The graft site of a reconstructive procedure in the knee is very strong within the first 6 weeks. By the 8-12 week period, the graft has lost strength but is not yet strong enough to handle a vigorous return to cutting and pivoting activities. The strong independent motions of the knee and quadriceps function should be achieved prior to initiating formal muscle endurance and strength training. At 4 months your graft has about 65% of its final strength and at 6 months it is at about 85% of its final strength. Be patient during the early phases of rehabilitation and do not sacrifice future gains for a quick return to full activities. This is a very common mistake and often results in re-injury. To reiterate, the patience and persistence that you display during the rehabilitation process will be directly correlated to your long term result after knee surgery.

The protocols provided in this document are guidelines. More important than the actual time spent in each phase or activity is your achievement of the specific goals. If you are involved in a specific competitive team sport it is appropriate to attempt to match the program with the onset of your team’s pre-season training, providing that you have achieved the specific goals of that phase. Note that the player rehabilitating a knee injury often provides an inspiration to his/her teammates. You can serve as an example of how to rehabilitate an injury the right way. This is an excellent role for anyone and can be very rewarding.

The purpose of post-operative after knee surgery care is to maximize your healing and minimize complications. During the postoperative period, our purpose shifts to a primary goal of regaining functional use of the operated knee. A rehabilitation program is a critical component of this process. Recent studies have demonstrated that the return to sports and other recreational activities following ACL reconstruction has occurred too rapidly. The result is reinjury to the graft and/or to the opposite knee. These reinjuries often require a subsequent surgery. It is our goal to provide a safe but rapid progression back to full functional activities. This will optimize your long term result and minimize the likelihood of re-injury. Err on the side of caution. This is a long term process and with sufficient effort and patience you will achieve an excellent result.

Purpose of Post-surgery Care

The knee is commonly injured and no more is this prevalent than in Singapore’s male population. A study by Fok et al showed that 26% of male military conscripts in Singapore had a history of knee symptoms in the preceding year, symptoms defined as pain, aching or discomfort. Despite the high incidence of knee injury and pain, many patients are often not given a proper diagnosis of the cause of their knee pain and are not given the opportunity for surgical intervention as newer procedures have only recently been introduced to Singapore and many surgeons are not knowledgeable in this area. With increasing technology and medical knowledge, many knee surgical procedures have been developed to alleviate knee pain and improve knee function in the hope of preventing knee osteoarthritis, which is a common end-point for many knee injuries. An understanding of the rehabilitation protocol is essential in order to maximize the surgical outcome. A study by Shelbourne et al showed that the rehabilitation program determined the treatment outcome, so much so that in some cases the surgery was deemed a failure because the wrong rehabilitation program was prescribed.

A critical aspect of any surgical procedure is the post-surgery care given to the patient. This not only ensures proper healing but also forms the bridge from the acute care to the self-reliant management of one’s condition. Rehabilitation has been described as undoing the psychological effects of bed rest as well as the physiological effects. This is especially important in surgical patients, as excessive periods of immobilization can lead to many deleterious effects on general health and well-being, and if applied to the musculoskeletal system, can cause major muscle atrophy and weakness, and a decreased ability to perform activities of daily living. The ultimate goal of rehabilitation is to improve the patient’s function and decrease the chance of re-injury or complications in the future.

Importance of Rehabilitation Protocols

In all instances, the key to successful outcomes in rehabilitation lies in the guidance of the patient through an appropriate program that is relevant to the specific surgery or injury that the knee has sustained.

There have been many advances in surgical techniques and post-surgery management of knee surgery over the years. The days of a 4-5 day stay in hospital with a leg in traction post knee surgery are long gone. Timeframes for rehabilitation have shortened significantly with less aggressive surgeries allowing an accelerated rehabilitation program. Conversely, there are still some surgeries or reconstructions that require a specific time period to allow for adequate healing of the tissues and therefore a delay in the aggressive rehabilitation phase. An example of this would be a biological enhancement procedure of a cartilage graft to the knee.

To secure optimal functional outcomes and to allow the patient to return to activities they enjoy as quickly as possible, appropriate post-surgery rehabilitation is crucial following knee surgery. Rehabilitation protocols encompass a comprehensive list of treatments and exercises. This has shown to be beneficial in the surgical management of the knee by facilitating an early recovery of range of motion, decreasing pain and inflammation, and improving strength and function of the knee, while also reducing the likelihood of re-injury or complication.

Overview of Knee Procedures in Singapore

Knee arthroscopy is one of the most common surgical procedures recommended to patients to decrease pain, increase weight bearing capabilities, and to increase the overall functionality of the knee joint. It is a minimally invasive procedure that allows the surgeon to assess and treat the inside of the knee joint, including the bones, cartilage, ligaments, and the synovium, which is the lining of the joint. The most common knee arthroscopy procedures performed globally and in Singapore are the removal of torn cartilage and repair of the anterior cruciate ligament. Patients undergoing arthroscopy are often highly recommended to pursue physiotherapy post-surgery to optimize the rehabilitation process. This is usually conducted in a clinic and includes hydrotherapy sessions. Physiotherapy in the early stages of the rehabilitation process is aimed at decreasing pain and inflammation, increasing range of movement, regaining muscular control, and increasing strength of the quadriceps and hamstring muscles. In the later stages, it will focus on muscular power, endurance training, and include functional exercises. Typically, the expected time to return to work is one to three weeks for sedentary jobs and four to eight weeks for heavy work. This varies depending on the specific procedure and the patient’s occupation. Full recovery and return to activities involving running, cutting, and pivoting movements are expected to be between 12 weeks and 6 months post-surgery.

Preparing for Post-surgery Care

Finally, prior to the surgery, the patient will need to prepare the home environment. This may involve purchasing an additional mattress if the patient is told he is not allowed to sleep on a very soft mattress in the early phase after knee meniscus surgery. It may also involve rearranging furniture and removing obstacles to provide a safe walking environment on crutches. This is often overlooked but is vitally important to ensure rapid progress and prevention of further injury.

Understanding the nature of the surgery is crucial in planning for the post-surgical rehabilitation phase. The surgeon should explain the specifics of the procedure and the rationale for the procedure. It is important that the patient has realistic expectations about the pace of recovery and the timeframe in which he is expected to return to normal activities. For example, many patients expect to be able to return to their competitive sports following ACL reconstruction surgery. However, the rehabilitation period is typically 6-9 months following surgery before return to competitive sports is deemed to be safe.

Once a surgery date has been confirmed, patients should engage in detailed discussion with their knee pain doctor Singapore regarding the post-surgical phase. The doctor is in the best position to recommend the specific rehabilitation program, which may also involve referral to a physiotherapist and/or occupational therapist for more detailed discussions and planning. Some expert ACL knee pain specialists in Singapore may even give you a printed copy of the rehabilitation protocol. This is an excellent opportunity for the patient to clear any doubts regarding the timeline and goals for the rehabilitation program.

Consultation with Knee Pain Doctor

It is important to select a surgeon who specializes solely in knee surgeries. Knee surgeons, whose practice is dedicated only to knee surgeries, are better equipped to stay current on the latest techniques and surgical procedures. It is important that your surgery be performed by a qualified and competent surgeon, and not just any orthopedic surgeon. Ask your surgeon how many of these surgeries he performs in a week, a month, and a year. Also ask about the types of knee surgeries he performs. The surgeon who routinely performs specific types of knee surgeries is more likely to be current on the latest procedures for that particular surgery. Remember, surgeons like everyone else are creatures of habit. It is important to determine if his habits are good ones and what his comfort level is with the procedure he is recommending for you. I am always amazed when patients tell me that they did not think to question their surgeon about how frequently he performs a recommended procedure. A surgeon’s responsiveness to your questions and concerns is often a good indicator of his willingness to listen to your needs and his ability to make you feel comfortable with going through a procedure. Ask your surgeon to throw all of his recommended treatment options on the table. Find out if there are non-surgical treatment options available and be sure to exhaust all of those before considering surgery. Understanding the severity of your condition, ask the surgeon to explain what his logical determination is for choosing surgery as the best option for treating your condition. Consider getting a second opinion from another knee surgeon especially if you do not feel entirely confident with your surgeon’s treatment plan. Remember a confident patient has a better chance of achieving a good outcome.

Understanding the Surgical Procedure

This will also allow the patient to seek further advice from physiotherapists or sports physicians on the rehabilitation program and what can be expected in making changes to conduct treatment of physiotherapy and exercises at a physiotherapy clinic. Changes in the methods of treatment between surgery and physiotherapy can be seen significantly with ACL reconstruction having high emphasis on the fixing of the graft and the prevention of re-tearing the ligament. A physiotherapist with an understanding of the surgery will be able to conduct appropriate rehabilitation for the progression of the treatment of the graft.

The understanding of each type of surgery is crucial in the sense that post-operative rehabilitation is directly linked with the surgical procedure. Therefore, it is important that before the surgery is conducted, the patient consults the surgeon for each procedure, the expected prognosis, and the rehabilitation protocol that must be followed. Ensure that the communication between patient and surgeon is in a language that both can understand, and all questions are addressed. The patient will be able to make a decision on which type of surgery can fit their lifestyle and timing.

ACL reconstruction is the most common surgery among the four conducted procedures. This is carried out to replace the torn ligament with a graft that is attached to the bone by tunnels and special screws. This can be done by using an artificial graft such as a tendon of some sort or from a cadaver. Alternatively, hamstring graft used is taken from the gracilis and semitendinosus tendons, which are removed through a small incision and do not require repair. The benefits of this type of procedure reduce the risk of osteoarthritis and the surgery itself and rehabilitation have shown to have long-term satisfaction for the patient. As for high tibial osteotomy and knee replacement, they are not often conducted and are only considered when the severity of the arthritis in the knees is far too severe. High tibial osteotomy is done to reduce the stress on the damaged area of the knee, and knee replacement is conducted with metal and plastic parts. This is to create a new surface as opposed to the previous surface damaged by arthritis. These two procedures are used to prevent worsening damage to the knee affected by arthritis.

Preparing the Home Environment

For a patient who lives alone and is having ambulatory surgery, he may need to arrange for a relative or friend to stay with him for a few days after surgery if he is not intending or is unable to arrange for a short stay in a community hospital. This is to ensure that the surgical wound heals well and is free of infection before the start of the rehabilitation phase. A wound infected with bacteria can sometimes lead to more serious complications. This is because the knee, like other artificial joints, is susceptible to infections, and if this happens, it may require a subsequent surgery to wash out the bacteria and/or a course of antibiotic treatment. Such infections can delay or prolong the rehabilitation time and may affect the overall final outcome of the surgery.

Before a patient is discharged from the hospital, it is important to ensure that the home environment is conducive to recovery. Most patients have, at best, a vague understanding of what they are about to go through. When a doctor advises knee surgery, the patient should find out as much as possible about the nature of the surgical procedure. Initially, patients can ask the knee surgeon or his assistant or nurse during clinic sessions. A new method is to ask the nurse in charge of the pre-admission assessment center to brief the patient about what to expect during the different phases of management, i.e. preoperative, immediately post-operative, and rehabilitation phase. If no such nurse is available, the patient can also try to approach another patient who has undergone similar surgery, but it is important to note that every patient’s condition is different and subsequent management may not be identical. The information given can affect how the patient is going to prepare his home environment, what help is hired, and what equipment is purchased for use during the rehabilitation phase.

Rehabilitation Protocols After Knee Procedures

Rehabilitation protocols deal with two important issues. The first is the desire to protect and allow for proper healing of the soft tissue and articular surface. This is accomplished through the use of various motion and strengthening exercises. The second commonly dealt with issue revolves around the prevention of arthrofibrosis. Arthrofibrosis is a condition in which a joint becomes stiff, usually through the excessive proliferation of collagen tissue. This tissue is a normal part of the healing process following injury and surgery, however when the proliferation is excessive (as often happens after surgery) the result is an inflexible and painful joint. The cause of arthrofibrosis is not known, but it is generally agreed on that the best preventative measure is an early return to full range of motion and strengthening exercises. Any rehabilitation program you develop should take into consideration your own specific surgery and anatomy, as well as your own physician’s protocols for your surgery. These protocols should be shared with your physiotherapist.

Early Postoperative Exercises

Early postoperative rehabilitation begins in the recovery room immediately following surgery. Specific exercises will be prescribed by the therapist and taught to the patient. The first priority immediately following surgery is to achieve full knee extension. It is extremely important to straighten the knee immediately to avoid complications with regaining full range of motion. It is much easier to prevent loss of extension in the first few days following surgery than it is to regain it after scar tissue has begun to form. Frequently the best exercise for this is simply propping the heel on a roll or pillow while sitting to allow the knee to straighten fully. This position should be held for 5-10 minutes every 1-2 hours. This position is usually well tolerated unless the patient has had a repair of extensor mechanism rupture and is usually maintained with the patient lying on his/her back to allow gravity to help straighten the knee. Also begun immediately following surgery is the patient’s exercises to regain quadriceps control. Contraction of the quadriceps while the knee is straightened should be performed frequently. This is a simple, easy to do exercise than can be done when lying down, sitting, or standing and the patient is encouraged to perform these “sets” of quad contractions often times up to 20-30 times per day. Emerging evidence does suggest that NMES can enhance quadriceps function and strength in the early postoperative phase after knee surgery. Ongoing research is being conducted to determine the ideal stimulation parameters and electrode placement. Other various types of knee surgery including ACL reconstruction, meniscectomy, chondroplasty, and microfracture will have differing specific exercise priorities immediately following surgery but will all focus on achieving full knee extension and regaining quadriceps function. A continuous passive motion (CPM) machine is frequently used in the immediate postoperative phase for anywhere from several days to several weeks and has been shown to help improve postoperative knee flexion and decrease the incidence of arthrofibrosis in those patients that respond well to this form of treatment. CPM has been shown to be especially beneficial in the postoperative management of patients following ACL reconstruction.

Physical Therapy Sessions

Physical therapy is an instrumental part of any rehabilitation process. The surgeon and his staff have a plan and goal for each individual patient based on the patient’s history, physical exam, and specific procedure. The therapist and patient then work as a team to reach that goal. This is done through a series of highly focused treatment sessions. During the initial evaluation, the therapist will examine the quality and mobility of the patient’s knee motion, the amount of pain and swelling involved, and the strength of the muscles above and below the knee. Range of motion exercises work to increase the amount the patient can bend and straighten their knee. This is highly important for normal daily activities. Manual stretching from the therapist is often used to help regain normal motion. Exercises to increase strength of the quadriceps, hamstrings, hip, and ankle musculature are beneficial since muscle strength is often lost after a knee injury or surgery. Finally, the therapist will work on functional activity training to help the patient get back to higher level activities. This often involves exercises to improve balance, agility, and coordination.

Pain Management Techniques

The use of medications to control pain after knee surgery can be tailored to the individual needs of the patient, the type of surgery performed, and the expected intensity of rehabilitation. Paracetamol is useful in controlling mild to moderate pain and has minimal side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating pain caused by inflammation and are often used after arthroscopic procedures and surgery to repair ligament injuries. However, these drugs can have adverse effects on the stomach, kidney function, and cardiovascular system, and caution should be taken in patients with comorbidities.

Pain is one of the most important symptoms and the most common reason why patients seek medical attention. This is especially pertinent in the case of knee surgery. Inadequately controlled pain can lead to slower rehabilitation, prolonged hospitalization, decreased satisfaction with the medical experience, and the development of chronic pain. There are many modalities to control pain after knee surgery, including medications, injection therapy, and physical modalities.

Gradual Return to Normal Activities

At this stage, the patient will begin more demanding strengthening exercises such as leg presses, step-ups, and squats, along with more intense balance training. These exercises are essential for a successful return to work or sports. Sports-specific exercises are incorporated to take the patient through all aspects of their chosen activity. Speed, agility, power, coordination, and specific strengthening are all addressed during this phase. If the patient is able to perform very intense pivoting and cutting maneuvers, they are generally at a lower risk of re-injury. This program will carry into the next phase until the patient has regained confidence in their knee and has reached or surpassed their pre-injury status. A successful pre-injury status can be defined as no pain, swelling, instability, or deficit in the function of the rehabilitation leg compared to the non-involved leg.

This is the final phase of the rehabilitation process before the patient is discharged from physiotherapy care. This phase will begin once the physiotherapist feels that the muscle strength, range of motion, and functional ability to perform daily activities are near optimal and that the patient is able to perform these tasks without pain. Some patients will require a home exercise program to progress onto the next phase, while for others, it may be more appropriate to supervise their progression during therapy.

Long-term Care and Follow-up

The next aspect of long-term care is increased maintenance of strength and flexibility of the knee. Increased muscle strength can be expected automatically with the increased exercise and activity level as described in previous sections, but a specific strengthening regimen targeting the quadriceps and hamstrings may be desired. Isometric exercises with minimal or no weight and straight-leg raises are usually the safest and most effective ways to increase muscle strength. Flexibility of the knee can be increased using a safe stretching regimen. Both strength and flexibility can be increased significantly with physical therapy. It is best to consult a therapist before undertaking an aggressive exercise regimen. This paragraph addresses the standard methods of increasing leg strength and flexibility and hints at the possible use of a physical therapist.

Monitoring the healing process can be done in several ways. The first is simple and informal; just pay attention to the knees. If there is pain and/or swelling after increased activity, caution should be exercised and a day of rest should be inserted into the routine. If the symptoms are persistent and/or increase, it may be an indication of oncoming problems; consult your doctor if such problems arise. More formal monitoring can be done in your doctor’s office. A physical examination may or may not reveal any problems. If your physician suspects a problem, he may order X-rays or other studies, and on occasion, he may draw fluid from the knee to send to the laboratory. Any direct or indirect attempt to examine the knee should be requested to be amplified in writing as a report to be sent to you for your records if they are not already a matter of medical record. Finally, if there is any doubt as to the knee’s condition, do not hesitate to call your doctor. This paragraph describes the differing procedures that can be used for monitoring knee health after a procedure.

Long-term care after a knee procedure is important to maximize the healing process and to minimize the chances of reinjury. A successful knee procedure does not necessarily mean fifty-year-old knees in a twenty-year-old ten days later, patience is important. There are several ways to ensure the best long-term care for your knees.

Monitoring Healing Progress

As healing progresses, direct dialogue with the patient becomes less relevant than observation for signs of progress. At regular intervals (biweekly or monthly), goniometry measurements of the knee’s range of movement should be made and compared to the values obtained from the same time period after the surgery. Normal values must be known in order to set progress goals. At 8-12 weeks post-surgery, the patient’s muscle strength can be objectively measured and compared to pre-injury values. Isokinetic dynamometry is the best method, but if not available, manual muscle testing and measurement of mid-thigh circumference are acceptable alternatives. Gait analysis can provide useful information in the patient with functional limitations, and direct observation in the clinic or video analysis may be used. Any observed limping should be corrected as it predisposes to future knee problems. Step activity can increase the risk of damaging the graft and should be discouraged until graft strength approaches normal. High impact activities must be avoided until healing is complete, and post-activity effusion is a sign of excessive stress on the knee. If the patient desires a specific return to an activity, a timeline can be set relative to objective measures in the patient’s rehabilitation program.

Maintaining Strength and Flexibility

One common question that knee replacement patients ask is “What can I do to increase the longevity of my new knee?” The answer is regular exercise and activity. Nothing is more important than regular exercise. Exercise increases strength and flexibility of the muscles and helps the patient maintain an appropriate body weight. Muscle strength and maintaining ideal body weight are two of the most important factors in preventing future knee arthritis. Arthritis is caused by the wearing out of joint surfaces. The more ideal body weight that is placed upon a joint, the more force is applied to the joint surface. This will cause the plastic and metal to wear out more quickly. The quadriceps, hamstrings, and other muscles act as shock absorbers for the joint. They decrease the amount of force that is applied to the joint surface. For instance, if the patient descends steps and the force of double body weight is applied to the knee joint, normal muscles can decrease this to only single body weight worth of force. Thus the less force that is applied to the joint, the slower the joint will wear out. An ideal way to increase strength is by riding a stationary bike. In the first few weeks after the surgery, patients can use the motion of pedaling with no resistance to increase their range of motion. Once it is safe and the knee is no longer painful and swollen, they can start to increase the resistance to help build up muscle strength. Hamstring curls and straight leg raises are also important for strengthening the back of the thigh and the quadriceps respectively. It may be helpful to see a physical therapist to learn a series of different exercises to improve muscle strength and endurance. In general, most patients can do simple exercises at home. It is important to be consistent and patient. Strength gains will occur very slowly over a period of weeks and months. Flexibility is also equally important for a good range of motion of the knee. A stretching routine can help increase flexibility. This should be done at the end of exercising while the muscles are still warm. A warm shower or bath prior to stretching may make the muscles more conducive to stretching.

Preventing Future Knee Problems

A 1999 study on the prevention of arthritis following meniscal (knee cartilage) injury highlighted the benefits of a supervised rehabilitation program. The study included a group of patients who had early arthroscopic surgery to remove the torn cartilage and a similar group who had a 2-3 week rehabilitation program to strengthen the muscles around the knee and modify behavior that would load the medial (inside) compartment of the knee. After a 4-year follow-up, the rate of arthritis in the rehabilitation group was significantly lower than the early surgical group. This gives evidence that post-operative rehabilitation should not be about getting the knee good enough to function for everyday activities but trying to make the knee as near normal as possible and preventing an onset of degenerative changes in the joint. This is done by addressing any underlying causes of damage to the joint and improving the stability and function of the knee.

It is very important that rehabilitation after surgery has been completed is adhered to, in order to prevent future complications. This is done by pooling all the knowledge and capability into preventing muscle, ligament, and joint problems, and thus preventing or at least delaying the onset of arthritis in the knee. This is especially significant for patients who have had surgery to repair damaged articular cartilage or surgery to stabilize the knee after an injury.