In this blog we take a look at the understandably frightening prospect of a client walking/limping through the door having had major knee surgery and now ready to either get back to activity or finding they are still having pain or limited movement despite having completed physiotherapy. Or maybe you find yourself in the position personally.
In this particular case we are using the example of somebody who suffered a grade three Medial Collateral Ligament tear, along with grade three Anterior Cruciate ligament tear, so has had a fair bit of reconstructive surgery.
Additional damage often occurs to related structures including the medial meniscus and the Popliteus muscle. However, it matters not if the client in front of you has all this, or just an ACL reconstruction, the bottom line is that if they have had reconstructive surgery of the knee a common set of principles will apply.
There is so much a trainer can do here that it almost exceeds what a therapist would do!
What Happens with major knee surgery?
Their knee has been largely rebuilt and they will almost certainly have had intensive Physiotherapy to get them through the immediate post operation rehabilitation and at least a three month review with the surgeon. However, at this point Physio has often ended as the client is now walking well and the longer term rehabilitation is something that most NHS departments simply don’t have the budget to provide for. As well as often lacking the facilities, as we are now into potential exercises and training, so clients may well need a gym environment.
I have concerns I may make things worse!
So for therapists and exercise professionals this is where things may sometimes get a little scary: “What if I make it worse?” “I don’t really understand the pain in this context, why does it hurt them?”. “What can and can’t they do?”, and so many more questions.
Well, the truth is everybody is different, their rehabilitation will be different, their pain perceptions will be different. Some will be scared to do anything, some will try to push through intense pain, both can be bad, and the list goes on. The most important thing to realise is that there is no definitive answer so let’s look at some principles that will help to guide you through these issues.
How do I approach the rehabilitation? (Trainers, have a look as there is cross over here)
Certainly, in the first three months there is a commonality in the way the body rebuilds and recovers before the longer term ‘personal differences begin to set in. So this is the first thing to be aware of. Establish if your client has gone through the process of initial rehabilitation and review, they should have a letter that outlines the procedure they have had, their recovery to date and the opinion of the consultant at the three month stage, as well as if they have been fully discharged or left on an open appointment. This can be interpreted to mean one of two things:
= happy that things are as good as can be.
- Open appointment
= not too sure all is as well as could be let’s not quite discharge yet.
So hopefully we have number one, but even if we have number two there will be a description of why there is some additional caution being applied. At the end of the day it must come down to your competency and knowledge level in relation to what you are seeing before you, never be afraid to, refer on to a more experienced practitioner or trainer.
Approaching it from a Therapy angle:
Much of the pain that clients present with is unlikely to be pain from the structures that have been operated on, this should have been dealt with in the initial stages of healing and the discharge letter should support this kind of recovery.
So why may the client be in so much pain? Well:
- It will almost certainly be related soft tissue pain.
- Never forget they have had a traumatic accident, the urgency has been the surgery.
At the point of the client presenting to you, it is likely no body has done or even considered anything to do with the soft tissue trauma that occurred at the time of the accident.
- That soft tissue damage is now potentially several months old at the very least.
- There will be additional soft tissue trauma from the operation itself and depending on the surgical techniques, some significant scarring.
- Don’t forget scar tissue is inflexible so can be guilty of limiting movement in otherwise flexible and elastic structures and on the skin Myofascial release can do wonders.
What if My treatments are making the pain worse? (Trainers, there’s lots of crossover info here too).
Sticking to our principles here: If you are treating all the soft tissues that you can see have adapted, tightened, shortened, scarred etc., have not started heavily loading the knee yet and things are getting worse, in the sense that the operated structures hurt, then refer your client back to the G.P. The principle here is that you have not loaded the knee yet, so why would some soft tissue work away from the deep structures cause an increase in pain? Usually because even at discharge you cannot be sure how the operated area will react long term as the loads increase and regardless of how you control loads, the client will be doing more every day activities.
From a Training angle:
Moving on then to strengthening and return to activity, the first thing we have to decide is are they ready? We are looking for pain free movement or at least a clear understanding of where any pain is coming from. If you are a trainer and a therapist then you have an advantage here.
If you are a solely trainer you may find this is where tying into your friendly local therapists is invaluable. Remember many therapist have no specific training knowledge and many trainers have no specific therapy knowledge.
However, our client is largely pain free, has a nice normal range of movement of ninety degrees or more at the knee and is medically cleared to exercise.
What do we need to do?
Well let’s apply some principles: The knee has had reconstructive surgery at the deepest level. We therefore need to ensure the knee is strengthened from the deepest structures outwards. Working the large prime mover muscles, such as quadriceps and hamstrings (and others) at this point, may well cause a misalignment issues of both the patella and the tibial femoral joint, if the stabilising and synergistic muscles are not strengthened along side these prime movers.
To achieve this we need to introduce low level instability to the joint:
Examples of stabilising work would be:
- Simple one leg stands
- Balancing on a Bosu. Done side up
- One leg mini squats
- One leg mini squats on Bosu
Make sure your client is able to stabilise through these types of exercises before introducing any heavy prime mover work.
How do I introduce larger exercises?
- When you are ready to introduce the larger muscle groups, we need to be mindful of the ability of these muscles to drag a partially unstable joint around and create pain or damage. To start stable exercises to bring back initial muscle bulk, such as leg press advancing to a squat (less stable) may be useful, but you will need to move this into a functional pattern, which means planning to move towards single leg versions of these exercises exercises.
- Make sure you also plan to introduce directional change too, once movement though straight (ish) lines such as lunges is achievable .
Directional movement would include:
- Side stepping
Begin, initially with both legs and ultimately though a single leg. The knee will experience these forces in a subtle way in everyday activity and with greater force in sports in sports.
How fast should you progress?
Unfortunately there is no specific answer to this, so once again follow some basic principles:
Introduce any new exercise at a low level and establish that it causes no pain before moving up a level. The importance of this approach is that if pain occurs at say 20 percent effort but is ok at 10 percent then we know we are good to work at 10percent for a little longer before trying again, as opposed to “just not ready’.
Furthermore, an initial pain onset is not likely to be damage if you have crept towards it, slowly exploring increasing forces. Imagine the client being pain free with everyday activities, therefore assuming all is ok ,and then trying to re-engage in exercise or at full pace (as is common).
When they suddenly get pain we have no idea if that is damage, or the body saying ‘go careful‘ and no idea of what percentage of effort it occurred at. We now have no idea of where to pitch their progression, other than to assume the worst and start back at the beginning.
This occurs very commonly and usually ends up in withdrawing from their sport. Part of the job of a trainer is to encourage patience and a measured approach in what will be frustrating circumstances.
Is there anything else I should consider?
Finally, for both therapist and trainers remember that the client is going to favour the non injured side for a while. For therapist this means looking after the non injured side by keeping ensuring not too much tightens up, potentially giving a whole new issue such as Trochanteric Bursitis.
For trainers, select carefully and activities that would involve repeated favouring of one side, such as running.
There is no magic formula to achieve ‘long term’ post surgery recovery. However, there are specific short term protocols that will follow the initial months of a specific surgical operation. These should have been carried out during the initial post operative physiotherapy. Question as to whether these have been followed, or met, before introducing any further interventions or exercises. Hopefully, it will be found on the discharge letter and in other information such as any exercise sheets the client should have. If not they can usually be found online within the NHS website.
Once you have established the basic protocols have been met then a measured approach, an understanding of what has occurred, and a graduated and graded recovery is the sensible way forward.
Reinge Education provide CPD courses for therapists and trainers across the country, these are in both an online format and in face to face workshops.
Our unique combination of knowledge allows us to provide a fresh approach, looking at how anatomy affects function within the body, merging therapy and sports science to give a unique perspective.