PHYSICAL THERAPY FOR

The rehabilitation after surgery is as important as the operation itself in regaining excellent function. This part of the process is up to you, the patient. All the members of the hospital team will help, but the success of the rehabilitation hinges on you.

The first thing to work on is to obtain a good range of movement. The goal is from straight or complete extension (which is called 0 degrees) to 120 degrees or more of flexion. Efforts to obtain this are started in the recovery room after surgery when the knee is placed in a C.P.M. machine (Continuous Passive Motion machine). This device, which slowly puts the knee through a range of motion, has been shown to accelerate the recovery by obtaining an acceptable range of motion faster. It may also have some other beneficial effects such as decreasing the swelling and improving circulation.

A physical therapist will visit you twice a day while you are in the hospital. During each of these sessions, you will be working to increase your flexion and extension. A knee range of motion graph will be filled in by the physical therapist each day. You should observe this to monitor your progress to see that you reach the goals prior to discharge.

Extension or straightening exercises are extremely important. To have stability when walking, the knee needs to go straight and be strong in that position. The following exercises should be done twice a day. They will help with both range of extension and strength:

1. Straight leg raises. Lie on your back and lift the leg straight off the floor about eighteen inches. Hold the knee as straight as possible. Keep the leg elevated five seconds and then lower it to the floor. Repeat this thirty times. You will have to work up to this many repetitions. As soon as you can do thirty repetitions, add a weight to your ankle. Start with two to three pounds and increase the number of repetitions you can do until you reach thirty again. Then increase the weight another two to three pounds (four to six pounds total). Keep repeating this sequence until you are able to do thirty straight leg raises with eight pounds of weight on your ankle. (Note - you might as well do both legs while you are exercising.)
2. Short arc quads. While lying on your back, place a roll of towels under your knee. This flexes your knee in the relaxed position. Straighten your leg by extending the knee and hold this position for five seconds. Relax and let the foot back down to the floor. Repeat this thirty times, twice a day. When you are able to do thirty repetitions, add two to three pounds and work up to thirty repetitions again. Then increase the weight another two to three pounds (four to six pounds total). Keep repeating this sequence until you are able to do thirty short arc quads with eight pounds of weight on your ankle.
3. Quad sets. Lie on your back with your leg extended. Tighten the muscle in the front of your thigh (the quadriceps). Keep it tight for five seconds and then relax. Repeat twenty times.
4. Hyperextension thrust. Lie flat on your back with a large roll of towels under your heel. This will suspend the knee above the floor. Contract the thigh muscles and try to force the knee back toward the floor. Hold for five seconds and relax. Repeat twenty times. Sometimes it helps to rest an ice bag on top of the knee during this exercise.

Following are some maneuvers to use in the hospital and when you go home to increase the amount your knee bends:

1. Sitting knee flexion. Sit in a chair and slide your foot along the floor back as far as it will go. Lock your foot to the floor at this point and then slide your buttocks forward on the chair. This will squeeze more bend into the knee. Hold this new position for five seconds then relax. Repeat this maneuver ten to fifteen times twice a day. Each repetition will be a little uncomfortable, but it will pay off.
2. Stationary bicycling. As soon as you have about 800 of flexion, you will be able to get on a stationary bicycle and start exercising. For the first six weeks, the resistance control should be set at zero. The only reason the bike is being used during that time is to improve your range of motion - not to increase strength. Initially the seat should be set as high as it will go. By slowly lowering the seat, you will increase the amount that your knee bends during exercise. Ride twice a day for approximately ten minutes and every two or three days lower the seat by one-fourth to one-half inch.
3. Prone knee flexion. Lie on your stomach and flex your knee. As your heel approaches your buttocks, you can grab your foot and gently pull it toward your hip. Pull until it is tight and hold it for five to ten seconds and then straighten the knee. Repeat this ten to fifteen times twice a day. This stretches the quadriceps (the muscle in the front of the thigh).
4. Stair knee flexion. At the foot of the stairs, hold on to the rail and put the foot of your operated knee on the second or third step. Slowly bend forward, staying in control until the knee feels a little tight. Bend just a little more and hold that position for five to ten seconds. Repeat ten to fifteen times twice a day. Be careful not to put too much pressure on the knee.

These exercises should be done when you go home from the hospital. They can be done twice a day and each exercise session should last twenty to thirty minutes. If these exercises are done consistently, your knee replacement result will be outstanding.

During your stay in the hospital, the therapist will teach you how to walk with crutches or with a walker. You should use either two crutches or a walker for the next six weeks. After that you will be able to progress to either a cane or no ambulatory aids. When you are walking with crutches for the first six weeks, the amount of weight you put on your leg should be limited to approximately one-half your body weight. It is important for you to put this much weight on the leg, but not your full weight. Probably the best way to estimate what it is like to put one-half of your bodyweight on your leg is to walk up to a set of bathroom scales and put the operated foot on the scales. Apply pressure on the foot until the scales read one-half of your weight. This tells you what it should feel like when you are walking. You should repeat this every week so you will not forget what it feels like to walk in this fashion.

You should try to walk a little more each day, of course using your crutches. This begins in your home and then progresses outdoors. If there is some flat pavement or sidewalk, you could walk up to a half-mile a day by six weeks.

Some patients are given a knee brace in the hospital. If you receive one of these braces, wear the brace only at night. This should be continued for the period of time which Dr. Bertin prescribes. The purpose of this brace is to help you regain or maintain extension. Often the tendency at night is to allow the knee to bend and stay bent. By morning the knee is stiff, and it can be very difficult to straighten. It is the purpose of the brace to resist this loss of extension. Not every patient needs it, and you should only wear the brace if you receive one in the hospital.

Six weeks after your surgery you should visit Dr. Bertin. X-rays will be taken, and the next phase of your rehabilitation will begin.

After arriving home from the hospital, it will take a number of weeks before your strength has returned to what it was before surgery. This is very normal. You should plan on taking a nap or resting at least daily for the first two or three weeks. Adequate rest and a good diet will help your recovery.

The exercises which were prescribed in the hospital and in previous sections of this booklet should be continued. They will help you regain your strength and your desired activity level. There is an optimal amount of exercise. If you find that you are too tired or that your operated joint is too sore, it may be that you are over-exercising. If this is the case, decrease the amount of exercise and let your leg rest for a while.

If any medical problems arise during your recovery, please call Dr. Bertin immediately. If there is any problem with your incision, this is especially important. Any increasing redness, drainage, swelling, or pain in that area should be reported. If an infection is detected early, its treatment is much easier than if it progresses. If you happen to develop a sudden shortness of breath or chest pain, this would be another reason to call for immediate consultation. This could be a problem with your lungs or heart which would need to be investigated.

During your recovery, it is much better to shower than bathe. Bathing should be avoided for the first three months. A stool that sits in the shower will make it easier and eliminate the need for standing during the period of the shower. The incision should be completely healed by the time you leave the hospital. When you shower, water can just run over this area without any problem. It should not be scrubbed or thoroughly washed. Simply allow the water to run over the incision site and then blot it dry after the shower. As the small pieces of tape (steri-strips) begin to loosen, you may gently remove them.

It is important during the recovery process to allow the skin, muscle and bone adequate time to heal. The muscles need to recover their strength. If a bone ingrowth prosthesis was used, time is necessary for this process to occur. This ingrowth will not happen if the joint is over-stressed. Two crutches or a walker should be used at all times for six weeks to help with this process. You should use them whenever you arise from sitting or do any walking. After your checkup and X-rays at six weeks, the need for further crutch or walker use will be discussed.

When two or three weeks have elapsed since surgery, you may feel strong enough to go for a walk outside. This is encouraged if weather conditions are appropriate. You should use your crutches and go for a short walk. This distance can be increased daily so that by six weeks you are walking up to one-half mile a day. Travel in the car is also acceptable after about three weeks. Long trips would be discouraged for about six weeks. You must remember to protect your new joint during these unusual activities. Driving should be postponed for approximately eight weeks, especially if the operated leg is used for gas, brake, or clutch pedals.

For the first four to six weeks after surgery, you are discouraged from participating in sexual relations. Return to normal sexual activity should thereafter be gradual, and you should take the less active role for two or three months.

You should call Dr. Bertin's office to schedule an appointment three weeks after surgery. This visit will consist of a clinical and X-ray evaluation. The next phase of your rehabilitation will be outlined.

You should have just had an appointment with Dr. Bertin and had your joint examined and X-rays taken. If everything looks appropriate, he will have started you on the following advanced rehabilitation protocol to increase your strength and performance capability. You should not suddenly increase your activity level, but rather gradually advance what you are doing. If your joint or muscles are uncomfortable, you are doing too much and should cut back.

You should increase the distance you walk daily. You should work up to about a mile, and you could walk farther if you desire. You should use crutches or a cane until Dr. Bertin recommends you not to do so. Even after you stop using crutches, if you have any limp or pain, you should resume the use of a cane or walking stick to eliminate this undesirable gait pattern. As soon as the limp disappears, usually in a few weeks, you can again discontinue the use of the cane.

You should ride daily for ten to fifteen minutes. The seat should be adjusted to a comfortable position, and the pedal resistance slowly increased. This can be gradually advanced to help build strength and endurance.

No new specific knee exercises are needed. Keep doing the routine you have previously established.