Proviso: This discussion is for knee injuries: non-surgical classifications as well as those requiring surgery. (If one is planning to begin workouts and strengthening of a non-injured knee the same principles apply but your baseline start will include an initial weight amount for resistance, often 60% of One RM or NSCA calculator).
Assuming you recover uneventfully from the initial acute postoperative stage, the involved tissues will then transition to their “differentiation/ specialization” training phase. Expect the surgeon and therapist to follow a logical sequence (protocol) in the rehabilitation process. See the above link’s “discussion” portion.
To start with, the three general phases of muscle rehabilitation should be followed: Endurance, strength, and power. Generally proper stretching techniques and timing for it to begin occur during the late endurance and early strength phases but each surgical procedure and tissues involved guide the therapist’s instruction for it.
Endurance/Stamina is the least stressing and, physiologically, the best tissue “stabilizing” approach. It follows parameters based either on the number of repetitions for the exercise (50-100 reps) or a set length (5-10-20 minutes)of time to do the exercise. The exercise may at first, not only be limited by fatigue, but also by postoperative pain (and possibly some “FEAR”). Some people are afraid the wound will open or the repaired tissues will “come apart”. Some patients with total knee replacements really don’t trust the leg will hold together.
So start easy with a few “test” repetitions and then get to work doing more repetitions in a row. Where legs are concerned 3 sets of 10 just doesn’t get much happening with the mitochondria, the energy factories in all cells, especially muscle cells. Depending on whether all or part of the kinetic chain is working, 100 repetitions may be a reasonable goal to attain before pressing on to the next exercise phase: Strength.
Strength (force, weight, or resistance) training begins when the muscles are well energized by their endurance/stamina and can begin to strengthen (hypertrophy) using free weights, body weight, elastic tubing, exercise machine systems, walls, and stairs. At some point now, in this injury recovery process, there’s no need to use a formula to determine how much weight to start with, the therapist will likely decide it. Even if you are NWB on crutches, walker, or in a wheel chair, you may still be able to start the strengthening phase while waiting for the surgeon to permit FWB.
Some knee surgeries are specialized; where either the therapist will be responsible for the rehabilitation “progression” or the surgeon himself or herself will have a specifically prescribed written protocol to follow; as may be the case for ACL repairs (common for athletes) or for more complicated surgeries such as hyaline cartilage repair called mosaic plasty.
Regardless, once FWB, the therapist should always be thinking about the nerve pathway components as the endurance-strength-power program progresses. In that phase you’ll hear terms like mechanoreceptors, muscle spindles, proprioceptors, and other components. This is the time (and phase) you’ll start to feel the muscles getting stronger and your normal activities of daily living (ADL), like stairs, carrying bags and objects, driving, and shopping, resume their normal place in your household responsibilities (and life). In fact you may be able to return to employment, depending on your state’s workers’ compensation law, (workers disability pay is usually much less than regular pay) in a light duty capacity as you proceed through the ensuing weeks of rehabilitation.
The last phase of knee rehabilitation should gradually be integrated based on the physiological healing response and the physical sport or employment demands. This may be the time to begin power training:
Power (P) doesn’t begin until the nerve pathways are properly reinstated for joint tissue functions. Power is a law-of-physics term expressed as a formula (this is when some people’s eyes may “glaze” over). It simply multiplies endurance (repetitions or distance) and strength (force or weight) (known as work) while also introducing a per unit time or velocity component. The formula is P=F x d/t. Power can begin with low weight (doing work over time) and then “speed it up” as the nervous system accepts and tolerates the recovery challenge.
At some point the “insurance therapy” concludes in the early power stages for most patients but perhaps at later stages for athletes. In any event, therapy is concluded. Then athletes can see their school strength and conditioning coach, join a sport specific/sports training facility, (it seems to be a growing industry in my office referral region) or follow their own program. Finally you are ready to return to play or work.
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