General Intervention Strategies for Post-Operative Knee Conditions

 

 

Video Resources for Knee Injuries Requiring Surgeries (Approximate time - 60 minutes)

These are excellent educational videos that provide a clear review of structure, function, typical injury patterns and grades of injury, and surgical approaches. The videos reinforce the structural roles of knee components. Although some of the anatomy information may be repetitive, full review of each linked video is recommended to support your understanding of assigned text and online lecture material.

ACL Injury with Hamstring Graft

ACL Injury with Patellar Tendon Graft

Meniscal Tears

PCL Reconstruction

Total Knee Replacement

 

Cruciate ligament repair highlights

Essential information to note for anterior cruciate ligament repairs (ACL):

• If patellar tendon or cadaver graft was used, always respect anterior knee pain and do not attempt to push or work through it. This is a warning sign that there is too much force placed through the tendon graft site.
• If a hamstring tendon graft was performed to repair the ligament, respect medial knee pain and do not attempt to push or work through it. This is a warning sign that there is too much force placed through the tendon graft site.
• Approved ROM for exercise training are: closed chain 0-60, open chain 90-40.

Review of ACL 12-week protocol - Video approximately 10 minutes

 

Posterior cruciate ligament repairs (PCL):

• Immobilization is typically about 4 weeks.
• Weight bearing will be advanced slower and exercises will be advanced slower than in an ACL reconstruction
• For both grafts and non-surgical management, the hamstrings training is very important to improving dynamic stability. Also remember that internal tibial rotation tightens/stresses both ACL and PCL ligaments

 

Meniscus injury and repair highlights

• Keep in mind that weight bearing must be pain free before advancing any significant stresses on the joint.
• Absolutely no undertaking of weight bearing combined with rotation on the involved leg until late in the recovery phase.
• When treating conditions associated with the medial meniscus, remember the multiple attachments that exert force on the meniscus. Excessive stress to muscles and connective tissue that attach to an partially healed meniscus will cause discomfort.
• Always take complaints of popping or clicking in the joint as very serious and notify the surgeon and the PT

 

Total Knee Arthoplasty highlights

There are many types of prostheses for use in TKAs (total knee arthroplasty). Surgeons drive how components are selected for patients.

Just make sure you have a general understanding of general structures that are replaced and still called "TKA"

• unicompartmental - replaces one tibiofemoral compartment (usually medial)
• bicompartmental
• total (includes patella)

All may be cemented or uncemented. Poor or reduced bone quality, advanced age, and sedentary lifestyle may increase the likelihood of the use of cement and post-operative WBAT status

Good bone health, younger age, and prior history of active lifestyle may result in increased likelihood of uncemented prosthesis and more restrictive early weight bearing orders.

Clinical Pearl: The highest priority is to attain full knee extension. Why? Try standing and walking on one slightly bent knee for any length of time (go ahead try it)! Can you appreciate how any long-term loss of extension will significantly and negatively impact function?

Gaining range into extension is an uncomfortable and often painful process. Be vigilant in patient monitoring during early rehab: are they stretching often? are they stretching effectively? are they taking the necessary steps to manage their pain? What does the use of quad setting during the knee extension stretch attain beyond passive stretching alone? Assess their understanding and positively influence their attitude toward exercise by listening and teaching. Positioning the affected limb to allow for gravity-assisted extension stretching helps with pain and long term motion gains. Add isometric quad sets and you've got a great tool for improving extension. Remember, hip flexion thighness can result in persistent knee flexion, so be sure to include hip flexion stretching and glut strengthening as needed.

Clinical Pearl: The knee must flex in order to make space for edema. Therefore, early edema management is a powerful way to prevent extension loss. (Patients who work with Christina get to hear, "You can't bend a full water balloon!")

Progressing flexion AROM is best achieved through a combination of open and closed chain activities. Start with AROM that includes static holding controlled by the patient. Reciprocal inhibition through active hamstrings recruitment is very powerful means to increase knee flexion.

Can you think of closed chain ROM or other functional activities that will increase active knee flexion and extension motion and control?

Continuous Passive Motion - an example of evidence based practice

Continuous passive motion machines (CPM) were often prescribed in the early 1990's through 2000 and beyond to help improve TKA flexion range of motion. CPM was initially supported in the evidence by animal studies. A systematic review (Harvey, Brosseau, & Herbert, 2014) of 41 randomized control trial study designs showed no significant effect on short term or long term gains in flexion or extension ROM after TKA. You may encounter CPM use today, and it is typically reserved for the acute phase or initial days of rehabilitation.

Harvey, L. A., Brosseau, L., & Herbert, R. D. (2014). Continuous passive motion following total knee arthroplasty in people with arthritis. The Cochrane Library.