Activity Immediately Following Surgery

The amount of weight you can put through your knee after surgery will depend on your doctor and the procedure itself. If a cemented procedure was performed, your doctor may approve for you to place a comfortable amount of weight through your operated leg after surgery using your walking aid. If the surgery was done without cement, you may be directed to limit the amount of weight through the operated leg to only a "toe touch" amount of weight for four to six weeks after surgery. There are different ways to surgically reconstruct knees, so the instructions you are to follow after surgery will depend on your doctor and the way the surgery was done.

Precautions:
Follow your instructions for the amount of weight you can put through your operated knee. Avoid activities that put a strain on the surgical area. During your activities, let pain guide your decisions. If you feel pain with any activity, stop or alter what you are doing because pain at this stage is an indicator of strain or irritation.

Exercises:
Any exercises you do should be done only by the direction of your doctor or therapist. The choices of exercise used after surgery will be gauged by the type of procedure used. You may be given a few exercises that you can do for your ankle and foot. Gently bending and straightening your ankle can keep your calf muscle flexible while "pumping" away excess swelling. Some exercises are used to help control pain and help with movement in the knee. Low grade exercises for the thigh muscles can usually begin right away. Extra pain felt after these or other exercises gives an idea if you are overdoing it. You may need to change the number of repetitions, the amount of pressure, or the how often you are doing the exercises.

Inpatient Physical Therapy

Some doctors will put your knee in a machine right after surgery that slowly and gently bends and straightens your knee. This is called continuous passive motion or CPM. It is often used along with a form of cold treatment that may include a flow of cold water that circulates through hoses and pads around your knee.

Your physical therapist may schedule to see you in the hospital on the same or next day after surgery. The first visit gives your PT an idea of how well your knee is moving, how well you can move in bed, your safety when getting up and sitting on the edge of the bed, and whether you can begin to walk using a walking aid and putting the right amount of weight through your foot. As you gain more confidence and endurance with walking, your therapist will begin to train you how to go up and down stairs using your walking aid.

You may also begin doing a few exercises in your hospital room during the first visit. Gentle range of motion exercises can be used to help begin to restore knee movement. You could begin a series of strengthening exercises for the thigh and leg muscles too. As your condition improves, you may be transported by wheelchair to the physical therapy gym for your treatment sessions.

While you are an inpatient, your therapist may see you for therapy up to two times each day. You can expect to stay in the hospital at least three to four days after surgery. You may be released to go home when you can get in and out of bed safely, walk with the right amount of weight on your foot using a walking aid, go up and down stairs safely, and do your exercises by yourself.

After You Leave the Hospital

Once discharged from the hospital, you may be seen in the home for treatment. This is to make sure you are safe in and around your home. You could be seen for at least one home visit for the safety check and to review your exercise program.

Outpatient Physical Therapy

On your first outpatient visit, your physical therapist will want to gather some more information about the history of your condition. You may be given a questionnaire that helps you tell about the day-to-day problems you are having because of your condition. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your therapist gauge how much pain you have now and how your pain and symptoms change once you've had treatment. Your therapist will probably ask some more questions about your condition to get an idea how your knee has been feeling since your surgery:

• How is your knee feeling since the surgery?
• Where do you feel your pain now?
• Do you have any popping or clicking in the knee?
• Are you getting any more swelling?

Physical Therapy Evaluation

Once all this information has been gathered, your condition will be evaluated. The main parts of the evaluation are listed below and may be done in the order chosen by your therapist.

Posture/observation:
Your physical therapist will check your overall posture, including the alignment of your low back, pelvis, and your knees and ankles. These have a significant role in the health of your knee. Your therapist will also check the surgical area to make sure the incisions are healing. By comparing each side, your therapist can determine if there is extra swelling, bruising, or a loss in the size of your muscles.

Gait analysis:
By watching you walk back and forth, your therapist can make sure your walking aid is adjusted for you and that you are using it safely. The amount of weight you put through your leg will depend on your doctor and the type of procedure done (cemented or not).

Range of motion (ROM):
Your therapist will check the ROM in your knee. This is a measurement of how far you can move your knee forward and back (flexion/extension). You may have pain and limited movement in both directions. Movement of the knee cap (patella) is also checked to see that it is moving freely. Your ROM is written down to compare how much improvement you are making with the treatments.

Strength:
Your therapist will test the strength of your muscles. You could be asked to hold against resistance as your therapist tests the muscles around the knee. Other muscles that may be checked include the hip, buttocks, and calf muscles. These measurements are compared to your other side. Weakness in key muscles will be addressed with a strengthening program.

Girth:
Using a tape measure, your therapist may compare the circumference of your thigh, knee, and calf. This can give an indication of swelling or whether your muscles have lost size (atrophied) from a lack of use or from having pain.

Manual examination:
You may be given a manual examination of the knee. Your therapist will carefully move your leg in different positions to make sure that the knee and other joints are moving smoothly. Your therapist will also look at the flexibility of the muscles and tendons around your knee. This type of exam can help guide your therapist to know which type of treatments will help you the most.

Palpation:
Palpation is when your therapist feels the soft tissues around the sore area. This is done to check the skin for changes in temperature, to see how much swelling you have, to pin-point areas of soreness, and to see if there are tender points or spasm in the muscles around the knee joints. This can help your therapist get a good idea about which treatments will help you the most.

Treatment plan:
Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. The plan also lists the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.

Using Physical Therapy to Ease Pain

Your therapist may choose from one or more of the following tools, or modalities, to help control the symptoms you may have from your knee surgery.

Rest:
Rest is an important part of treatment after surgery. If you are having pain with an activity or movement, it should be a signal that there is still irritation going on. You should try to avoid all movements and activities that increase your pain. Be sure to use your crutches as assigned by your doctor, and put only the amount of weight on your leg as approved by your doctor.

Ice:
Ice makes the blood vessels in the sore area become more narrow, called vasoconstriction. This helps control inflammation that is causing pain and can easily be done as part of a home program. Some ways to put ice on include cold packs, ice bags, or ice massage. Cold packs or ice bags are generally put on the sore area for 10 to 15 minutes.

Heat:
Heat makes blood vessels get larger, which is called vasodilation. This action helps to flush away chemicals that are making your knee hurt. It also helps to bring in nutrients and oxygen which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin doesn't overheat and burn. It's also not a good idea to sleep with an electric hot pad at night.

Swelling control:
Massage, cold whirlpool treatment, or compression therapy may be used to control swelling by flushing the extra fluid away from the area. The use of cold, compression, and elevation are a beneficial combination for reducing swelling.

Electrical stimulation:
This treatment stimulates nerves by sending an electrical current gently through your skin. In the acute treatment after meniscal surgery, the stimulation can ease pain and help remove swelling. It is often used in combination with ice in the early stages and heat in the later stages of recovery. This treatment stimulates nerves by sending an electrical current gently through your skin. Some people say it feels like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort.

Improving range of motion (ROM):
To improve your ROM, your therapist can use graded joint mobilization, manual stretching, and select exercises. The swelling and irritation from a knee surgery can cause movement problems in the knee cap. Getting your knee cap moving will help with your overall knee ROM. Active movement and stretching as part of a home program can also help restore movement.

Gait Training: Once you are safe to put full weight through your operated leg, your therapist will work with you to "fine tune" your gait. Retraining may be needed if you've developed a limp, which may be due to apprehension of pain or simply from a habit you've developed since your injury or surgery. Getting a normal walking pattern starts with shifting your weight when you walk. If you can visualize the way competitive speed skaters sway their hips when they skate, you'll get the picture of what it means to shift your weight. When you place your sore-side foot down and prepare to step through with the opposite foot, you may be hesitant to shift the weight of your hip over your planted foot. This leads to an antalic gait--better known as a limp. Practicing this part of the walking cycle may be all that is needed to help you "remember" how to walk without a limp. Your therapist will also make sure that your steps are equal in width and length.

Aquatic therapy:
By doing exercise in a pool, the properties of buoyancy and warmth let you exercise with ease of movement. The buoyancy of the pool can be used to make exercise easier, to give resistance with some of the exercise, and to help you begin walking with less stress on your new knee. The warmth can help muscles relax, improve circulation, and ease soreness; letting you move easier. If your therapist works with you in the pool, a few visits are usually all that is needed before you get into a regular program on land. If you are getting good benefits in the pool, you will probably want to get a membership to the pool so your other visits can be used to work on strengthening, walking, and getting you back to doing the activities you enjoy.

Strengthening and Exercise

After a knee surgery, you can expect that your leg muscles will be weak. When muscles weaken from pain or disuse, other muscles overpower the weaker ones. This leads to an imbalance where the weaker muscles become longer and the stronger muscles become shorter. These imbalances change the way the joints usually work. The swelling and pain from your knee pain and surgery can lead to weakened muscles around the knee. The quadriceps muscle usually is affected. Exercises can be chosen to help regain the strength in the muscles around the knee.

Biofeedback:
Muscle control is the basis for strength. Using biofeedback can help you get back the contol of the quadriceps muscle. The biofeedback unit has surface electrodes that are put on the skin over the muscle that needs help. As you practice working the muscle, the machine will give you "feedback" to let you see and hear how the weak muscle is performing. The biofeedback unit can also be set to alert you if other muscles are overpowering the weak muscle. Biofeedback can be used while you do your exercise program so you'll know if you're actually working the right muscle.

Functional Electrical Stimulation (FES):
This is a way to use electrical stimulation to help retrain a weakened or deconditioned muscle. Electrodes are placed over the muscle that is to be retrained. The electrical current passes through the skin and stimulates the motor nerve of the muscle causing it to tighten for a set time without your conscious effort. The machine is usually set to go on for about 10 to 15 seconds and then off for 15 to 30 seconds. Once you get the idea of how the muscle feels when it tightens, you can begin tightening the muscle when the current comes on again. After you get a good contraction going, you should be able to sucessfully tighten the muscle without the use of the current.

Progressive Resistive Exercises (PREs):
Many choices of PREs are now used in rehabilitation. Some of these choices include pulley systems, free weights, rubber tubing, manual resistance, and computerized exercise devices. Using PREs is a way to apply graded resistance to muscle groups to gradually help them gain endurance and strength. These exercises typically start with lighter weights with lots of repetitions, and as endurance increases, more weight is gradually used with fewer repetitions.

Exercise Precautions:
First, avoid "overdoing" it. If you find that your knee swells up late in the day, it may be a sign you may doing too much too quickly. Second, avoid pain. Pain is an indicator that something isn't right. You may feel some discomfort with your exercises, but this should be "reasonable" discomfort. If pain is excessive or lasts more than one hour after exercise, inform your therapist at your next visit. You may need to change the number of repetitions, the amount of pressure, or the how often you are doing the exercises.

Progressive Exercise:
Exercises will be given to help improve motion, strength, and endurance in the knee. Your program will also address key muscle groups of the buttocks, thigh, and calf. Other exercises can be used to simulate day-to-day activities like stair climbing, pivoting, and squatting, depending on which phase you have completed. Following are some types of exercises that may be used to help your condition.

Closed Kinetic Chain (CKC) Exercises:
These are exercises in which the foot is kept on the ground while movement and resistance take place in the joints and muscles above. These types of exercises are important because they are so much like the activities we do every day. For example, a partial squat exercise is the same action as lowering yourself onto a chair or couch. A leg press is a lot like the action of going up a stair or step. These exercises add strength and stability around the muscles and joints of the hip and leg.

Proprioceptive Exercises:
These are exercises that help retrain your position sense, also called "joint sense." If you close your eyes and hold up your hand, you know what your hand is doing, even though you don't "see" it. We get position sense by way of our vision, middle ear balance, and from tiny receptors in the ligaments and joints. When we close our eyes, we rely on middle ear balance and these special receptors to keep us upright. If there has been swelling or injury in or around a joint, these tiny receptors get injured and do not recover. You can do certain exercises to get the other receptors to do more, regaining what was lost with the damaged receptors. The loss of position sense puts the joint at further risk of injury because the joint loses stability, like having loose lug nuts on a wheel of a car. Special exercises, called proprioceptive or neuromuscular exercises, help protect the knee by "tightening the lug nuts." You can think of these exercises like balance training. Examples include balancing on one leg with your eyes open/closed, walking on uneven or soft surfaces, or practicing on a special balance board. Some therapists use special manual exercises to get the other receptors working better.

Home Program

As your condition keeps getting better, you will be given advanced exercises to do at home or in a gym setting. You will recheck with your therapist at regular intervals to make sure you are doing these exercises routinely and safely. During these rechecks, you may be given additional exercises to work on over the next few weeks. Eventually you will be progressed to a final home program. Once you've been released to full activity, you may be instructed to follow up with a few visits over the next few months. This will give a comparison of strength and function of the operated knee and to make sure you are performing at peak levels. Before you are completely done with therapy, more measurements will be taken to see how well you're doing now compared to when you first started in therapy.