In previous blogs and videos, I have touched on various considerations for exercise positions and postures and keeping in mind the 3 F’s: Form Follows
Function. During surgery, the surgeon causes trauma, through invading, altering, and repairing 4 kinds of tissues: soft – skin, circulatory vessels, nerves, and muscles; hard – bone; rubbery – cartilaginous; and rigid – ligaments, tendons, and joint capsule tissues;
Whatever injured and traumatized tissue the surgeon addresses, afterward it will need some sort of rehabilitating (supervised or self home program), keeping the 3 F’s in mind. Soft tissues mend through a healing process of 3,generalized, somewhat distinct, but overlapping phases. In general, Wolf’s Law applies to bone healing. Cartilage is mostly an inert tissue and essentially doesn’t have a direct physiological reparative property (what’s removed stays removed, what’s left is left). The soft tissues and the rigid tissues go through the healing phases too, but absolutely require the rehabilitation mantra: Form Follows Function; keeping in mind the 3 stages of healing so various functional motions are not initiated until their appropriate physiological mending time is right.
For the knee, once an operative report is obtained, the therapist should know the path to follow with the patient, keeping in mind any extraordinary precautions the surgeon may indicate as a consequence of his/her observation during the surgery. In some instances the surgeons are also using platelet-rich plasma (PRP) in reparative or debridement procedures, which should be in the operative report. This link has a reference to Tiger Woods knee. (PRP could be another blog).
Most incisions have 2 layers of suturing for mending cuts: the bottom layer (hypodermis/subcutaneous) of the skin and the outer layer (epidermis). Most orthopedic surgeons are now often using surgical glue and/or steri strips for the external or epidermal incision (in place of ”thread like” sutures and staples), and resorbable sutures primarily for the bottom layer of skin (subcutaneous). Sometimes, 3-5 weeks post operative, a tip or part of a resorbable suture may work its way out through the skin, adjacent to the incision, and usually can be pulled out or allowed to erupt by itself. Seldom does it cause an infection problem, but for total knee arthroplasties (TKA) the therapist or surgeon should be made aware if noticeable redness or local swelling around it occurs or persists. That usually won’t interrupt your therapy. But on occasion, knee swelling from that or other unknown reasons occurs and a 2-3 out of 5 scale level of warmth develops, often slowing down the progress of attaining full extension and/or flexion range of motion of the joint (ROM). Less common is the complication of wound dehiscence, often from premature bending of the knee, such as falling on the knee with loss of balance. That requires surgeon intervention.
The surgeon has to decide if anti-inflammatories (antibiotic if infected) are indicated. If general constant pain accompanies the swelling (described as 3-4/10 ache or throb pain), some doctors find it resolves with a short course of “pain killers”. For those patients, controlling the pain results in relief of what otherwise could evolve into a chronic healing inflammation. Rarely RSD/CRPS can occur in the knee itself and become quite disturbing and significantly inhibit good functional recovery. Infrequently, even after a “routine” arthroscopic knee surgery, swelling and pain develops. That too will be very disturbing to the patient and extend the need for supervised care (or sometimes rest).
Using ice or heat is always a question. That’s a short blog in itself because it depends on various factors and circumstances. So ask the surgeon or therapist about that.
The above, all though very much abridged to keep this blog readable, are some of the common observations I have observed over nearly 40 years. Fortunately, most knee surgeries fully recover uneventfully as long as the patient puts forth the proper effort and respects the physiological timelines in the tissue healing sequence.
My next blog will delve into the principles of the exercises (protocols) for knee rehabilitation, surgical or non-surgical.
Principles for knee rehabilitation protocols – Part II - Stamina, strength, power
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