Clinical Pearls: Function Applied/ Total Knee
Patient Scenerio: a post op total knee. Surgery 9 months ago. Has had several months of physical therapy at another facility . Presents to PT with complaints of continued significant pain and bogginess in his surgical knee with lack of motion despite very aggressive painful passive stretching as well as diligent home exercising . He reports inability to perform stairs either up or down secondary to acute pain and that he can’t walk for exercise.
Can this patient make any gains so far out past surgery?
Upon exam: surgical knee significantly effused.
Standard MMT of the entire involved side 5/5. AROM of involved knee: 10-90 and painful.
PROM: 7-95 and painful. Patient could not single led stand on involved side secondary to acute pain. Could not test step down capability secondary to acute pain on single leg even with upper extremity support in parallel bars.
Fast forward: 4 weeks. Patient able to perform a 4 inch step down without upper extremity support and 6 inch step up without upper extremity support ...all with no pain. AROM improved to 3-110 degrees and patient able to ambulate without antalgia and was back walking for exercise.
How Function allowed the gains: Patient was started initially on discontinuing all of his lunges , step exercises and squats that he had been previously instructed in by initial therapist. Patient was started with weight bearing hip strengthening in 80% weight bearing on involved side performing sagittal plane hip excursions to work on posterior hip eccentric strength which will assist the quad in the eccentric lowering of the body down the step. He was also started on calcaneal eversion mobilization followed by active excursions in 80% weight bearing. BOTH were completely painfree.
Calcaneal eversion was limited and during gait and functional testing exhibited that the calcaneous on the involved side was not everting during the stance phase of gait and there was lack of tibial internal rotation and knee pronation during step downs partially secondary to this lack of calcaneal eversion. The patient did not have enough calcaneal eversion passively therefore the manual mobilization. With gaining some passive calcaneal eversion, this was neuromuscularly trained by performing the weight bearing excursions post mobilization and using TRI-STRETCH® in both sitting and standing positions to mobilize the calcaneous in the frontal plane while performing other functional exercises.
Summary: Although there were several other bio-mechanical faults that needed correcting with this patient. The take home message for this blog is: the patient hit a plateau with his initial therapy secondary to good intentions of the therapist having the patient performing functional exercise but it was generic functional exercise. What needs to be remembered is to utilize functional exercise specific to each individual patient instead of patients performing multiple directions of multiple weight bearing exercises in hopes of generalized strengthening.
Analyze the quality of motion at every joint during your functional testing and alter their exercise program to reflect the needs of the patient standing before you to optimize their biomechanics.
In this case: the patient was performing deep lunges, squat and step exercises that were not bio-mechanically sound secondary to functional hip weakness(remember that MMT were normal!) and lack of calcaneal eversion for both joint motion and control. The hip and foot were not helping out the knee.
This caused significant irritation to the surgical knee and once addressed, function improved dramatically and pain reduced significantly.
For more information on functional rehabilitation click here.