
Weeks 7-12:
Exercises: Continue previous exercises
Continue pool activities
Continue walking
Continue stationary bike
Aggressive AROM 0-115 degrees
Strengthen quad/hamstrings
88. (Proposed Rehab Protocol for Total Knee Replacement cont).
Phase IV: Advanced Activity Phase (Weeks 12 and beyond)
Goals:
Allow patients to return to advanced level of function such
as recreational sports
Maintain/improve strength and endurance of lower
extremity
Return to normal life and routine
Criteria to enter Phase IV:
Full non painful ROM 0-115
Strength 90% of contralateral limb (if contralateral limb is
normal)
Minimal pain and swelling
Satisfactory clinical examination
89. Exercises:
o Quad sets
o SLR
o Hip abduction/adduction
o Step ups
o Knee extension
o Stationary bike
Swimming
Walking
Stretching 0-115 degrees
Return to pre op activities and develop HEP to maintain
function of leg.
NO SQUATS OR LUNGES AT ANY TIME!
90. Remember:
Don’t permit the session if:
o The wound site is red
o There is excessive drainage or pus
o Tense ,swollen ,tender leg
o The patient has a fever over 37.5°C
o The patient is experiencing severe
pain
91. D)Muscles tears
Quad & Hamstring Injuries
. Types of traumas:
Pulls and Strains
Partial tears
Complete tears
Contusions and bruises
92. Management:
• Rest
• Ice + splinting
• Stretching .
•Physical modalities for pain
•Surgeries could be indicated in full thickness
complete tears
98. Remember
1)Each patient has his own circumstances.
2)Modalities of physical Rehabilitation are not constant
for all patients having same disorders.
3)Revise every detail with the physician & therapist in
charge.
4)Working in a team is the best way for cure
