REHAB PROTOCOLS

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This section helps you to understand the recovery after surgery.

Day of Surgery

After your surgery, your knee will be in a cotton bandage and knee brace. You will be shifted to your room after the effect of anesthesia wears out. Pain killer medication will be given in the ward to control your pain. Cryotherapy may also be applied to reduce swelling.

Day 1 to 7

Goals

  1. Control pain and swelling
  2. Early range of motion exercises
  3. Achieve full passive extension
  4. Prevent Quadriceps shutdown
  5. Gait training

The cotton bandage will be removed and smaller dressing pads will be applied. You will be discharged home the same day or next day after surgery. The wound should be kept dry for 10 days. If you want to have a shower, apply water proof dressings or use a plastic cover.

Pain killer medication will be prescribed to take home after discharge.

Apply cold compression on top of the dressings at home 3 times a day for 10 mins each.

You will be made to walk by the physiotherapist in the hospital. You are allowed to put weight on the operated leg using the knee brace. Use a crutch in opposite side while walking if required.

Knee brace should be worn during sleep and while walking for 2 weeks. You may remove the knee brace other times.

We recommend that you limit walking to prevent knee swelling. Keep your leg elevated on a stool while sitting to prevent ankle swelling.

Start early range of movements by physio

  • Passive knee extensions- Use a rolled towel under the heel and let the knee hang down with gravity.
  • Assisted active extensions: Sitting in a chair, raise the operated leg by using opposite leg for support. 90degrees to 0 degrees. Avoid hyperextension.
  • Assisted flexion: Sitting edge of table or chair, let the leg hang free and use the other leg to gently press. 0 to 90

Start Quadriceps isometric contractions as soon as possible. 3 sets of 10 repetitions 3 times a day.

Start straight leg raises in supine position as the quads strength improves.

Days 8-14

Goals

  1. Maintain full extension
  2. Continue Isometric Quadriceps exercices.
  3. Continue knee ROM
  4. Continue knee brace

Continue SLR, Isometric quadriceps, active flexion, assisted active extension exercises.

Please make a clinic appointment for suture removal at the end of 2 weeks. After suture removal, you can apply emollient as this will improve the appearance of scars.

continue cold compressions for 1 more week.

Week 3 to 4

Goals:

  1. Maintain full extension
  2. Achieve 100-120 degree flexion
  3. Develop enough muscular control to wean off the knee brace
  4. start active knee extension exercises.
  5. Start hamstring exercises. Avoid resistance.
  6. Start heel raises in standing position
  7. Start using a stationary cycle if possible. No resistance. Initially 5 mins maximum, slowly  increase  to 20 mins at the end of 6 weeks.

Try to wean off the crutches and knee brace.  If your job is a desk job, you can start going to work after 2 weeks. But driving is not allowed for 6 weeks. while walking outdoors, it is better to use the knee brace or a crutch for balance. You can climb stairs one step at a time using the non operated leg.

Continue to keep the operated leg elevated while sitting if possible to prevent swelling of leg.

You may require dolo 650 tablet twice a day for mild pain. Sometimes if the pain is severe or swelling is more, you can take tablet Ultracet or Hifenac P only if prescribed.

Week 4-6

Goals:

  1. Increase knee flexion to 125 degrees
  2. Increase strength building
  3. Introduce proprioception

Start partial squats(quarter). Can start using cross trainer if going to gym.

At the end of 6 weeks, you should aim to get maximum knee bend, full extension, reasonable muscle control to walk without support. Most people will be in a position to start riding a bike or car. You can start climbing stairs using both legs.

Weeks 6-12

Goals:

  1. Flexion to 135 degrees
  2. continued strength training

You should be able to do normal walking and stairs climbing at this stage.

Continue balance board, Partial squats, start leg curls, quad sets, heel raises.

Introduce resistance for quads and hamstrings. Introduce gluteal and core strengthening. Do not start jogging or running. Increase squats

Weeks 12-20

Continue all 6-12week strength training programme

Start jogging and slow running

Start agility drills, zig zag, crossover drills after assessment by your physiotherapist

Start Plyometrics

Week 24(6 months)

Goal : Return to training but not competitive sport

Start running, jumps, hops, plyometrics

To return to sports, you should have:

  1. 80% strength of quadriceps, hamstrings and gluteal muscles.
  2. No pain
  3. No swelling
  4. Good balance and stability
  5. Ability to complete running programme

This section helps you to understand the recovery after surgery.

Day of Surgery

After your surgery, your knee will be in a cotton bandage and knee brace. You will be shifted to your room after the effect of anesthesia wears out. Painkiller medication will be given in the ward to control your pain. Cryotherapy may also be applied to reduce swelling.

Day 1 to 7

Goals

  1. Control pain and swelling
  2. Early range of motion exercises
  3. Achieve full passive extension
  4. Prevent Quadriceps shutdown
  5. Gait training

The cotton bandage will be removed and smaller dressing pads will be applied. You will be discharged home the same day or next day after surgery. The wound should be kept dry for 10 days. If you want to have a shower, apply waterproof dressings or use a plastic cover.

Painkiller medication will be prescribed to take home after discharge.

Apply cold compression on top of the dressings at home 3 times a day for 10 mins each.

You will be made to walk by the physiotherapist in the hospital. You are allowed to put weight on the operated leg using the knee brace. Use a crutch in opposite side while walking if required.

Knee brace should be worn during sleep and while walking for 2 weeks. You may remove the knee brace other times.

We recommend that you limit walking to prevent knee swelling. Keep your leg elevated on a stool while sitting to prevent ankle swelling.

Start early range of movements by physio

  • Passive knee extensions- Use a rolled towel under the heel and let the knee hang down with gravity.
  • Assisted active extensions: Sitting in a chair, raise the operated leg by using opposite leg for support. 90degrees to 0 degrees. Avoid hyperextension.
  • Assisted flexion: Sitting edge of table or chair, let the leg hang free and use the other leg to gently press. 0 to 90

 

Start Quadriceps isometric contractions as soon as possible. 3 sets of 10 repetitions 3 times a day.

Start straight leg raises in supine position as the quads strength improves.

Days 8-14

Goals

  1. Maintain full extension
  2. Continue Isometric Quadriceps exercices.
  3. Continue knee ROM
  4. Continue knee brace

Continue SLR, Isometric quadriceps, active flexion, assisted active extension exercises.

Please make a clinic appointment for suture removal at the end of 2 weeks. After suture removal, you can apply emollient as this will improve the appearance of scars.

continue cold compressions for 1 more week.

Week 3 to 4

Goals:

  1. Maintain full extension
  2. Achieve 100-120 degree flexion
  3. Develop enough muscular control to wean off the knee brace
  4. start active knee extension exercises.
  5. Start hamstring exercises. Avoid resistance.
  6. Start heel raises in standing position
  7. Start using a stationary cycle if possible. No resistance. Initially 5 mins maximum, slowly increase to 20 mins at the end of 6 weeks.

Try to wean off the crutches and knee brace.  If your job is a desk job, you can start going to work after 2 weeks. But driving is not allowed for 6 weeks. while walking outdoors, it is better to use the knee brace or a crutch for balance. You can climb stairs one step at a time using the non-operated leg.

Continue to keep the operated leg elevated while sitting if possible to prevent swelling of leg.

You may require dolo 650 tablet twice a day for mild pain. Sometimes if the pain is severe or swelling is more, you can take tablet Ultracet or Hifenac P only if prescribed.

Week 4-6

Goals:

  1. Increase knee flexion to 125 degrees
  2. Increase strength building
  3. Introduce proprioception

Start partial squats(quarter). Can start using the cross trainer if going to a gym.

At the end of 6 weeks, you should aim to get maximum knee bend, full extension, reasonable muscle control to walk without support. Most people will be in a position to start riding a bike or car. You can start climbing stairs using both legs.

Weeks 6-12

Goals:

  1. Flexion to 135 degrees
  2. continued strength training

You should be able to do normal walking and stairs climbing at this stage.

Continue balance board, Partial squats, start leg curls, quad sets, heel raises.

Introduce resistance for quads and hamstrings. Introduce gluteal and core strengthening. Do not start jogging or running. Increase squats

Weeks 12-20

Continue all 6-12week strength training programme

Start jogging and slow running

Start agility drills, zig zag, cross over drills after assessment by your physiotherapist

Start Plyometrics

Week 24(6 months)

Goal: Return to training but not competitive sport

Start running, jumps, hops, plyometrics

To return to sports, you should have:

  1. 80% strength of quadriceps, hamstrings and gluteal muscles.
  2. No pain
  3. No swelling
  4. Good balance and stability
  5. Ability to complete running programme

 Arthroscopic Rotator Cuff Repair Physio Protocol

  1. 0 to 3 weeks:

 Precautions:

  • No active range of motion (AROM) of Shoulder
  • Maintain arm in a sling, remove only for exercise
  • No lifting of heavy objects
  • No shoulder motion behind back
  • No excessive stretching or sudden movements
  • No supporting of body weight by hands
  • Keep incision clean and dry

EXERCISES

  • Intermittent pendulum exercises (3 sessions per day of 10 minutes each
  • Scapulothoracic exercises
  • Start scapula glides and gentle mobilizations
  • Shoulder immobilizer when not exercising
  • Cryotherapy

 3 to 6 weeks (Supervised physio begins):

    • Passive range of motion exercises 0-90 degrees: forward elevation and abduction up to shoulder level, gentle rotation stretching
    • Discard shoulder immobilizer when comfortable

6 to 12 weeks:

    • Continue active assisted range of motion exercises: allow forward elevation and abduction beyond shoulder level (beyond 90 deg)
    • Gradually progress to anti-gravity active rotator cuff strengthening exercises(for supraspinatus & Infraspinatus) & belly presses (for Subscapularis)
    • Continue rotation stretching

12 weeks to 6 months:

    • Resistive rotator cuff and deltoid strengthening exercises using free weights (start with small weights and gradually increase every week as tolerated)
    • Continue ROM stretching exercises if stiffness persists

General considerations

  • Use of a sling for 6 weeks unless instructed otherwise by your surgeon
  • Arm is restricted from these movements for 4 weeks:
    • extension (backward) past the plane of the body
    • External rotation (arm rotation outwards) greater than 0° (straight in front); extensive repairs may require more restrictions
    • For posterior repairs, avoid any internal rotation (turning in) past the body
  • No passive forceful stretching into external rotation/extension for 3 months following an anterior repair and into internal rotation for a posterior repair
  • Good posture is critical throughout the rehabilitation process to improve healing and decrease the risk of developing poor mechanics
  • Aerobic conditioning throughout the rehabilitation process
  • All active exercises should be carefully monitored to minimize substitution or compensation

Week 1

  • ­Do not wet the surgical wounds.
  • ­Ice shoulder every 2 hours for 15­-20 min during wake hours for first 2 weeks.

Manual

  • soft tissue mobilization to surrounding musculature
  • gentle scapula glides.

Exercise:

  • Intermittent pendulum exercises (3 sessions per day of 10 minutes each)
  • Shoulder immobilizer when not exercising

Home program to consist of:

  • ­Elbow flexion / extension
  • wrist and forearm strengthening
  • cervical stretches
  • postural education and exercises.

*It is important to come out of the sling frequently to bend and straighten elbow for 10­-15 repetitions each time to minimize arm and hand swelling.

Weeks 2-4

sutures to be removed after 10-14 days

Manual:

  • soft tissue mobilization to surrounding musculature
  • gentle scapula glides.
  • Pain control (i.e. cryotherapy).

Exercises

  • An active assisted range of motion exercises: forward elevation and

abduction up to shoulder level only

  • No elevation or abduction beyond shoulder level
  • No external rotation stretching

Weeks 4 – 6

Manual

Soft tissue mobilization to surrounding musculature, initiate scar mobilization to surgical incisions if completely closed.

Exercise:

Passive and active assisted flexion out to the scapular plane as tolerated (cane exercises, wall walking, table slide).

  • Progress to active exercises from flexion into the scapular plane against gravity as tolerated
    *No resistance until able to perform 30 reps with perfect mechanics.
  • No external rotation stretching
  • Forward elevation to shoulder level
  • Isotonic wrist, forearm, and scapular exercises.
  • Thera band resisted pull downs from the front and the scapular plane; elbow flexion; submaximal isometrics (as dictated by pain); active scapular elevation, depression, and retraction exercises; lightweight bearing
  • Add proprioceptive training (alphabet writing, fine motor skills, work/sport specific).

Goals

  • Out of sling; minimal resting pain.
  • Initiate active range of motion flexion/scaption.

Weeks 6 – 8

Manual

Continue with soft tissue mobilization, the range of motion.

Exercise

  • Continue to increase active range of motion exercises as tolerated (serratus anterior, upper and lower trapezius); add eccentrics into protected ranges.
  • Okay to begin LIGHT stretching into external rotation.
  • Okay to begin LIGHT glenohumeral joint mobilization.
  • Okay to add light resistance internal rotation exercises from 0 degrees to the body only
  • Increase proprioceptive training.

Goals

  • The range of motion greater than 80% of normal, initiate tolerance to hand behind head/back exercises.
  • Initiate jogging, road cycling, and standing arm resistance exercises in the pool.

Weeks 8 – 12

  • Continue active assisted range of motion exercises: allow forward
  • elevation and abduction beyond shoulder level (beyond 90 deg)
  • Anti-gravity rotator cuff strengthening exercises.
  • Emphasis on regaining strength and endurance.
  • active range of motion exercises to include internal rotation and external rotation as motion allows, lateral raises and supraspinatus isolation, a rower with a high seat, decline bench press, military press in front of the body.

3 – 6 Months:

Doctor appointment at 12 weeks.

  • Aggressive stretching; begin strenuous resistive exercises.
  • Add light throwing exercises with attention to proper mechanics.

6 Months:

  • Increase throwing program/sport-specific program. Focus on return to sports as mechanics, conditioning, and strength allow.General Principles

    This protocol for rehabilitation after knee meniscus repair surgery is designed to provide the rehabilitation professional with a general guideline for patient care. The protocol should be individualized based upon each patient’s specific needs, surgical variables, pain level, the specific surgeon’s guidelines, physical examination, progress, and presence of any complications.

    PHASE I: MAXIMUM PROTECTION PHASE (Weeks 1-6)

    GOALS

    • Control inflammation/effusion
    • Allow early healing
    • Full passive knee extension
    • Gradually increase knee flexion
    • Independent quadriceps control

    STAGE 1: IMMEDIATELY POST-SURGERY
    DAYS 1 THROUGH 10

    • Ice, compression, elevation
    • Brace locked at 0 degrees for ambulation only
      • Brace may be unlocked while sitting, etc.
    • ROM (passive 0-90)
    • Patellar mobilizations
    • Stretch hamstrings and calf
    • Strengthening exercises:
      • Quad sets
      • SLR flexion
      • Hip Abd/Adduction
      • Knee extension 60-0 degrees
    • Avoid active knee flexion
    • Weight-bearing:
      • For peripheral tears: 25-50% WB as tolerated with 2 crutches
      • For complex tears: toe touch with crutches

    STAGE 2: WEEKS 2 THROUGH 4

    • Continue use of ice and compression
    • Brace locked for ambulation at 0 degrees
    • ROM Guidelines: 0-90
    • Weight Bearing
      • For peripheral tears 50% wt bearing
    • For complex tears: Toe touch wt bearing

    *Discontinue crutches when safe and proper gait

    • Continue PROM exercises and stretching
    • Strengthening exercises
      • Multi-angle quad isometrics
      • SLR (all 4 planes)
      • Knee extension 90-0 degrees

     

    *Avoid twisting, deep squatting and stooping
    *Avoid hamstring curls
    * Peripheral tears can progress to Phase II: Moderate Protection Phase at week 5 if progressing well and displays normal gait mechanics.

    stage 3: weeks 4-8

    *Peripheral tears can progress to Phase II at week 4; Complex tears can progress to Phase II at week 6
    GOALS

    • Full PROM
    • No swelling/inflammation
    • Re-establish muscle control
    • Proper gait pattern
    • Continue use of ice and compression as needed
    • Continue ROM and stretching;
      • Peripheral tears maintain 0-135 degrees
      • Complex tears progress to 0-125/130 degrees
    • Strengthening Exercises
      • Leg press 70-0 degrees
      • Knee extension 90-40 degrees
      • Hip Abd/Adduction
      • Wall squats 0-70 degrees
      • Vertical squats 0-60 degrees
      • Lateral step-ups
    • Balance/proprioception training from week 6
      • Squats rocker board
      • Cup walking
    • Bicycle (if ROM permits)
    • Pool program
    • Discontinue brace

     

    STAGE 4: CONTROLLED ACTIVITY PHASE (Weeks 9-16)

    GOALS

    • Improve strength and endurance
    • Maintain full ROM
    • Gradually increase applied stress

    WEEK 9

    • Continue all strengthening exercises listed above
    • Initiate light resisted hamstring curls
    • Initiate stair stepper
    • Toe calf raises
    • Progress balance training
    • Progress to the isotonic strengthening program
    • Initiate pool running week 12

    STAGE 5: CONTROLLED ACTIVITY PHASE (Weeks 9-16)

    *Peripheral tears can progress to Phase IV at month 4; Complex tears can progress at month 6
    GOALS

    • Improve strength and endurance
    • Prepare for unrestricted activities

    CRITERIA TO PROGRESS TO STAGE 5

    1. Full non-painful ROM
    2. No pain or tenderness
    3. Satisfactory clinical exam
    4. Satisfactory isokinetic test
    5. Normal gait mechanics while running on the AlterG Anti-Gravity Treadmill

    EXERCISE

    • Continue and progress all strengthening exercises and stretching drills
    • For peripheral tears:
      • Deep squatting permitted at 4 months
      • Initiate straight line running: 4 months
      • Initiate pivoting and cutting: 5 months
      • Initiate agility training: 5 months
      • Gradually return to sports: 6 months

     

    This section helps you to understand the recovery after surgery.

    Day of Surgery

    After your surgery, your knee will be in a cotton bandage and knee brace. You will be shifted to your room after the effect of anesthesia wears out. Pain killer medication will be given in the ward to control your pain. Cryotherapy may also be applied to reduce swelling.

    Day 1 to 7

    Goals

    1. Control pain and swelling
    2. Early range of motion exercises 0-30 degrees
    3. Achieve full passive extension
    4. Prevent Quadriceps shutdown
    5. Gait training

    The cotton bandage will be removed and smaller dressing pads will be applied. You will be discharged home the same day or next day after surgery. The wound should be kept dry for 10 days. If you want to have a shower, apply waterproof dressings or use a plastic cover.

    Painkiller medication will be prescribed to take home after discharge.

    Apply cold compression on top of the dressings at home 3 times a day for 10 mins each.

    You will be made to walk by the physiotherapist in the hospital. You are allowed to put weight on the operated leg as tolerated using the knee brace. Use 2 elbow crutches while walking

    PCL Knee brace should be worn at all times for 6 weeks

    We recommend that you limit walking to prevent knee swelling. Keep your leg elevated on a stool while sitting to prevent ankle swelling.

    Start early range of movements by a physio. Avoid flexion beyond 30 degrees for 2 weeks

    • Passive knee extensions- Use a rolled towel under the heel and let the knee hang down with gravity.
    • Assisted active extensions: Sitting in a chair, raise the operated leg by using opposite leg for support. 30degrees to 0 degrees. Avoid hyperextension.
    • Assisted flexion: 0-30 degrees

     

    Start Quadriceps isometric contractions as soon as possible. 3 sets of 10 repetitions 3 times a day.

    Start straight leg raises in the supine position as the quads strength improves.

    Days 8-14

    Goals

    1. Maintain full extension
    2. Continue Isometric Quadriceps exercises.
    3. Continue knee ROM 0-30 degrees
    4. Continue knee brace

     

    Weight bear to tolerance using 2 crutches

    Continue SLR, Isometric quadriceps, assisted active flexion 0-30

    Please make a clinic appointment for suture removal at the end of 2 weeks. After suture removal, you can apply emollient as this will improve the appearance of scars.

    continue cold compressions for 1 more week.

    Week 3 to 6

    Goals:

    1. Maintain full extension
    2. Achieve 0-90 degree flexion
    3. Develop enough muscular control to wean off one crutch
    4. start active knee extension exercises.
    5. Start hamstring exercises. Avoid resistance.
    6. Start heel raises in standing position

               

    Try to wean off the one crutch but continue with PCL knee brace.  You can climb stairs one step at a time using the non-operated leg.

    Continue to keep the operated leg elevated while sitting if possible to prevent swelling of the leg.

    You may require dolo 650 tablet twice a day for mild pain. Sometimes if the pain is severe or swelling is more, you can take tablet Ultracet or Hifenac P only if prescribed.

    Weeks 6-12

    Goals:

    1. Flexion to 135 degrees
    2. continued strength training
    3. Proprioception

    Wean off the crutches and knee brace. You should be able to do normal walking and stairs climbing at this stage.

    stationary bicycle.

    Start balance board, Partial squats, start leg curls, quad sets, heel raises.

    Introduce resistance for quads and hamstrings. Introduce gluteal and core strengthening. Do not start jogging or running.

    Weeks 12-20

    Continue all 6-12week strength training programme

    Start jogging and slow running

    Start agility drills, zig zag, crossover drills after assessment by your physiotherapist

    Start Plyometrics

    Week 24(6 months)

    Goal: Return to training but not competitive sport

    Start running, jumps, hops, plyometrics

    To return to sports, you should have:

    1. 80% strength of quadriceps, hamstrings and gluteal muscles.
    2. No pain
    3. No swelling
    4. Good balance and stability
    5. Ability to complete running programme