Pre and Post-Operative Physiotherapy in Knee Arthroscopy Surgeries

Knee arthroscopy from a physios perspective

¢  Young patient

¢  Active lifestyle

¢  Traumatic injury

¢  Athlete

¢  Functional Goal Setting: Patient may need to attain functional independence in BADL’s and also in relation to work demands and rarely to attain the sports activities being played.

Indications for Arthroscopic Repair/ Reconstruction:

¢  Injured ligament (different healing capabilities)

¢  Location & size of lesion

¢  Degree of instability experienced by patient

¢  Other associated injury – meniscal tear, articular damage etc

¢  Patients desired level of function

¢  Risk of re-injury

¢  Prevention of future impairment

Arthroscopy – Physiotherapist’s consideration

Indication for ligament surgery –

            Failed conservative management, early degenerative changes seen, pain/ loss of function.

Type of ligament surgery:

            Intra articular, extra articular, combined procedures

Grafts used:

            Autograft, allograft, synthetic, area of harvesting etc.

Pre-operative physiotherapy

¢  Deficits in pre-operative quadriceps strength influence function 6 months after ACL reconstruction

            David Logerstedt et al, The Knee, 2013

Pre-operative management & goals

‘Injuries around the Knee’ Symposium: Sancheti Parag et al, Br J Sports Med, 2010

¢  Oedema Control

¢  Minimize muscular atrophy

¢  Maintain ROM as much possible

¢  Protected ambulation

¢  Patient education

¢  Restoration of joint stability & motion

¢  Pain free & stable weight bearing

¢  Sufficient post-operative strength & endurance to meet functional demands

¢  Ability to return to pre injury activities

           

Post-operative management

1. Maximum protection phase  – Weeks 1 – 4
2. Moderate protection phase – Weeks 4 – 8
3. Minimum Protection phase – Weeks 8 & beyond

Maximum protection phase – weeks 1 – 4

            TREATMENT GOALS:

¢  Protect healing tissues

¢  Prevent reflex inhibition of muscles

¢  Reduce joint effusion

¢  ROM 0 – 110°

¢  Active control of ROM

¢  Weight bearing 75% to tolerance (depends on specificity of tissue repaired)

¢  Early controlled weight bearing does not compromise knee joint stability and provides a better outcome in terms of VMO function

            Tyler TF Clin Orthop Relat Res, 1998

Intervention

Early: Days 1 – 14

¢  RICE

¢  Gait training – crutches PWB

¢  Passive to active ROM (with range limiting braces if required)

¢  Using CPM for ROM does not offer any additional benefits

Rosen MA Am J Sports Med, 1992

¢  Patellar mobilization

¢  Muscle setting exercises – Quads, hams, adductors at multiple angles

¢  Assisted SLR in supine (with brace when needed)

¢  Ankle pumps

Late: weeks 2 – 4

¢  Continue previous exercises

¢  Full weight bearing & closed chain exercises for hip & knee muscles (with permission)

            (Not in meniscal injuries)

¢  Low resistance PRE in open chain activities

¢  Core stabilisation exercises

¢  Aerobic conditioning – static cycles

¢  Physiotherapy is equally effective as arthroscopic partial menisectomy for meniscal tears and OA knees

            Katz et al. Engl J Med. 2013

¢  In a RCT, home exercise program alone was better versus arthroscopy in addition to home exercise program for chronic patello-femoral pain syndrome

            Kettunen et al Br J Sports Med. 2012

¢  Post-operative physical therapy accelerated rehab in arthroscopic partial menisectomy: Systemic Review with Metanalysis

            Dias et al J Orthop Sports Phys Ther 2013

¢  Electromyographic feedback along with conventional exercise therapy speeds up the rehab process

            Akkaya N et al Clin Rehabil. 2012

      

     

BRACING

¢  Using a functional brace or a neoprene sleeve post arthroscopic repair helps in improving joint position sense in early rehab phase

            Beynnon BD, J Orthop Sports Phys Ther, 2002;

                Brandson S et al Scand J Med Sci Sports, 2001

Moderate protection phase weeks 4 – 10

TREATMENT GOALS:

¢  Full pain free ROM

¢  Strength Gr. 4/5

¢  Dynamic joint (knee) control

¢  Improved kinaesthetic awareness

¢  Normalise gait pattern & ADL function

¢  Home exercises program

Intervention

            Early – weeks 5 – 6:

¢  Multiple angle isometrics

¢  Advanced closed chain strengthening & PRE

¢  Stretching exercises

¢  Endurance training

¢  Proprioceptive training – single leg, tilt board

¢  Stabilization exercises with elastic bands

Proprioceptive training and core strengthening

¢  Both form important aspects of phase 2 rehabilitation.

            Lephart SM Am J Sports Med, 1997

¢  Lack of core strengthening and proprioceptive training post arthroscopic cruciate reconstruction have been found to be associated with reduced stability and performance in patients

            Cinar-Medeni O, Am J Phys Med Rehabil, 2014

Intervention

            Late – weeks 7 – 10:

¢  Continue with previous exercises

¢  Advance strengthening (PNF patterns)

¢  Endurance & flexibility training

¢  Advanced proprioceptive training

¢  Walking/ jogging

¢  Initiate plyometric training (with permission in athletes)

Minimum protection phase weeks 11 - 24:

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Improve neuromuscular control, dynamic stability & balance

¢  Improve cardio pulmonary fitness

Joint stability achieved by neuro musculoskeletal system

Intervention

¢  Continue stretching program

¢  Advanced PRE. Initiate isokinetic training if desired.

¢  Advanced close chain exercises & plyometric drills.

¢  Advanced proprioceptive training.

¢  Progressive agility drills (fig of 8, specific drills)

¢  Progress running program

Return to activity phase – 6 months & beyond

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Regain ability to function at highest desired level

¢  Maintenance program

¢  Reduce risk of re-injury

Balance and Proprioceptive Training

Plyometric Training (Sports Specific)

Intervention

¢  Progress PRE & flexibility exercises

¢  Advanced agility drills

¢  Sports or occupation specific drills

¢  Need of protective bracing prior to return to work or sports.

Current trends in rehabilitation

¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual

¢  Functional training programs – exercises similar to ADL’s of the individual

¢  Limited Use of CPM machines

¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling

¢  Functional Testing to assess joint stability

¢  Emphasis on Proprioceptive Training

¢  Patient Perceived joint stability most important criteria for Prognosis

¢  Time not a major factor in determining treatment progression

¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression

¢  Delayed Surgery – faster strength recovery

            Wasilewski  et al 1993 , Shelbourne and Foulk 1995

Things to remember!

¢  No fixed Protocol for rehab

¢  Modify Exercises by regular patient evaluation

¢  Task Specific and Functional Exercises more effective

¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program

Dr. Parag Sancheti

Dr. Apurv Shimpi (PT)

Dr. Anand Gangwal (PT)