Transcript Setting Specific Orthopedic Exercises

Author: Jorit Wijnmaalen, DPT, MBA, MTC,
CEAS
Educator:
Jorit Wijnmaalen (Dr. J)
John van Ooyen, PT, MTC
FPTA Approved for 9.5 CEU’s (2012)
About this course:
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The Setting Specific Orthopedic Exercise Course is the new
version of our Anatomy of Exercise course and now
includes exercise protocols for most major Orthopedic and
Spine Surgeries.
We have added more material to the course and it has
been submitted for FPTA approval for 9.5 CEU's. This
course is required for the CORS certification, but if you
have taken The Anatomy of Exercise in 2012 or 2011, you
do not need to take this course to become eligible for the
CORS certification.
This hands-on exercise course will review in depth clinical
protocols that are currently in place for the various,
common orthopedic procedures including joint
replacement, ligamentous and tendon repairs surgeries
and many spine surgeries.
This clinical review will include protocols as they are
applied in the various rehab settings including Inpatient
Acute Care, Subacute Rehab and Skilled Nursing settings,
Homecare and Outpatient.
SunCoast Seminars
Why do we need to know and understand the
anatomy of muscle?
•This will allow the clinician to specify their exercise program
geared towards the function of the muscle. Different muscles
have different functions and these functions are in part defined by
the anatomy of the muscle.
•There are approximately 639 skeletal muscles in the human
body. There are different types of muscles, each with their
distinct anatomy.
•Understanding the anatomy of the muscle will help the clinician
understand how different (intrinsic and extrinsic) factors can
impact muscles and exercising.
•We are looked upon as the experts when it comes to exercise
therapy. Understanding the anatomy of muscles is an important
part of being an exercise expert.
Program Objectives:
•Reviewing muscular anatomy and physiology
•This will include a review of tissue healing
•Discuss how extrinsic factors such as medication,
progression, exercise objectives etc. may affect the exercise
therapy program
•Discuss how intrinsic factors including disease processes
age, vital signs etc. may affect muscles and exercise
programs.
•Discuss the basics of exercise therapy
•Discuss common exercise principles
•Open chain vs. closed chain
•Eccentricisometricconcentric
SunCoast Seminars
About the educator:
•Background
•Education
•Work experience
•Hobbies
About SunCoast Seminars
• 5 educators
– Dr. Brian Healy
– Dr. Willem Stegeman
– Dr. Jorit Wijnmaalen
– John Van Ooyen, PT
– Dr. Nathan A. Possert, PT, DPT
About SunCoast Seminars
More courses:
• Orthopedic Joint Replacement course: 9.5 CEU
• Comprehensive Management of back &
neck pain: 9.5 CEU
• Clinical Imaging for the Rehab Specialist, 9.5 CEU
• Joint Replacement, online: 7 CEU
 Thoracic Outlet Syndrome: 6.0 CEU, Online
 HIV/Medical Errors/Abuse: 4 CEU
 The Anatomy of Excercise: online
 An Introduction to Manual Therapy : 9.5 CEU
 Setting Specific Orthopedic Exercises : 9.5 CEU’s
 CORS: 9.0 CEU’s
SunCoast Seminars
Muscular anatomy and physiology
Muscle Types:
Smooth muscles
Cardiac muscles
Skeletal muscles
SunCoast Seminars
Smooth muscles
•These muscles are very important in physiological
regulation.
•Help to regulate the flow of blood.
•Help control BP
•They control the movement of food through the digestive
system.
•Control of the uterus during labor
•Contraction of a smooth muscle cell is generated by a sliding
mechanism of the myofilaments.
•Contraction is involuntary and may be initiated by
•Nerve impulse
•Hormones (i.e. cardiac function)
•Mechanical change to the muscle
SunCoast Seminars
Smooth Muscles :
•Crucial difference with skeletal
muscles: nervous control is
absolutely required for skeletal
muscles, smooth muscles can, to a
degree, work without nervous
stimulation!
•Lastly, these muscles are not
striated (the myofilaments are
arranged into light and dark bands
as in striated muscles).
Striations are formed by alternating segments of thick and thin
protein filaments, which are anchored by segments called T-lines
SunCoast Seminars
Cardiac Muscles :
This muscle may look like a
skeletal muscles (especially
the contraction of it since
they are striated as well)
but it acts much like
smooth muscle (it does not
require nervous system
input to function)
• The attachment site
between cells is called an
intercalated disc, which is
present only in cardiac
muscle cells and allows
forces to be transmitted
from one cell to the next.
SunCoast Seminars
Skeletal Muscles:
•Striated (banded) type. This distinctive banding pattern of
striated muscle is an effect that comes from the alignment of
sarcomeres in register across the myofibrils
•Skeletal muscles are under voluntary control; no skeletal
muscle works without “orders” from the nervous system
•Skeletal muscles have elongated muscle cells (fibers) with
multiple nuclei lying along the periphery of the cell. The
sarcoplasm of each cell is contained by a sacrolemma (plasma
membrane) and an external lamina.
•Each muscle contains many myofibrils and each myofibril
contains thin actine and thick myosin myofilaments.
•These muscles normally make up the largest portion of a
person's lean body mass
SunCoast Seminars
Skeletal Muscles
•These are the muscles that are responsible for all voluntary
movements (movements controlled by the central nervous
system and which typically are directed at some sort of
interaction with the environment)
•These muscles only contract in response to instructions
from the central nervous system (with a few exceptions)
•In short, skeletal muscles have the following functions:
•provide joints with the forces necessary to produce
movement
•to control movement
•to stabilize and protect joints when loads are applied to
them.
•generating heat, maintaining normal body temperature,
because they account for 40% of the body mass.
Skeletal Muscles
•Skeletal muscles are a striated type of muscle with a rich
blood supply, extensive afferent and efferent innervations and
an extremely high metabolic capacity.
•Skeletal muscles have a tremendous adaptive capacity that
allows them to hypertrophy, atrophy, increase in
physiological length, decrease in physiological length and
change metabolic capacities.
Out of the three muscle types discussed, the skeletal muscle
are the muscles that we will be most concerned within this
course.
Muscular anatomy and physiology
Let’s review!
The Anatomy review of a skeletal muscle
•Each muscle cell is surrounded by a basal lamina and
connective tissue.
•They are bound to each other and to surrounding tissues by
connective tissue to form a gross "muscle". Skeletal muscle
fibers are NOT joined by cell junctions.
•The endomysium consists of the basal lamina and thin
connective tissue that surrounds individual muscle cells.
•The perimysium consists of sheets of connective tissue
which separate the fibers into groups known as fascicles.
•The epimysium surrounds the groups of fasicles that
comprise the “muscle”.
•
•
•
Endomysium – delicate
connective tissue sheeth that
encloses each muscle fiber
Fasciculus – bundle of muscle
fibers covered by perimysium
(coarser fibrous membrane)
Epimysium – covers bundle of
fasciculi (entire muscle);
blends into either:
– Tendon – cord of dense, fibrous
tissue attaching a muscle to a
bone
– Aponeurosis – fibrous or
membranous sheet connecting
a muscle and the part is moves
(usually found on torso)
The Anatomy review of a skeletal muscle
•Connective tissue transmits the mechanical force of muscle.
•Tendons connect muscle to bone. The myotendinous junction
occurs at the end of the muscle cell where the terminal actin
filaments connect to the plasma membrane
•Skeletal muscle fibers are multi-nucleated cells that arise by
fusion of mono-nucleate myoblasts.
•The many nuclei are located at the periphery of the cell.
•Mono-nucleate satellite cells, associate with the muscle fiber
and reside within the muscle basal lamina. They promote
limited regeneration of muscle in the adult.
The Yellow line is
corresponding to
the tendon. How
do we classify this
Connective tissue?
Dense Regular. The
yellow arrows are
pointing the nuclei
of the fibroblasts
making the
collagen.
The blue line is
showing where the
Striated Muscle is
beginning
The muscle-tendon junction
Innervation of a Skeletal Muscle
•Skeletal muscle is innervated and highly vascularized, due to
its high energy requirements. It is penetrated of blood vessels
into the epimysium with branches into the peri- and
endomysium.
Innervation of a Skeletal Muscle
•Motor end plates (neuromuscular junctions) are
specialized sites at which a nerve contacts a muscle cell.
•The terminal branches of motor axons lie in the surface of
the muscle cell, where the plasma membrane is highly
folded.
•Muscle action begins at the motor end plate (or
neuromuscular junction), which is analogous to a synapse
•Acetylcholine(ACh) binds to receptors localized in the
muscle membrane at the motor end plate, resulting in local
depolarization at the end plate.
•When this depolarization exceeds the threshold, it will
result in an action potential
Neuromuscular Junction or
Motor End Plate
axon of Motor (Efferent)
Neuron
White arrow - Skeletal
Muscle Fiber
Innervation of a Skeletal Muscle
•Additional proprioceptor endings (Golgi tendon organs) are
located at the point where muscle fibers attach to tendon
•These Golgi tendon organs (GTO) respond to tension (force)
exerted by the muscle; activity in these axons inhibits muscle
contraction (they are for instance stretched when a joint is
swollen).
Nerve Conduction
•Both nerve cells and muscle cells are excitable
•Their cell membrane can produce electrochemical
impulses and conduct them along the membrane.
•In muscle cells, this electric phenomenon is also associated
with the contraction of the cell
•The origin of the membrane voltage is the same in nerve
cells as in muscle cells. In both cell types, the membrane
generates an impulse as a consequence of excitation.
•The long nerve fiber, the axon, transfers the signal from
the cell body to another nerve or to a muscle cell
•The axon may be covered with an insulating layer called
the myelin sheath, which is formed by Schwann cells
Nerve Conduction
•This myelin sheath is not continuous but divided into sections,
separated at regular intervals by the nodes of Ranvier
•The junction between an axon and the next cell with which it
communicates is called the synapse.
•Information proceeds from the cell body uni-directionally over
the synapse, first along the axon and then across the synapse to
the next nerve or muscle cell (think about peripheral leasion)
•The part of the synapse that is on the side of the axon is called
the pre-synaptic terminal
•The part on the side of the adjacent cell is called the
postsynaptic terminal. Between these terminals, there exists a
gap.
•A chemical neurotransmitter, released from the pre-synaptic
cell, is responsible for the impulse to transfer across the synapse.
Nerve Conduction
•This transmitter, when released, activates the postsynaptic
terminal. The synapse between a motor nerve and the muscle it
innervates is called the neuromuscular junction
Nerve Conduction
•If a nerve cell is stimulated, the trans-membrane voltage
necessarily changes. The stimulation may be
•excitatory (i.e., depolarizing; characterized by a decrease
in the normally negative resting voltage) or
•inhibitory (i.e., hyperpolarizing, characterized by an
increase in the magnitude of the membrane voltage).
•After stimulation the membrane voltage returns to its original
resting value
•If the excitatory stimulus is strong enough, the trans-membrane
potential reaches the threshold, and the membrane produces a
characteristic electric impulse, the nerve impulse.
•Remember the Na+/K+ pump?
Nerve Conduction
Many factors may affect nerve conductivity but discussion of
those factors would be outside the scope of this lecture.
•Temperature
•Properties of the membrane
•Sodium levels
•Age
•Anatomical changes because of disease (ALS)
Nerve Conduction
•A myelinated axon (surrounded by the myelin sheath) can
produce a nerve impulse only at the nodes of Ranvier
•In these axons the nerve impulse propagates from one node to
another
•The myelin sheath increases the conduction velocity
•The conduction velocity of the myelinated axon is directly
proportional to the diameter of the axon
Nerve Conduction
Types of Skeletal muscles
Not all skeletal muscles are the same.
•Some cells are thicker than others
•Some shorten faster
•Some produce more tension
•Some fatigue more rapidly
Looking at these different features, there appear to be three
major types of skeletal muscles:
Types of Skeletal muscles
• Slow Twitch
• Fast Fatigue Resistant
• Fast Twitch Fatigable
Slow Twitch
•These muscles produce the least amount of
force. They actually produce less than half the
force produced by fast twitch fatigue resistant
fibers and are most resistant to fatigue.
•Slow twitch muscles use oxygen for power and
have a predominance of aerobic enzymes.
•Slow twitch muscles are red, because they
contain lots of blood vessels.
•These muscle fibers are "hit", or engorged with
nitrogen-rich blood, during higher rep training,
specifically in sets of 12 to 20 reps.
• Slow twitch muscles are used for holding
posture
Fast Twitch (Type II)
•Fast Twitch fibers use anaerobic metabolism to create
fuel and so they are much better at generating short
bursts of strength or speed than slow muscles.
•These types of muscles are best trained during sets of 25 repetitions.
•They fatigue more quickly.
•Fast twitch fibers generally produce the same amount
of force per contraction as slow muscles, but they get
their name because they are able to fire more rapidly.
•Having more fast twitch fibers can be an asset to a
sprinter since she needs to quickly generate a lot of
force (genetically determined, 50/50 on average; some
research suggests that some fibers might be able to
convert).
Two Types:
Type IIa Fibers / Fast Fatigue Resistant
•These fast twitch muscle fibers are also known as
intermediate fast-twitch fibers.
•They can use both aerobic and anaerobic metabolism
almost equally to create energy.
•In this way, they are a combination of Type I and Type II
muscle fibers.
•Produce forces greater than slow twitch fibers but less than
fast twitch fatigable fiber.
•These fibers are more resistant to fatigue than fast
fatigable but less fatigue resistant than slow twitch fibers.
Type IIb Fibers
•These fast twitch fibers use anaerobic metabolism to
create energy and are the "classic" fast twitch muscle fibers
that excel at producing quick, powerful bursts of speed.
•This muscle fiber has the highest rate of contraction
(rapid firing) of all the muscle fiber types, but it also has a
much faster rate of fatigue and can't last as long before it
needs rest.
•Produce the greatest amount of force
•Are least resistant to fatigue
•Force produced is typically 2-3 times greater than fast
twitch fatigue resistant fibers
Skeletal
Muscle
Types
Slow
Twitch
Fibers
Other
name
Red, Slow
oxidative
Type I
White, fast
Fast
oxydative,
Fatigue glycolytic
Resistant Type IIA
Twitch Twitch Fatigue Oxydative Fiber
Motor Capillary Mitotime tension rate
capacity diameter unit size density chondria
Slow
Low
High
Small
Small
High
Many
Fast
Interme Interme
diate diate High
Large
Large
High
Many
High
Large
Large
Low
Few
Fast
Twitch White, fast,
Fatiguable Type IIB Fast
Slow
Fast
Low
• Low frequency stimulation of motor units of type
II fibers transforms these fibers in type I fibers
(endurance training, easier to accomplish)
• High frequency stimulation of motor units of type
I fibers transforms these fibers in type II fibers
(strength training, harder to accomplish)
This is due to rest periods with low frequent
stimulation of type II fibers, only metabolism and
muscle fiber diameter stay increased.
Conclusion
•So the lesson here is quite simple. As we are exercising our
patients, we must keep in mind the main objective of our
exercise program.
•In order to recruit the largest possible number of muscle
fibers of both types during the exercise program, we must
vary the repetition ranges .
•Keeping in mind that on average, there is a 50/50 split of
these fibers so…
•Any therapist, who puts a patient on an exercise program
that doesn't include a variation of repetition ranges might
significantly limit the success of the exercise program.
Skeletal Muscle Fiber Arrangement
•It is important to realize that there are different alignments of
muscle fibers in the various skeletal muscles.
•These different fiber arrangements will have an effect on the
length, mechanical properties and the number of muscle fibers
of a muscle.
•Muscle fibers can be arranged in parallel or at angles to the
tendon.
•Parallel fibered muscles are muscle composed of parallel aligned
fibers. These muscles have long muscle fibers that can produce a
large excursion on the tendon.
•Fusiform
•Triangular
•Spiral
•Pinnated fibers muscles are muscles composed of angled fibers
•Unipinnate
•Bipinnate
•Multipinnate
Structure & Function of a Skeletal muscle
•The cell comprises a series of striped
or striated, thread-like myofibrils.
•Within each myofibril there are
protein filaments that are anchored by
dark Z line.
•The fiber is one long continuous
thread-like structure.
•The smallest cross section of skeletal
muscle is called a sarcomere which is
the functional unit within the cell. It
extends from one Z line to the next
attached Z line. The individual
sarcomere has alternating thick myosin
and thin actin protein filaments.
•Myosin forms the center or middle of
eache M line. Thinner actin filaments
form a zig zag pattern along the anchor
points or Z line.
Muscle Contraction
Upon stimulation by an action potential, skeletal muscles
perform a coordinated contraction by shortening each
sarcomere.
The best proposed model for understanding contraction is
the sliding filament model of muscle contraction.
•Actin and myosin fibers overlap in a contractile motion
towards each other.
•ATP binds to the cross bridges between myosin heads and
actin filaments. The release of energy powers the
swiveling of the myosin head
•Myosin filaments have club-shaped heads that project
toward the actin filaments.
•Larger structures along the myosin filament called myosin
heads are used to provide attachment points on binding
sites for the actin filaments.
Muscle Contraction (cont.)
•The myosin heads move in a coordinated style, they swivel
toward the center of the sarcomere, detach and then reattach to
the nearest active site of the actin filament.
•This is called a rachet type drive system.
•This process consumes large amounts of adenosine
triphosphate (ATP).
•Calcium ions are required for each cycle of the sarcomere.
•Calcium is released from the sarcoplasmic reticulum into the
sarcomere when a muscle is stimulated to contract. This
calcium uncovers the actin binding sites.
•When the muscle no longer needs to contract, the calcium ions
are pumped from the sarcomere and back into storage in
the sarcoplasmic reticulum
Images from Purves et al., Life: The Science of Biology, 4th Edition, by Sinauer Associates
(www.sinauer.com) and WH Freeman (www.whfreeman.com)
Muscle contraction
-
In rest the average human body uses as much energy as a
75W light bulb.
- During 24 hours of resting one still uses 1400-1800 kcal
(25 mile stroll)
- During extreme endurance sports the body is able to
burn 10500-15000 kcal
- Muscle tissue is a very effective power source:
power versus weight for a jet motor is 1:5
power versus weight for the biceps muscle is approx. 1:360
Muscle contraction (cont.)
•ATP is the main source of energy for all muscle contraction.
•There are several chemical reactions that take place to produce
ATP.
•When a muscle is used, a chemical reaction breaks down ATP
to produce energy:
ATP + Actin + Myosin
Energy
Actomyosin + Phosphate + ADP +
•This is the chemical reaction that produces energy, however,
there is only enough ATP stored in the muscle cell for two or
three slow twitch contractions, or one burst of power from a
fast twitch contraction.
• Surprisingly muscles store very limited reserves of ATP 4-6
seconds worth at most, just enough to get you going.
Muscle contraction (cont.)
• ATP is the only energy source used directly for
contractile activities.
• It must be regenerated as fast as its broken down for
continuation of the contraction.
 Fortunately, after ATP is hydrolyzed to ADP and
inorganic phosphate in muscle fibers, it’s generated
in a second by one or more of the three pathways,
 (1) direct phosphorylation of ADP by Creatine
Phosphate
 (2) the anaerobic pathway called glycolysis,
which converts glucose to lactic acid
 (3)Aerobic pathway, aerobic cellular respiration
Muscle contraction (cont.)
(1) Direct phosphorylation of ADP by Creatine Phosphate
 a phosphate group transfers from CP to ADP,
regenerating more ATP; CP supplies exhaust in about 20
seconds
 Duration of energy provision 15 seconds
(2) Anaerobic glycolysis and lactic acid formation
• initial steps of glucose breakdown occur via glycolysis
which is anaerobic.
• Duration of energy provision
 Glucose -> pyruvic acid with energy captured in ATP
bonds (2ATP/ 1 glucose)
(3) Aerobic respiration:
• provides 95% of ATP at rest and during light
• Exercise occurs in mitochondria & involves a series of
metabolic pathways that use oxygen
• called oxidative phosphorylation
• glucose is broken down into CO2 & H2O
• some released energy is captured in ATP bonds (get
36ATP/1 glucose)
There is also another way to look at those three steps, when
we talk about the enzyme systems.
There are three enzyme systems that can create more ATP. The
enzyme system that is used depends on whether the type of
muscle is fast twitch or slow twitch, and whether the muscle is
used for strength, burst power, or endurance.
Muscle Contraction (Cont.)
The Strength Enzyme System
•When muscle strength is required, ATP is created quickly
from the following chemical reaction.
•The enzyme creatine kinase mediates ATP production from
the high energy molecule creatine phosphate by an anaerobic
reaction:
•CP + ADP
ATP + Creatine
•The CP (Creatine Phosphate) is depleted in just a few
seconds. This is the reason your maximum power can be
maintained for only a few seconds. To continue producing
high strength power, the speed enzyme system kicks in.
Muscle Contraction (Cont.)
The Burst Power Enzyme System
•The enzymes required for this reaction are depleted in less
than two minutes.
•This reaction is called Anaerobic Glycolysis because it uses
glucose without oxygen.
•Glucose
2ATP + 2 Lactate
•Continued muscle usage requires the aerobic system to kick
in.
•The aerobic system uses oxygen and sugar for fuel.
•The ability to perform well after about two minutes of
maximum exertion depends on the aerobic conditioning of
the body which is trainable
Muscle Contraction (Cont.)
The Endurance Enzyme System
This system consists of three processes:
1. Carbohydrate Metabolism: Carbohydrates metabolize most
efficiently and are therefore used first
2. Fat Metabolism: If no carbohydrates are available, the body
metabolizes fat.
3. Amino Acid Protein Metabolism: If no fat is available, the
body metabolizes Amino Acids.
The body stores glucose and fatty acids for these reactions. In
addition, the cardiovascular system provides a continuous
supply of oxygen.
Muscle Contraction (Cont.)
The Endurance Enzyme System
This system consists of three processes:
1. Carbohydrate Metabolism: Carbohydrates metabolize most
efficiently and are therefore used first
2. Fat Metabolism: If no carbohydrates are available, the body
metabolizes fat.
3. Amino Acid Protein Metabolism: If no fat is available, the
body metabolizes Amino Acids.
The body stores glucose and fatty acids for these reactions. In
addition, the cardiovascular system provides a continuous
supply of oxygen.
Muscle Contraction (Cont.)
•Cardiac muscle is adapted to be highly resistant to fatigue: it
has a large number of mitochondria, enabling continuous aerobic
respiration.
•The heart is so tuned to aerobic metabolism that it is unable to
pump sufficiently in ischaemic conditions. (It has no back up
system).
•At basal metabolic rates, about 1% of energy is derived from
anaerobic metabolism. This can increase to 10% under
moderately hypoxic conditions, but, under more severe hypoxic
conditions, not enough energy can be liberated by lactate
production to sustain ventricular contractions.
•Under basal aerobic conditions, 60% of energy comes from
fat (free fatty acids and triglycerides), 35% from carbohydrates,
and 5% from amino acids. However, these proportions vary
widely according to nutritional state. For example, during
starvation, lactate can be recycled by the heart
Muscle Contraction (Cont.)
•Glycogen is stored in the muscles and liver in sufficient
quantities for about two hours of strenuous exercise.
•This timeframe can be extended by aerobic physical
conditioning and high carbohydrate diet.
•After the glycogen stores are used up, the body obtains its
energy from fatty acid metabolism and amino acid protein
metabolism.
•These reactions are not efficient, which consequently causes
your strength and endurance to drop drastically (hitting a brick
wall or man with the hammer).
Motor Units within a muscle
•A motor unit is defined as all of the muscle fibers supplied by a
single motoneuron, and therefore, by a single axon and its branches
•Skeletal muscles are organized into hundreds of motor units,
each of which involves a motor neuron, attached by a series of thin
finger-like structures called axon terminals.
•These attach to and control discrete bundles of muscle fibers. A
coordinated and fine tuned response to a specific circumstance will
involve controlling the precise number of motor units used.
•While individual muscle units contract as a unit, the entire muscle
can contract on a predetermined basis due to the structure of the
motor unit.
•Motor unit coordination, balance, and control frequently come
under the direction of the cerebellum of the brain. This allows for
complex muscular coordination with little conscious effort, such as
when one drives a car without thinking about the process.
Motor Units within a muscle
•Muscles responsible for fine coordination have small motor
units.
•Muscles responsible for gross movements have large motor
units.
•The smaller motor units are more excitable than the larger
ones, and are stimulated first when a weak signal is sent by
the CNS to contract a muscle
•As the strength of the signal increases, more motor units are
excited in addition to larger ones, with the largest motor units
having as much as 50 times the contractile strength as the
smaller ones
• As more and larger motor units are activated, the force of
muscle contraction becomes progressively stronger. This
concept is know as “the size principle”.
Motor Units within a muscle: Conclusion
•At low exercise intensities, like walking or slow running, slow
twitch fibers are selectively utilized because they have the lowest
threshold for recruitment.
•If suddenly the pace is increased to a sprint, the larger fast units
will be recruited.
•In general, as the intensity of exercise increases in any muscle,
the contribution of the fast fibers will increase.
•For the muscle, intensity translates to force per contraction and
contraction frequency/minute.
•Motor unit recruitment is regulated by required force. In the
unfatigued muscle, a sufficient number of motor units will be
recruited to supply the desired force (wave contraction).
Motor Units within a muscle: Conclusion
•Initially desired force may be accomplished with little or no
involvement of fast motor units. However, as slow units
become fatigued and fail to produce force, fast units will be
recruited as the brain attempts to maintain desired force
production by recruiting more motor units.
•Consequently, the same force production in fatigued muscle
will require a greater number of motor units.
•This additional recruitment brings in fast, fatigable motor
units.
•As a result, fatigue will be accelerated toward the end of long
or severe bouts due to the increased lactate produced by the
late recruitment of fast units. (Again, the man with the
hammer)
Contraction Strength
•For skeletal muscles, the force exerted by the muscle is
controlled by varying the frequency at which action potentials
are sent to muscle fibers.
•Action potentials do not arrive at muscles synchronously,
and during a contraction some fraction of the fibers in the
muscle will be firing at any given time.
•Typically when a human is exerting a muscle as hard as they
are consciously able, roughly one-third of the fibers in that
muscle will be firing at once, but various physiological and
psychological factors (including Golgi tendon organs and
Renshaw cells) can affect that.
•This 'low' level of contraction is a protective mechanism to
prevent avulsion of the tendon - the force generated by a 95%
contraction of all fibers is sufficient to damage the body.
Contraction Strength
•The repetitive firing of a motor unit creates a train of impulses
known as the motor unit action potential train (MUAPT).
•To sustain muscle contraction, the motor units must be
repeatedly activated . As the firing rates of motor units active in
a contraction increase, the twitches associated with each firing
will eventually fuse to yield large forces
•The firing rates of earlier recruited motor units are greater
than those of later recruited motor units at any given force value
•The control to the muscle is not designed to generate constantforce contractions.
Maximal Voluntary Contraction (MVC)
Contraction Strength
• So concluding, the strength of a muscular contraction can be
influenced 2 factors:
1. By increasing the number and size of contractile units
simultaneously, called multiple fiber summation.
2. By increasing the frequency at which action potentials
are sent to muscle fibers, called frequency summation.
Types of Muscle Contraction
1. Concentric muscle contraction
2. Eccentric muscle contraction
3. Isometric muscle contraction
4. Isotonic muscle contraction
Concentric muscle contraction
• Muscle contraction in which the muscles shorten while
generating force. The insertion and origin of the muscle are
moving toward eachother.
• During a concentric contraction muscle fibers slide across
each other pulling the Z-lines together
• During a concentric contraction, a muscle is stimulated to
contract according to the sliding filament mechanism.
• This occurs throughout the length of the muscle, generating
force at the musculo-tendinous junction, causing the muscle
to shorten and changing the angle of the joint.
• In relation to the elbow, a concentric contraction of the
biceps would cause the arm to bend at the elbow.
• A concentric contraction of the triceps would change the
angle of the joint in the opposite direction, straightening the
arm.
Eccentric Muscle Contraction
•During an eccentric contraction, the muscle elongates while
under tension. The origin and the insertion of the muscle are
moving away from eachother.
•The muscle acts to decelerate the joint at the end of a
movement or otherwise control the repositioning of a load.
•This can occur involuntarily (when attempting to move a
weight too heavy for the muscle to lift) or voluntarily (when the
muscle is 'smoothing out' a movement).
•Over the short-term, strength training involving both
eccentric and concentric contractions appear to increase
muscular strength more than training with concentric
contractions alone.
•During an eccentric contraction of the biceps muscle, the elbow
starts the movement while bent and then straightens as the hand
moves away from the shoulder. During an eccentric contraction
of the triceps muscle, the elbow starts the movement straight and
then bends as the hand moves towards the shoulder.
Eccentric Muscle Contraction
•Exercise featuring a heavy eccentric load can actually result
in greater muscular damage and delayed onset muscle
soreness one to two days after training.
•Exercise that incorporates both eccentric and concentric
muscular contractions (i.e. involving a strong contraction and a
controlled lowering of the weight) can produce greater gains in
strength than concentric contractions alone.
•While unaccustomed heavy eccentric contractions can easily
lead to overtraining, moderate training may confer protection
against injury.
Isometric Muscle Contraction.
•An isometric contraction of a muscle generates force without
changing length.
•An example can be found in the muscles of the hand and
forearm grip an object; the joints of the hand do not move but
muscles generate sufficient force to prevent the object from
being dropped.
• Isometrics are done in static positions, rather than being
dynamic through a range of motion.
•The joint and muscle are either worked against an immovable
force (overcoming isometric) or are held in a static position
while opposed by resistance (yielding isometric).
Eccentric Muscle Contraction
•Muscles are approximately 10% stronger during eccentric
contractions than during concentric contractions
•Eccentric contractions are being researched for their ability to
speed rehab of weak or injured tendons. Achilles tendinitis has
been shown to benefit from high load eccentric contractions.
•During virtually any routine movement, eccentric contractions
assist in keeping motions smooth.
•Muscles undergoing heavy eccentric loading suffer greater
damage when overloaded (such as during muscle building or
strength training exercise) as compared to concentric loading.
•During an eccentric contraction, the filaments slide past each
other the opposite way, though the actual movement of the myosin
heads during an eccentric contraction is not known.
Isotonic Muscle Concentration
Isotonic contractions occur when tension in the muscle
remains constant despite a change in muscle length. This
can occur only when a muscle's maximal force of
contraction exceeds the total load on the muscle.
A: Concentric/eccentric
B: Isometric
EXERCISING AND BUILDING MUSCLES
•Muscles change and develop with regular exercise but the
effects differ, depending on whether you engage in strength,
speed, or endurance training.
•Strength and burst training causes the muscle fibers to enlarge.
•Individual muscle fibers increase in diameter as a result of an
increase in intracellular protein fibrils.
•Endurance training causes more blood vessel formation than
does speed or strength training, which produces an increased
capacity for aerobic metabolism within the muscle cell.
•This change is seen after a few weeks of training and is
maximized in about three months. The aerobic enzymes that
metabolize carbohydrates, fats, and proteins, double.
•It is important to develop your strength and speed systems, but
if you want to continue past about two minutes of high intensity
workouts, you need to have your aerobic systems developed
EXERCISING AND BUILDING MUSCLES
Effect of Exercise on Muscles:
Aerobic or endurance exercise
 Examples – biking, jogging, swimming laps
 Results in stronger more flexible muscles with greater
resistance to fatigue
 blood supply increases
 individual muscle cells form more mitochondria and store
more oxygen (makes overall body metabolism more
efficient
 Improves digestion and elimination of wastes
 Enhances neuromuscular coordination
 Makes the skeleton stronger
 Heart enlarges
 Fat deposits are cleared from blood vessel walls
 Lungs become more efficient at gas exchange
 Does NOT cause muscles to increase in size
EXERCISING AND BUILDING MUSCLES
• Effects of Exercise on Muscles:
• Resistance or isometric exercise
• Examples – weightlifting, theraband or medicine ball
training, bodyweight exercises like push-ups or pull-ups,
plyometrics
• Key is that muscles are being forced to contract with as
much force as possible or as quickly as possible
• Muscles increase in size and strength
• Due to enlargement of individual muscle cells (more
contractile filaments), not because more muscle fibers are
made
• Size of reinforcing connective tissue also increases to
support increased muscle size
Muscle Functions
Muscle tissue has four main properties:
•Excitability or the ability to respond to stimuli
•Contractibility or the ability to contract
•Extensibility or the ability of a muscle to be stretched
without tearing
•Elasticity or the ability to return to its normal shape
Through contraction, the muscular system performs three
important functions:
•Motion - walking, running etc.
•Heat production - maintain normal body temperature
•Maintenance of posture - standing, sitting etc.
Muscle Functions
•Muscles have two states
•Relaxed
•Contracted.
Common Medications and their effect on Exercise
•Blood thinners: Coumadin, Lovenox, Warfarin, Plavix
Aspirin: Watch the side effects. Do not take with NSAID’s (will
negate the blood thinning effect). Thinning of mucosa of the
stomach wall, gastric ulceration, increased bleeding risk
•Muscle relaxors: Flexeril, Soma, Valium, Skelaxin
Flexeril: Duration of action 12-24 hour
Skelaxin: Duration of action 4-6 hours
Side effects: Drowsiness, dizziness, vertigo, ataxia, dependency
•Parkinson's disease: Levodopa, Dopamine agonists, Anti cholinergics
Sinemet/dopamine: arrhythmia's, postural hypotension
•Diuretics: Bumex, Lasix, Aldactone
Hypokalemia, hyponatremia, fluid depletion, orthostatic
hypotension
Common Medications and their effect on Exercise
(continued)
•Cardiac function controlling medication: Beta blockers (Tenormin,
Lopressor, Inderal, Betapace)
Digitalis toxicity, dry cough, bradycardia, hypotension
•BP controlling medication: Beta blockers, Alpha blockers (Cardura,
Minipress)
Broncho constriction, bradycardia, hypotension
•HR controlling medication: Norpace, Beta blockers, Cordarone,
Cardizem
Increase of arrhythmia's, dizziness, hypotension
•Pulmonary function controlling medication: Albuterol, Epinephrine,
Theo-Dur, Pulmicort, Decadron, Aerobid, Cortef
Osteoporosis, muscle wasting, skin breakdown, diabetes mellitis,
hypertension
The importance of a thorough evaluation
•The concept is very simple here; without a complete and
detailed evaluation, you cannot develop an appropriate
exercise program.
•This evaluation is ongoing and does not stop after the “
initial evaluation” (there is a reason for that name…)
•Understanding the true dysfunction and understanding why
that dysfunction exists will put the clinician in the position to
address the dysfunction effectively.
Different types of exercises with different objectives
•Objectives/Goals of exercise:
•Strength
•Muscular Dystrophy
•Coordination
•Firing Patterns
•Endurance
•ROM
•PROM vs. AROM
•Endfeel?
•PROM of the Joint
•Muscle length (Muscle energy)
•Muscle tone
•Decrease of muscle tone
•Increase of muscle tone
•Pain control
Components of an effective Exercise Program:
•Starts with a thorough and complete evaluation (evaluate the
complete chain.
•Have clear outcome objectives.
•What are you looking to exercise
•Why are you exercising that
•What outcome do you expect
•Depends on patient/age/function/other intrinsic and
extrinsic factors
•Measure and document these objectives ongoing
•Don’t over exercise. Exercise to improve function not too
complete a number of reps.
•When you feel or see the correct movement, continue to the
Components of an effective Exercise program:
•Get the buy-in from the patient
•Detailed documentation
•Quality of the movement
•Speed
•Cues given/needed
•Strength
•Shaky/Tremorous
•Coordination
•Sensation
•Intensity
•Activity it is related to improve
Progression/Regression of exercise
•Establish base point or midline
•Points of contact: Progress from larger base of
support to smaller base of support
•Open chain vs. Closed chain
•# of repetitions or sets
•Speed of the reps
•Cues: tactile& Verbal
•Level of resistance
•Point of reference
•eccentric Isometric  concentric
•Stabilize vs. destabilize
•Weight shifting  weight bearing
•Sequence: Instruct correct
movementrepeatchallenge add
complexityput into a functional activity
•Method of observation: visual, tactile, bio feed back
Total Hip Arthroplasty
Brief description of procedure:
• Hip replacement is a surgical procedure in
which the hip joint is replaced by a prosthetic
implant.
• Hip replacement surgery can be performed as a
total replacement or a hemi (half)
replacement. A total hip replacement (total hip
arthroplasty) consists of replacing both the
acetabulum and the femoral head while
hemiarthroplasty generally only replaces the
femoral head
Variations: Hemi Arthroplasty, Revision, Hip,
.
Resurfacing, ORIF
Muscles involved:
Anterior approach: No muscles are cut other than
the Piriformis which is transected 50% of the time
Posterior approach:The piriformis muscle and the
short external rotators (tendons) are taken off the
femur
Lateral approach: The hip abductors (gluteus
medius and gluteus minimus) are elevated – not cut
– to provide access to the joint
When does Rehab start? For most elective orthopedic
procedures, the patient can start strengthening prior to the
surgery, as allowed by their pain and functional level.
Unfortunately, this is typically not reimbursed by insurance
companies, or it may take away from their post-op rehab
visits.
Precautions and time frames
Total hip precautions; restricted Hip Adduction, ER and
Flexion as per the surgeon.
Avoid SIMULTANEOUS/COMBINATION movements of the
operative hip.
Patients are allowed to flex, extend, abduct, adduct, or
rotate their operative hip in cardinal planes of motion with
NO restriction to movement. Any combination of motion
during the initial three (3) months, post operative period
should be avoided.
Surgical Hip Precautions
•
Weight bearing: Typically WBAT unless there was a
surgical complication, so ALWAYS read the operative
report. ALWAYS FOLLOW WB INSTRUCTIONS
Acute Care Protocol: Hip
DOS:
Patient should get up with PT on the DOS, unless the
patient had surgical complications, or had Total Anasthesia
Patient can get up on the surgical or non-surgical site and will
use a walker to ambulate with the appropriate WB and may sit
in a chair, maintaining the 90 degrees hip angle.
Patient should also start Muscle Setting Exercises in bed .
Day 1-4: Patient should get up with nursing as well for BRP and for short
ambulation.
Physical Therapy and Occupational Therapy will focus safe
transfers, following WB directions, using a walker, focusing on
posture as well. AAROM will be started today in all cardinal
planes as well. Walking distance will steadily increase and
precautions will be reviewed with the patient and their family.
Ambulation Guidelines:
• Cemented Prosthesis: Weight bearing as tolerated (WBAT)
ambulation. Patients are required to initially use a
walker/crutches for a period of time, then are progressed
to cane ambulation.
• The cane is discontinued when the patient is ambulating
without a positive Trendelenberg test.
• Uncemented Prosthesis: Patients are required to ambulate
using a walker/crutches and partial weight bearing for 6
post-operative weeks. Patients are progressed to WBAT
over the following 2 weeks. When patients are able to
ambulate without a positive Tredelenberg test, they may
ambulate without any assistive devices.
• No running or involvement in sporting activities requiring
running and/or jumpingfor 12 weeks.
Acute Care Protocol: Hip
POD #0:
• Begin isometric exercises and ankle pumps to leg.
Encourage the patient to perform these exercises every
two hours while awake.
• Begin assisted bed-to-chair transfers using an assistive
device to a chair of appropriate height.
• Weight bearing status is dependent upon the type of
prosthesis implanted.
• Patients may sit in an upright position if comfortable.
• Discuss post-operative dislocation
precautions/restrictions.
Post-Operative Day 1:
• Continue lower extremity isometrics and ankle
pumps.
• Initiate upper extremity and contralateral limb
strengthening exercises.
• Begin assisted ambulation on level surfaces using
an assistive device, weight
• bearing status dependent upon prosthesis used.
• Begin discharge planning and home needs
assessment.
• Review dislocation precautions/restrictions.
Post Operative Day 2:
• Review lower extremity isometric and ankle
pumping exercises.
• Begin supine lower extremity active assisted
range of motion exercises to the operative
extremity.
• Motions are to the patient’s tolerance and in
cardinal planes.
• Continue assisted ambulation on level surfaces.
• Reinforce hip dislocation precautions/restrictions.
Post Operative Day 3:
• Continue comprehensive exercise program with
emphasis on increasing hip ROM and general
muscle strength in the operative extremity.
• Begin sitting exercises.
• Refine gait pattern and instruct in stair climbing.
• Review home instructions/exercise program with
emphasis on hipdislocation/precautions.
• Finalize discharge plans. All patients require an
assistive device for ambulation, an elevated toilet
seat, and follow-up physical therapy.
Hip Surgery: Phase II: Days 3-10
Goals:
• Achieve functional hip range of motion, within cardinal
planes of movement.
• Muscle strengthening of the entire hip girdle of the
operative extremity with emphasis on hip abductor
and extensor muscle groups.
• Attention should also be directed toward any
weakness present in the operative extremity as well as
any generalized weakness in the upper extremities,
trunk or contralateral lower extremity.
• Proprioceptive training to improve body/spatial
awareness of the operative extremity in functional
activities.
• Functional training to promote independence in
activities of daily living and mobility.
Hip Surgery: Phase II: Days 3-10
Modalities for Pain Control and Edema Reduction:
• Moist Heat, Ice
Therapeutic Exercise:
• Gentle Passive, Active-Assisted, and active lower
extremity range of motion
• Stationary Biking - No resistance to motion
Balance/Proprioception Training:
• Tandem Walking (line walking)
Gait Training:
• Level Surface
• Forward Walking
Functional Training:
• Standing Activities
• Transfer Activities
Hip Surgery: Phase III 10 days to 6 weeks:
Goals:
• Muscle strengthening of the entire hip girdle of the operative
extremity with emphasis on hip abductor and extensor muscle
groups.
• Attention should also be directed toward any weakness present
in the operative extremity as well as any generalized weakness
in the upper extremities, trunk or contralateral lower
extremity.
• Proprioceptive training to improve body/spatial awareness of
the operative extremity in functional activities.
• Endurance training to increase cardiovascular fitness.
• Functional training to promote independence in activities of
daily living and mobility.
• Gait training: Assistive devices are discontinued when the
patient is able to ambulate without a positive Trendelendberg
test based upon the ambulation
• guidelines (usually 4-6 weeks).
Hip: Phase III 10 days to 6 weeks:
Modalities for Pain Control and Edema Reduction:
• Moist Heat, Ice
Exercises
• Continue previous exercises
• Lower Extremity Strengthening Exercises using
Theraband
• Aquatic Therapy/Activities
• Iliotibial Band Stretches-Supine
Scar Massage/Mobility-May be instituted after suture
removal when the incision is clean and dry.
• Advance Passive, Active-Assisted, and active lower
extremity range of motion
• Closed Kinetic Chain Activities
• Continue stationary bike, progress resistance
Hip: Phase III 10 days to 6 weeks:
Balance/Proprioception Training:
• Weight-Shifting Activities
• Closed Kinetic Chain Activities
• Lateral Stepping over/around objects
Gait Training:
• Level Surface
• Forward Walking
• Sidestepping
• Retro Walking
• Uneven Surfaces
Functional Training
• Lifting, Carrying
• Pushing or Pulling, Squatting or Crouching
• Return-To-Work Tasks
Phase IV 6-12 weeks:
Exercises:
• Continue previous exercises
• Advance Passive, Active-Assisted, and active lower
extremity range of motion
• Nordic Track
• Stair-Step Machine
Iliotibial Band Stretches- standing at twelve (12) weeks
post-operatively
• Develop walking program
• Continue pool and bike work
Endurance Training:
• UBE
• Ambulation Activities
Phase IV 6-12 weeks:
Balance/Proprioception Training:
• Obstacle Course
• Functional Training
• Lifting
• Carrying
• Pushing or Pulling
• Squatting or Crouching
• Return to sport tasks
Total Knee Arthroplasty
Brief description of procedure
• The normal knee joint functions as a complex hinge
allowing primarily flexion and extension, but also
rotation and gliding.
• The knee joint is made up of three compartments,
the lateral, medial and patellofemoral.
• Damage to the cartilage of one or more
compartments may be the result of osteoarthritis
(idiopathic or post-traumatic), inflammatory arthritis
(rheumatoid, psoriatic, etc.), avascular necrosis,
tumors, or congenital deformities.
• Osteoarthritis and rheumatoid arthritis are the
causes of the overwhelming majority of total joint
arthroplasties
Total Knee Arthroplasty
Brief description of procedure
• Modern total knee arthroplasty consists of resection
of the diseased articular surfaces of the knee,
followed by resurfacing with metal and polyethylene
prosthetic components.
• For the properly selected patient, the procedure
results in significant pain relief, improved function
and quality of life
Variations: Partial Knee Arthroplasty, Fixed Bearing
device or Rotating Platform Device. Cemented or
Compressed Fit; ACL/PCL sparing, Patella
preserving
When does Rehab start? For most elective
orthopedic procedures, the patient can start
strengthening prior to the surgery, as allowed by
their pain and functional level. Unfortunately, this
is typically not reimbursed by insurance
companies, or it may take away from their post-op
rehab visits.
Precautions and time frames
• Follow WB directions
• Kneeling onto knee is typically not allowed/not
recommended.
• Screen for blood clots
• Screen for infection
Acute Care Phase: Knee
Phase I
Immediate Postoperative Phase (Day 0 – 10)
Goals:
• Active quad contraction
• Safe independent ambulation with walker or crutches as needed
• Passive knee extension to 0 degrees
• Knee flexion to 90 degrees or greater
• Control of swelling, inflammation, bleeding
Total Knee Surgery Protocol
Day 0-2:
• Weight bearing as tolerated with walker/2 crutches as
needed starting on Day 0-1
• Cryotherapy immediately and continuously unless
ambulating
• ROM of knee to begin immediately post op
• Exercises, Ankle pumps, PROM/extension to 0 degrees
• SLR
• Quad sets
• Knee flexion to at least 90 degrees
• Knee extension to 0 degrees
• Instruct in gait training - safe transfers
Total Knee Surgery Protocol
Day 3-10:
• Weight bearing as tolerated with walker/2 crutches
as needed
• Cryotherapy
• Exercises: Ankle pumps, PROM knee extension to 0
degrees, SLR, Quad sets
• AAROM - Knee flexion to at least 90 degrees
• Hip adduction/abduction
• Instruct in gait training – safe transfers
• Start stationary bike, low resistance
Total Knee Surgery Protocol
Phase II: Motion Phase (Week 2-6)
Goals: Improve ROM
• Enhance muscular strength, endurance
• Dynamic joint stability
• Diminish swelling/inflammation
• Establish return to functional activities
Criteria to enter Phase II:
• Leg control, able to perform SLR
• AROM 0-90 degrees
• Minimal pain/swelling
• Independent ambulation/transfers
Total Knee Surgery Protocol
Weeks 2 -4:
• WBAT with assistive device as needed. Wean from
walker to cane or from 2 crutches to 1 by 2 weeks.
• Wean off all assistive devices by no later than 4
weeks.
Exercises:
• Quad sets, SLR, VMO recruitment during quad sets
and SLR
• Knee extension 90-0 degrees
• Terminal knee extension 45-0 degrees
• Hip abduction/adduction
• Hamstring curls
• Knee flexion to at least 115 degrees
Total Knee Surgery Protocol
Stretching:
• Hamstrings
• Gastroc/soleus
• Quads
• Passive knee extension stretch
Continue stationary bike and advance resistance as
tolerated
• Continue cryotherapy
• Patellofemoral mobilization
• Incision mobilization
• Patients may begin to drive if they are no longer
using assistive devices
• for ambulation (about 2 weeks post op)
Total Knee Surgery Protocol
Weeks 4-6:
Exercises:
• Continue previous exercises
• Initiate front and lateral step ups
• Advance resistance on stationary bike
• Initiate progressive walking program
• Initiate endurance pool program, swimming with
flutter kick
Return to functional activities
• Continue compression, ice, elevation as needed for
swelling
• Patients should be walking and driving
independently at this point
Total Knee Surgery Protocol
Phase III: Intermediate Phase (Weeks 7-12)
Goals: Progression of ROM to greater than 115 degrees
• Enhancement of strength and endurance
• Eccentric/concentric control of limb
• Cardiovascular fitness
• Functional activity performance
• Criteria to enter Phase III:
• ROM 0-115 degrees
• Voluntary quad control
• Independent ambulation
• Minimal pain
Total Knee Surgery Protocol
Weeks 7-12:
• Exercises: Continue previous exercises
• Continue pool activities
• Continue walking
• Continue stationary bike
• Aggressive AROM 0-115 degrees
• Strengthen quad/hamstrings
Total Knee Surgery Protocol
Phase IV: Advanced Activity Phase (Weeks 12 and
beyond)
Goals: Allow patients to return to advanced level of
function such as recreational sports
• Maintain/improve strength and endurance of lower
extremity
• Return to normal life and routine
• Criteria to enter Phase IV:
• Full non painful ROM 0-115
• Strength 90% of contralateral limb (if contralateral
limb is normal)
• Minimal pain and swelling
• Satisfactory clinical examination
Total Knee Surgery Protocol
Exercises:
• Quad sets, SLR, Hip abduction/adduction, Step ups,
Knee extension
• Stationary bike
• Swimming
• Walking
Stretching 0-115 degrees
• Return to pre op activities and develop HEP to
maintain function of leg.
NO SQUATS OR LUNGES AT ANY TIME!
Partial Knee Surgery: Brief Description of the procedure.
• Unicompartmental knee replacement is an option for a
small percentage of patients with osteoarthritis of the
knee
• In a unicompartmental knee replacement, only the
damaged compartment is replaced with metal and
plastic
• Partial Knee Replacement can only be revised with a
Total Knee Replacement
Partial Knee Surgery Protocol
General Considerations:
• All times are to be considered approximate, with actual
progression based upon clinical presentation.
• Patients are full weight bearing with the use of crutches, a walker,
or a cane to assist walking until they are able to demonstrate good
walking mechanics.
• Early emphasis is on achieving full extension equal to the opposite
leg as soon as able.
• No passive or active flexion range of motion greater than 90° for
the first two weeks.
• No two-legged biking or flexion exercises for at least two weeks.
Well-leg biking is fine.
• Regular manual treatment should be conducted to the patella and
all incisions so they remain mobile.
• Early exercises should focus on recruitment of the vastus medialis
obliquus (VMO).
• No resisted leg extension machines (isotonic or isokinetic) at any
Partial Knee Surgery Protocol
• Hospital Stay is typically 24 hours and as soon as
the sensation and motor control is back in the
surgical leg and as soon as the patient is able to
void, the patient will go home and start OP PT.
• Initial focus is on transfers, ambulation and
AROM.
• 90 % are done on the medial aspect of the knee
• May become OP procedure surgery soon
Partial Knee Surgery Protocol
Week 1:
• Goal is to allow the medial arthrotomy to heal and decrease
swelling.
• MD visit on post-op Day 1 to change dressing and review home
exercise program.
• Icing, elevation, and aggressive edema control (i.e. circumferential
massage, compression wraps).
• Straight leg raise exercises (standing and seated), and passive and
active ROM exercises.
• OK to gently bend knee < 90° 1 - 2x per day.
• Initiate quadricep/adduction/gluteal sets, gait training,
balance/proprioception exercises.
• Well-leg cycling and upper body conditioning.
• Soft tissue treatments and gentle mobilization to the posterior
musculature, patella, and incisions to avoid flexion or patella
contracture.
Partial Knee Surgery Protocol
Weeks 2 - 4:
• Clinic visit at 14 days for suture removal and check-up.
• Continue with home program, progress flexion range
of motion, gait training, soft tissue treatments, and
balance/proprioception exercises.
• Incorporate functional exercises as able (i.e.
seated/standing marching, hamstring carpet drags,
hip/gluteal exercises, and core stabilization exercises).
• Aerobic exercise as tolerated (i.e. bilateral stationary
cycling as able, UBE, pool workouts once incisions are
healed.)
Partial Knee Surgery Protocol
Weeks 4 - 6:
• MD visit at 4 weeks post-op.
• Increase the intensity of functional exercises (i.e.
progress to walking outside, introducing weight
machines as able).
• Continue balance/proprioception exercises (i.e. heelto-toe walking, assisted single leg balance). Slow-tonormal walking without a limp.
Partial Knee Surgery Protocol
Weeks 6 - 8:
• Add lateral training exercises (i.e. lateral steps,
lateral step-ups, step overs) as able.
• Incorporate single leg exercises as able (eccentric
focus early on).
• Patients should be walking without a limp and range
of motion should be <10° extension and >110° flexion.
Partial Knee Surgery Protocol
Weeks 8 - 12:
• Begin to incorporate activity-specific training (i.e.
household chores, gardening, sporting activities).
• Low-impact activities until after Week 12.
• Patients should be weaned into a home/gym
program with emphasis on their particular
activity/sport.
NOTE: All progressions are approximations and should be used
as a guideline only. Progression will be based on individual
patient presentation, which is assessed throughout the
treatment process.
• Plyometrics (also known as "plyos" and "jumping")
is a type of exercise training designed to produce
fast, powerful movements, and improve the
functions of the nervous system, generally for the
purpose of improving performance in sports.
• Plyometric exercises may also be referred to as
explosive exercises.
• Plyometric movements, in which a muscle is
loaded and then contracted in rapid sequence, use
the strength, elasticity and innervation of muscle
and surrounding tissues to jump higher, run faster,
throw farther, or hit harder, depending on the
desired training goal.
• Plyometrics is used to increase the speed or
force of muscular contractions, providing
explosiveness for a variety of sport-specific
activities. Plyometrics has been shown across
the literature to be beneficial to a variety of
athletes. Benefits range from injury prevention,
power development and sprint performance
amongst others
• Plyometric training involves and uses practicing
plyometric movements to enhance tissues abilities
and train nerve cells to stimulate a specific pattern of
[muscle contraction] so the muscle generates as
strong a contraction as possible in the shortest
amount of time.
• A plyometric contraction involves first a rapid muscle
lengthening movement (eccentric phase), followed
by a short resting phase (amortization phase), then
an explosive muscle shortening movement
(concentric phase), which enables muscles to work
together in doing the particular motion.
• Plyometric training engages the myotatic reflex,
which is the automatic contraction of muscles when
their stretch sensory receptors are stimulated (PNF).
Knee Surgery Protocol : Meniscopy
• The intent of this protocol is to provide the clinician
with a guideline of the post-operative rehabilitation
course of a patient that has undergone a meniscal
repair.
• It is no means intended to be a substitute for one’s
clinical decision making regarding the progression of
a patient’s post-operative course based on their
physical exam/findings, individual progress, and/or
the presence of post-operative complications.
• If you require assistance in the progression of a postoperative patient you should consult with the
referring Surgeon.
Knee Surgery Protocol : Meniscectomy
Description of procedure:
• Removal of a part of one of the menisci of the knee or
part thereof through an arthroscopic procedure,
typically done at an ASC.
• General Considerations:
• Weight-bearing as tolerated. Walk with crutches.
• Surgical knee will be in a hinged rehab brace locked
in FULL EXTENSION for 4 weeks post-op.
• Regular assessment of gait to avoid compensatory
patterns.
• Regular manual mobilizations to surgical wounds
and associated soft tissue to decrease the incidence
Knee Surgery Protocol : Meniscectomy
General Considerations:
• Weight-bearing as tolerated. Walk with crutches.
• Surgical knee will be in a hinged rehab brace locked in
FULL EXTENSION for 4 weeks post-op.
• Regular assessment of gait to avoid compensatory
patterns.
• Regular manual mobilizations to surgical wounds and
associated soft tissue to decrease the incidence of
fibrosis.
• No resisted leg extension machines (isotonic or
isokinetic).
• No high impact or cutting/twisting activities for at
least 4 months post-op
Knee Surgery Protocol : Meniscectomy
Progression to the next phase based on Clinical
Criteria and/or Time Frames as Appropriate.
Key Factors in determining progression of rehabilitation
after Meniscal repair include:
• Anatomic site of tear
• Suture fixation (failure can be caused by too vigorous
rehabilitation)
• Location of tear (anterior or posterior)
• Other pathology (ligamentous injury)
Knee Surgery Protocol : Meniscectomy
Phase I –Maximum Protection- Weeks 1-6:
Goals:
• Diminish inflammation and swelling
• Restore ROM
• Reestablish quadriceps muscle activity
Stage 1: Immediate Postoperative Day 1- Week 3
• Ice, compression, elevation
• Electrical muscle stimulation
• Brace locked at 0 degrees
• ROM 0-90
Knee Surgery Protocol : Meniscectomy
Meniscal Repair Protocol
• Motion is limited for the first 7-21 days, depending
on the development of scar tissue around the repair
site.
• Gradual increase in flexion ROM is based on
assessment of pain and site of repair (0-90 degrees).
• Patellar mobilization
• Scar tissue mobilization
• Passive ROM
Knee Surgery Protocol : Meniscectomy
• Exercises
• Quadriceps isometrics
• Hamstring isometrics (if posterior horn repair, no
hamstring exercises for 6 weeks)
• Hip abduction and adduction
• Weight-bearing as tolerated with crutches and
brace locked at 0 degrees
• Proprioception training with brace locked at 0
degrees
Knee Surgery Protocol : Meniscectomy
Stage 2: Weeks 4-6
• Progressive resistance exercises (PREs) 1-5 pounds.
• Limited range knee extension (in range less likely
to impinge or pull on repair)
• Toe raises
• Mini-squats (less than 90 degrees flexion)
• Cycling (no resistance)
• PNF with resistance
• Unloaded flexibility exercises
Knee Surgery Protocol : Meniscectomy
Phase II: Moderate Protection- Weeks 6-10
Criteria for progression to phase II:
• ROM 0-90 degrees
• No change in pain or effusion
• Quadriceps control (MMT 4/5)
Goals:
• Increased strength, power, endurance
• Normalize ROM of knee
• Prepare patients for advanced exercises
Knee Surgery Protocol : Meniscectomy
Exercises:
• Strength- progression
• Flexibility exercises
• Lateral step-ups
• Mini-squats
Endurance Program:
• Swimming (no frog kick), pool running- if available
• Cycling
• Stair machine
Coordination Program:
• Balance board
• Pool sprinting- if pool available
• Backward walking
Knee Surgery Protocol : Meniscectomy
Phase III: Advanced Phase- Weeks 11-15
Criteria for progression to phase III:
• Full, pain free ROM
• No pain or tenderness
• Satisfactory clinical examination
• SLR without lag
• Gait without device, brace unlocked
Goals:
• Increase power and endurance
• Emphasize return to skill activities
• Prepare for return to full unrestricted activities
Knee Surgery Protocol : Meniscectomy
Exercises:
• Continue all exercises
• Increase plyometrics, pool program
• Initiate running program
Return to Activity: Criteria
• Full, pain free ROM
• Satisfactory clinical examination
Criteria for discharge from skilled therapy:
1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4/5
4) Independent with home program
5) Normal age appropriate balance and proprioception
6) Resolved palpable edema
Knee Surgery Protocol : Partial Meniscectomy
Rehabilitation after a partial meniscectomy may
progress aggressively because there is no
anatomic structure that requires protection.
Knee Surgery Protocol : Partial Meniscectomy
Phase I – Acute Phase:
Goals:
• Diminish pain, edema
• Restore knee range of motion (goal 0-115, minimum of 0 degrees
extension to 90
degrees of flexion to progress to phase II)2
• Reestablish quadriceps muscle activity/re-education (goal of no
quad lag during SLR
• Educate the patient regarding Weight bearing as tolerated, use of
crutches, icing, elevation and the rehabilitation process
Weight bearing:
• Weight bearing as tolerated. Use two crutches initially progressing
to weaning crutches as swelling and quadriceps status dictates.
Knee Surgery Protocol : Partial Meniscectomy
Modalities:
• Cryotherapy for 15 min 4 times a day 1
• Electrical stimulation to quadriceps for functional
retraining as appropriate
• Electrical stimulation for edema control- high volt
galvanic or interferential
stimulation as needed
Knee Surgery Protocol : Partial Meniscectomy
Therapeutic Exercise:
• Quadriceps sets
• SLR
• Hip adduction, abduction and extension
• Ankle pumps
• Gluteal sets
• Heel slides
• ½ squats
• Active-assisted ROM stretching, emphasizing full knee
extension (flexion to tolerance)
• Hamstring and gastroc/ soleus and quadriceps stretches
• Use of compression wrap or brace
• Bicycle for ROM when patient has sufficient knee ROM. May
begin partial revolutions to recover motion if the patient does
not have sufficient knee flexion
Knee Surgery Protocol : Partial Meniscectomy
Phase II: Internal Phase :
Goals:
• Restore and improve muscular strength and endurance
• Reestablish full pain free ROM
• Gradual return to functional activities
• Restore normal gait without an assistive device
• Improve balance and proprioception
Weight bearing status:
• Patients may progress to full weight bearing as
tolerated without antalgia.
• Patients may require one crutch or cane to normalize
gait before ambulating without assistive device.
Knee Surgery Protocol : Partial Meniscectomy
Therapeutic exercise:
• Continue all exercises as needed from phase one
• Toe raises- calf raises
• Hamstring curls
• Continue bike for motion and endurance
• Cardio equipment- stairmaster, elliptical trainer, treadmill and
bike as above.
• Lunges- lateral and front
• Leg press
• Lateral step ups, step downs, and front step ups
• Knee extension 90-40 degrees
• Closed kinetic chain exercise terminal knee extension
• Four way hip exercise in standing
• Proprioceptive and balance training
• Stretching exercises- as above, may need to add ITB and/or hip
flexor stretches
Knee Surgery Protocol : Partial Meniscectomy
Phase III – Advanced activity phase:
Goals:
• Enhance muscular strength and endurance
• Maintain full ROM
• Return to sport/functional activities/work tasks
Therapeutic Exercise:
• Continue to emphasize closed-kinetic chain exercises
• May begin plyometrics/ vertical jumping
• Begin running program and agility drills (walk-jog)
progression, forward and
backward running, cutting, figure of eight and carioca
program
• Sport specific drills
Knee Surgery Protocol : Partial Meniscectomy
Criteria for discharge from skilled therapy:
1) Non-antalgic gait
2) Pain free /full ROM
3) LE strength at least 4+/5
4) Independent with home program
5) Normal age appropriate balance and
proprioception
6) Resolved palpable edema
Knee Surgery Protocol : ACL Reconstruction, Allograft
(donor tissue)
Brief description:
• Allograft is most commonly used in lower demand patients,
or patients who are undergoing revision ACL surgery (when
an ACL reconstruction fails).
• Biomechanical studies show that allograft (donor tissue
from a cadaver) is not as strong as a patient's own tissue
(autograft).
• For many patients, however, the strength of the
reconstructed ACL using an allograft is sufficient for their
demands.
• Therefore this may be an excellent option for patients not
planning to participate in high-demand sports (e.g. soccer,
basketball, etc.).
Knee Surgery Protocol : AUTOGRAFT BONE-PATELLA
TENDON-BONE and ALLOGRAFT PROTOCOL
Variation: Autograft, ACL repair, Patello Tendon Autograft, Hamstring
tendon Autograft.
Phase I-Early Functional (Weeks 1-2)
Goals:
1. Educate re: the proper use of continuous passive motion (CPM)
machine a
Home exercise program (HEP).
2. Decrease pain and effusion.
3. Educate re: the importance of icing.
4. Independent donning,doffing, adjusting hinges, and use of knee brace.
5. Safe ambulation with assistant device and knee brace WEIGHT
BEARING AS TOLERATED (WBAT) on the involved leg.
6. Promote normal gait mechanics.
7. Early balance control.
8. Attain full extension and functional flexion of the involved knee.
9. Obtain baseline values for the uninvolved limb (isokinetic testing).
Knee Surgery Protocol : ACL Reconstruction, Allograft
Phase I-Early Functional (Weeks 1-2)
Goals:
1. Educate re: the proper use of continuous passive
motion (CPM) machine a
Home exercise program (HEP).
2. Decrease pain and effusion.
3. Educate re: the importance of icing.
4. Independent donning,doffing, adjusting hinges, and
use of knee brace.
5. Safe ambulation with assistant device and knee brace
WEIGHT
BEARING AS TOLERATED (WBAT) on the involved leg.
Knee Surgery Protocol : ACL Reconstruction, Allograft
6. Promote normal gait mechanics.
7. Early balance control.
8. Attain full extension and functional flexion of the
involved knee.
9. Obtain baseline values for the uninvolved limb
(isokinetic testing).
10. Initiate early neuromotor control of all muscle
groups.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Day of Surgery:
•Ambulate WBAT with knee brace range from 0º to
tolerated active flexion (maximum 60º) on level
surfaces with axillary crutches. The brace will initially
be set by the physical therapist.
•CPM will be set at 0º to 60º unless otherwise
documented.
- Brace SHOULD NOT be worn while the operated
limb is in the CPM.
- Brace is required only when ambulating and while
performing straight leg raise (SLR) exercises outlined
below.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-Operative Day #1:
- Ambulate as above on level surfaces and stairs.
- CPM progression can be 10º – 20º daily but should not exceed 5 º
every 3 hours.
- Review of patient ACL ( PATELLA TENDON-BONE GRAFT) Home
instructions.
- KNEE BRACE MUST BE WORN WITH THE STRAIGHT LEGRAISE (SLR)
EXERCISES LOCKED AT 0º.
- ankle strengthening for all planes with theraband.
- quad set with towel roll under the ankle to promote full extension.
- heel slides.
- hamstring sets.
- seated hip flexion.
- seated active assisted knee extension.
- straight leg raises (SLR) in all 4 planes with BRACE LOCKED AT 0º.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-operative Day #2-7:
- Continue with above ambulation and exercise guidelines.
- Increase knee brace setting with active knee motion.
- Continue CPM until 90º active knee flexion is achieved. CPM
progression can be 10º – 20º daily but should not exceed 5º every 3
hours.
- BAPS- in sitting.
- Stationary bicycle- start with a low, comfortable seat height to
promote flexion, most force through non-operated limb-increase
seatheight in subsequent sessions.
- Supine wall slides- allow gravity to assist with knee flexion. DO
NOT perform wall slides in the upright or stance position.
- Home stretching – for quadriceps, hamstrings, and gastrocnemius.
- Balance activities – begin with bilateral stance activities and
progress to unilateral on the ground.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Bilateral standing modified knee bends (0-30º)-begin with body
weight and then add light extrinsic weight accordingly.
- Marching in place- begin in sitting and progress to standing.
- Sidestepping
- Multi hip – to involved lower limb. Be sure weight is applied
proximal to the knee. (flexion, extension, abduction, adduction,
terminal knee extension)
- Retro walking – Begin with body weight then progress to pulling a
weighted sled. Increase the load as tolerated.
- Quadriceps isometrics – at varied degrees of knee flexion.
- Active knee extension – of the involved knee (full) as tolerated.
- Active knee flexion – full.
- Rolling chair activity – active hamstring/quad activity by
performing forward propulsion/retropulsion of rolling chair using
alternating lower extremities (90º-0º).
Knee Surgery Protocol : ACL Reconstruction, Allograft
• Proprioceptive training: static stabilizing technique – at various
degrees of knee flexion using therapeutic ball.
• Begin in supine with legs on the ball then progress to sitting on
the ball (90º-0º).
• Heel raises – begin with bilateral lower limbs then progress to
unilateral.
Knee Surgery Protocol : ACL Reconstruction, Allograft
** IN ALL CLOSED CHAIN KNEE EXERCISES, DO NOT ALLOW THE
ANTERIOR ASPECT OF THE KNEE TO PASS THE TOES.**
BY THE END OF WEEK 1:
AROM: PROM:
0-80º 0-90º
0-105º 0-120º
0-120º 0-125º
**DO NOT PUSH >125º WITH PASSIVE RANGE OF MOTION.
CONTINUE TO CHECK RANGE OF MOTION PERIODICALLY TO MAKE
SURE RANGE IS MAINTAINED.**
Knee Surgery Protocol : ACL Reconstruction, Allograft
Post-operative Day #8-14:
- Continue as above.
- Straight leg raises- without the brace if the patient demonstrates good
quad control, with resistance applied proximal to the knee. Use the
brace locked at 0º if an extension lag still exists.
- Standing leg curl- begin in standing with no added weight. The patient
must demonstrate easy effort prior to adding weight.
- Multi hip- to bilateral lower limbs. (Flexion, extension, abduction,
adduction, terminal knee extension).
- Leg press- begin using bilateral lower limbs (30º - 0º). Begin with low
extrinsic weight (10-50% maximum of the patient’s body weight) and
progress weight if the patient demonstrates good quad control during
terminal knee extension. The patient at this time may begin unilateral
leg press (10-30% maximum of the patient’s body weight).
- Balance activities – progress to bilateral activities on the disc the
unilateral.
- Discontinue crutches at POD #14 if proper gait mechanics are obtained.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Phase II-Progressive Functional (Weeks 3-11)
Goals:
1. Decrease pain and effusion.
2. Discontinue the postoperative brace when the
patient demonstrates good
quad control.
3. Continue the development of neuromotor control of
all muscle groups.
4. Retrain for proprioception and normalize responses
to dynamic
challenges.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 3 through 4:
• Continue as above.
• Cable column- should be performed once the patient is able to straight
leg raise with resistance distal to the knee with good quad control.
• Begin with flexion and extension followed by abduction and adduction. Be
more cautious with those patients who have meniscal, medial or lateral
collateral involvement.
• Unilateral modified knee bends (0-30º)- Stand erect. Extend hip and flex
the knee and place the dorsum of the foot on a bench or box behind you.
With support to the upper limb, lower the torso, allowing your stance knee
to flex to 45º. **DO NOT ALLOW THE ANTERIOR ASPECT OF THE KNEES TO
PASS THE TOES.**
• Begin with body weight and progress with light extrinsic weight.
• Step ups- begin with body weight then add weights and step height
gradually. Discontinue if the patient has any complaints of pain.
• Balance activities- incorporate multi task activities, i.e. unilateral modified
knee bend while performing arm curls while balancing on a disc.
Knee Surgery Protocol : ACL Reconstruction, Allograft
• Closed chain step machine (0-30º)- begin with low
resistance and maintain short steps throughout.
• Swimming- the patient may perform side stroke or
flutter kick initiating motion from the hip. No
butterfly.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 5 through 6:
• Continue as above.
• Progressive resisted knee extension- perform activity with a
slow controlled motion.
• Begin with cuff weights for the involved leg and continue to
do so until the patient can comfortably lift 20 lbs. Do not
allow the activity to begin with >80º of knee flexion.
• Advanced hamstring activity – with the trunk flexed perform
hip extension with upper extremity support, with the hip
extended to midrange perform a hamstring curl, in the
supine position perform bridging on the theraball with hip
flexion, and relaxed knee dead lifts if there is no history of
low back problems.
• Cross friction massage to scar.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 7 through 8:
• Continue as above.
• Lateral activities – begin by increasing the speed with lateral
stepping progressing to lateral shuffles, ski simulator, modified
slide board activities (restricted distance slide board) to full range
slide board.
• **WITH ALL OF THESE EXERCISES BE AWARE OF VALGUS
STRESSES**
• Cable column simulated running – once the patient exhibits good
control with single plane motion progress to multi joint motion.
• Crossover stepping –progress to cariocas as tolerated.
• BAPS – in standing. Beware of rotation occurring at the knee and
valgus/varus stresses.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 8 through 11:
• Continue as above.
• Standing bicycle- with high resistance, may progress to a
bike
• spectrum.
• Plyometrics- begin with mini jumps on the leg press at
approximately
• 30% of body weight.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 8 through 11:
• Continue as above.
• Standing bicycle- with high resistance, may progress to a
bike spectrum.
• Plyometrics- begin with mini jumps on the leg press at
approximately 30% of body weight.
Phase III-Functional (Weeks 12-16)
Goals:
1. Master functional tasks of desired physical activity.
2. Optimize force production and absorption with various
activities.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 12-15:
• Continue as above.
• Lateral shuffles weighted, Stop and Go.
• Slide board with the patient wearing a weighted vest (or
holding a hand dumbbell) incorporating a ball toss.
• Begin Dynamic skills progression- (jumping, hopping, and
leaping).
• Agility drill
• May initiate light jogging program if the patient
demonstrates good force production (i.e. jumping) and
absorption (i.e. landing), especially when leaping from
uninvolved to the involved limb.
• 10RM testing as 12 weeks: begin heavy, moderate and light
workout days according to strength assessment guidelines.
Knee Surgery Protocol : ACL Reconstruction, Allograft
Weeks 16+:
• Continue as above.
• May initiate running of the patient demonstrates good force
production and absorption, especially when leaping from
uninvolved to involved.
The patient may return to activity without a derotation brace
if:
1. Pain free with ADL and rehab activities including agility and
sport specific drills.
2. No c/o stiffness during or after all above activities.
3. No c/o giving way during all above activities.
Objective:
1. Full AROM and PROM (0-135º).
Knee Surgery Protocol : PCL Reconstruction
ISOLATED AND COMBINED PCL RECONSTRUCTION POSTOP REHABILITATION PROTOCOL
GENERAL PRINCIPLES
• No open chain hamstring work
• Assume 8 weeks for graft to bone healing time
• Caution against posterior tibial translation (gravity,
muscle action)
• CPM 0°-60° to start
• PCL with posterolateral corner or LCL repair follows
different post-op care, i.e.,
• crutches x 3 months
• Supervised physical therapy takes place for
approximately 3-5 months post-op.
Knee Surgery Protocol : PCL Reconstruction
GENERAL PROGRSSION OF ACTIVITIES OF DAILY
LIVING (ADLs)
• Patients may begin the following activities at
the post-op dates listed (unless otherwise
specified by the physician):
• Bathing/Showering without brace (surgical
incisions should be healed before immersion
in water) – 1 week post-op
• Sleep without brace – 8 weeks post-op
• Driving – 6-8 weeks post-op
• Full weight bearing without assistive devices –
8 weeks post-op (with physician clearance)
Knee Surgery Protocol : PCL Reconstruction
PHYSICAL THERAPY ATTENDANCE
The following is an approximate schedule for
supervised physical therapy visits:
0 to 1 month: 1 x week
1 to 3 months: 2-3 x week
3 to 9 months: 2 x month
9 to 12 months: 1 x month
Knee Surgery Protocol : PCL Reconstruction
REHABILITATION PROGRESSION
0-1 WEEK POST-OP
• Brace: Locked at 0°-60° maximum
• Weight bearing Status: WBAT with crutches,
with brace locked
• Special Considerations: Pillow under proximal
posterior tibia at rest to prevent posterior sag
• Therapy: Quad Sets Ankle Pumps
• SLR Hip Alphabets
• Hip AB/AD
Knee Surgery Protocol : PCL Reconstruction
7-28 DAYS POST-OP
• Brace: Locked except for protected range of
motion performed by physical therapist.
• WB Status: WBAT with crutches, with brace
locked
• Special Considerations: Continue use of pillow
under tibia at rest.
Knee Surgery Protocol : PCL Reconstruction
Therapy:
• PT Assisted knee flexion
• For PCL only patients: Maintain anterior
pressure on proximal tibia as knee is flexed.
• For combined PCL/ACL patients, maintain
neutral position of proximal tibia as knee is
flexed.
• It is important to prevent posterior tibial
sagging at all times.
• Hamstring and Calf stretching
• Calf press with Theraband
• Standing calf raises with full knee extension
• Standing hip extension from neutral
Knee Surgery Protocol : PCL Reconstruction
4-8 WEEKS
• Brace: 4-8 weeks: Brace is unlocked for supervised
gait training only (patients must be under the direct
supervision of a PT)
• WB status: WBAT with crutches
• Ther. Ex: - When patient exhibits independent quad
control, may begin open chain extension, if no
flexion contracture exists.
• Wall slides (0° to 45°)
• Begin isometric, progress to active against body
weight.
• Ambulation in pool (only while in physical therapy)
• Continue to maintain hamstring flexibility
Knee Surgery Protocol : PCL Reconstruction
8-12 WEEKS
• D/C Brace 8 weeks
• WB status: Wean off crutches at 8 weeks postop
• May D/C crutches if patient exhibits:
• No quad lag with SLR
• Full knee extension
• Knee flexion 90°-100°
• Normal gait pattern
• Therapy: Stationary bike: Foot forward on
pedal (no toe clips), seat high
• Balance and proprioception, Seated calf raises
• Leg press (within available range of motion)
Knee Surgery Protocol : PCL Reconstruction
12 WEEKS (3 MONTHS)
• Progress functional and symptomatically Therapy:
• Treadmill walking
• Jogging in pool with
• Swimming – no breaststroke emphasize flutter kick
from hip (minimize active knee flexion)
3-6 MONTHS
• Reduce frequency of physical therapy sessions.
• Pt may continue therapy at gym club if released by
physician.
• During this phase the patient should check in with
the supervising physical therapist once every 2
weeks.
Knee Surgery Protocol : PCL Reconstruction
6-12 MONTHS
• Return to full activity per MD release and
testing shows surgical side quad strength at
least 90% of unoperated side. (e.g. Return to
work based on function capabilities)
• Sports specific functional progression
• Nordic Track
• Jog/Run progression
• Backward running, Cutting
• Jumping (Plyometrics)
• NO SQUATS OR LUNGES AT ANY TIME!
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Brief description procedure:
• A SLAP repair is a procedure performed for treatment of a
SLAP tear.
• Surgical treatment of a SLAP tear is considered for patients
who do not respond to more conservative treatments
• A SLAP repair is performed arthroscopically using sutures to
reattach the torn labrum back to the bone
• A SLAP repair restores the normal anatomy of the shoulder b
reattaching the labrum in its normal position.
• Once healed, the SLAP repair allows normal function of the
previously damaged labrum and biceps attachment.
Rehab after a SLAP repair
• Rehabilitation varies depending on factors such as the strength of
the SLAP repair, and the preference of the surgeon.
• Most often, a period of time of restricted motion is maintained
for about six weeks following a SLAP repair.
• During this first phase of rehabilitation, some passive motion is
allowed to prevent shoulder stiffness.
• In the first phase, the torn labrum is healing into its proper
position.
• Once healed, patients enter the second phase of rehabilitation
and can begin more motion at about six weeks.
• Physical therapy continues to help maintain motion and regain
strength of the shoulder.
• The final phase of rehabilitation involves more active
strengthening of the muscles that surround the shoulder joint,
and full recovery is expected between 3 to 4 months.
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• For the first three weeks your sling must be worn in bed.
• Sleeping can be uncomfortable if you try and lie on the operated
arm.
• It’s recommended that you lie on your back or on the opposite
side.
• Pillows can be used to give you comfort and support.
• If you are lying on your side one pillow slightly folded under your
neck gives enough support for most people.
• A pillow folded in half supports the arm in front and a pillow
tucked along your back helps to prevent you rolling onto the
operated shoulder during the night.
• If you are lying on your back, tie a pillow tightly in the middle (a
"butterfly pillow") or use a folded pillow to support your neck.
Place a folded pillow under the elbow of the operated arm to
support that.
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• Superior Labral Tear Anterior to posterior (SLAP) are rare
injuries and studies have suggested that magnetic
resonance imaging (MRI) scans often produce false positives
and that SLAP lesions are difficult to diagnose clinically.
• Numerous studies suggest that even experts disagree on
how to define a type II SLAP tear and it was found that the
rate of repair increased over time to peak at 10.1 percent in
the final year of the study. Sports medicine specialists
performed SLAP repairs at the highest rate—12.4 percent—
compared to a rate of 9.2 percent among general
orthopaedists
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• This rehabilitation protocol has been developed for the patient
following a SLAP (Superior Labrum Anterior Posterior) repair.
• It is extremely important to protect the biceps/labral complex for
6 weeks post-operatively to allow appropriate healing.
• This protocol has been divided into phases. Each phase may vary
slightly based on the individual patient and special circumstances.
• The overall goals of the surgical procedure and rehabilitation are
to:
• Control pain and inflammation
• Regain normal upper extremity strength and endurance
• Regain normal shoulder range of motion
• Achieve the level of function based on the orthopedic and patient
goals
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• Early passive range of motion with noted limitations is highly
beneficial to enhance circulation within the joint to promote
healing.
• The physical therapy should be initiated within the first
week following surgery.
• The supervised rehabilitation program is to be
supplemented by a home fitness program where the patient
performs the given exercises at home or at a gym facility.
• Important post-operative signs to monitor include:
• Swelling of the shoulder and surrounding soft tissue
• Abnormal pain response, hypersensitive-an increase in night
pain
• Severe range of motion limitations
• Weakness in the upper extremity musculature
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• Return to activity requires both time and clinical evaluation.
• To safely and most efficiently return to normal or high level
functional activity, the patient requires adequate strength,
flexibility, and endurance.
• Functional evaluation including strength and range of
motion testing is one method of evaluating a patient’s
readiness to return to activity.
• Return to intense activities following a SLAP repair requires
both a strenuous strengthening and range of motion
program along with a period of time to allow for tissue
healing.
• Symptoms such as pain, swelling, or
• instability should be closely monitored by the patient.
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Phase 1: Week 1-3
ROM :Gentle pendulum exercise only
STRENGTH :No strengthening
BRACE Brace for 6 weeks
Brace removed for exercises above
MODALITIES
E-stim as needed
Ice 15-20 minutes
GOALS OF PHASE:
• Promote healing of tissue
• Control pain and inflammation
• Independent in HEP
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Phase 2: Week 3-6
• ROM
Gradual gentle passive range of motion
Flexion/Elevation 0-60°
Passive range of motion-scapular plane
External Rotation 0-15°
Internal Rotation as tolerated
Continue pendulum exercise
• STRENGTH
Submaximal isometric activities
Shoulder shrugs with resistance
• MODALITIES
Ice 15-20 minutes
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• GOALS OF PHASE:
Control pain and inflammation
Enhance upper extremity strength
Gradual increase in ROM.
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Phase 3: Week 6-12
• ROM
Gentle passive range of motion
Flexion/Elevation 0-145°
Passive range of motion-scapular plane
External Rotation 0-50°
Internal Rotation Full ROM
Posterior capsule stretching
Towel stretching
Rope/Pulley activities
Wand exercises
Manual stretching
Shoulder Surgery Protocol : SLAP Lesion repair protocol
• STRENGTH
Continue all strengthening from previous phases increasing resistance
and repetition
Initiate supine rhythmic stabilization at 90° flexion
Initiate IR/ER at neutral with tubing
Initiate forward flexion, scaption, empty can
Initiate sidelying ER and tricep strengthening
Prone abduction with external rotation
Shoulder shrugs with resistance
Supine punches with resistance
Shoulder retraction with resistance
Initiate UBE for endurance and Prone rows
Initiate light biceps curls at week 10
Initiate plyotoss (overhead toss) chest pass and initiate PNF patterns
with theraband
Initiate IR/ER exercises at 90 ° abduction
Initiate isokinetic IR/ER at neutral at wk 10-12
Shoulder Surgery Protocol : SLAP Lesion repair protocol
MODALITIES
Ice 15-20 minutes
GOALS OF PHASE:
• Minimize pain and swelling
• Reach full ROM
• Improve upper extremity strength and endurance
• Enhance neuromuscular control
• Normalize arthrokinematics.
Shoulder Surgery Protocol : SLAP Lesion repair protocol
Phase 4: Week 12-24
ROM
• Continue with all ROM activities from previous phases,
goal full ROM in all planes
• Posterior capsule stretching
• Towel stretching
• Joint mob. as needed for full ROM
Shoulder Surgery Protocol : SLAP Lesion repair protocol
STRENGTH
• Progress strengthening program with increase in resistance
and high speed repetition
• Progress with eccentric strengthening of posterior cuff and
scapular musculature
• Initiate single arm plyotoss
• Progress rhythmic stabilization activities to include standing
PNF patterns with tubing
• UBE for strength and endurance
• Initiate military press, bench press, lat pulldown
• Initiate sport specific drills and functional activities
• Initiate interval throwing program week 16
• Initiate light plyometric program week 12-16
• Progress isokinetics to 90 ° of abduction at high speeds
Shoulder Surgery Protocol : SLAP Lesion repair protocol
MODALITIES
Ice 15-20 minutes
GOALS OF PHASE:
• Full ROM
• Maximize upper extremity strength and endurance
• Maximize neuromuscular control
• Initiate sports specific training/functional training
Shoulder Surgery Protocol : RTC Lesion repair protocol
Brief Description of the procedure:
• There are a few options for repairing rotator cuff tears.
Advancements in surgical techniques for rotator cuff
repair include less invasive procedures.
• While each of the methods available has its own
advantages and disadvantages, all have the same goal:
getting the tendon to heal
• The type of repair performed depends on several
factors, including your surgeon's experience and
familiarity with a particular procedure, the size of your
tear, your anatomy, and the quality of the tendon
tissue and bone.
Shoulder Surgery Protocol : RTC Lesion repair protocol
• Many surgical repairs can be done on an outpatient
basis and do not require you to stay overnight in the
hospital.
• The orthopaedic surgeon will discuss the best
procedure to meet the patients individual health
needs.
• There may be other shoulder problems in addition to a
rotator cuff tear, such as osteoarthritis, bone spurs, or
other soft tissue tears which the surgeon may be able
to take care of as well during the surgery.
Shoulder Surgery Protocol : RTC Lesion repair protocol
• The three techniques most commonly used for rotator
cuff repair include traditional open repair,
arthroscopic repair, and mini-open repair.
• In the end, patients rate all three repair methods the
same for pain relief, strength improvement, and overall
satisfaction.
Shoulder Surgery Protocol : RTC Lesion repair protocol
Open Repair
• A traditional open surgical incision (several centimeters
long) is often required if the tear is large or complex.
• The surgeon makes the incision over the shoulder and
detaches the shoulder muscle (deltoid) to better see and
gain access to the torn tendon.
• During an open repair, the surgeon typically removes bone
spurs from the underside of the acromion (this procedure is
called an acromioplasty).
• An open repair may be a good option if the tear is large or
complex or if additional reconstruction, such as a tendon
transfer, is indicated.
• Open repair was the first technique used for torn rotator
cuffs. Over the years, new technology and improved
surgeon experience has led to less invasive procedures.
Shoulder Surgery Protocol : RTC Lesion repair protocol
All-Arthroscopic Repair
• During arthroscopy, your surgeon inserts a small
camera, called an arthroscope, into your shoulder joint.
The camera displays pictures on a television screen,
and your surgeon uses these images to guide miniature
surgical instruments.
• Because the arthroscope and surgical instruments are
thin, your surgeon can use very small incisions (cuts),
rather than the larger incision needed for standard,
open surgery.
• All-arthroscopic repair is usually an outpatient
procedure and is the least invasive method to repair a
torn rotator cuff.
Shoulder Surgery Protocol : RTC Lesion repair protocol
Mini-Open Repair
• The mini-open repair uses newer technology and
instruments to perform a repair through a small
incision. The incision is typically 3 to 5 cm long.
• This technique uses arthroscopy to assess and treat
damage to other structures within the joint. Bone
spurs, for example, are often removed arthroscopically.
This avoids the need to detach the deltoid muscle.
• Once the arthroscopic portion of the procedure is
completed, the surgeon repairs the rotator cuff
through the mini-open incision. During the tendon
repair, the surgeon views the shoulder structures
directly, rather than through the video monitor
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
This rehabilitation protocol has been developed for the
patient following a rotator cuff surgical procedure.
This protocol will vary in length and aggressiveness
depending on factors such as:
• Size and location of tear
• Degree of shoulder instability/laxity prior to surgery
• Acute versus chronic condition
• Length of time immobilized
• Strength/pain/swelling/range of motion status
• Rehabilitation goals and expectations
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
Early passive range of motion is highly beneficial to enhance
circulation within the joint to promote healing. The protocol is
divided into phases. Each phase is
adaptable based on the individual and special circumstances.
The overall goals of the surgical procedure and rehabilitation
are to:
• Control pain, inflammation, and effusion
• Regain normal upper extremity strength and endurance
• Regain normal shoulder range of motion
• Achieve the level of function based on the orthopedic and
patient goals
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
Physical therapy should be initiated within the first week postop.
The supervised rehabilitation program is to be supplemented
by a home fitness program where the patient performs the
given exercises at home or at a gym facility.
Important post-op signs to monitor:
• Swelling of the shoulder and surrounding soft tissue
• Abnormal pain response, hypersensitive-an increase in night
pain
• Severe range of motion limitations
• Weakness in the upper extremity musculature
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
• Return to activity requires both time and clinical evaluation.
• To safely and most efficiently return to normal or high level
functional activity, the patient requires adequate strength,
flexibility, and endurance.
• Functional evaluation including strength and range of
motion testing is one method of evaluating a patient’s
readiness return to activity.
• Return to intense activities following a rotator cuff repair
require both a strenuous strengthening and range of motion
program along with a period of time to allow for tissue
healing.
• Symptoms such as pain, swelling, or instability should be
closely monitored by the patient.
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
Phase 1: Week 1-6
ROM
• Pendulum exercises
• Elbow (flex/ext) range of motion
STRENGTH
• NO Active Shoulder flexion or abduction
• allowed in the first 6 weeks
• Grip strengthening with putty or ball
BRACE
• Brace for 6 weeks
• Brace removed to perform exercises above
MODALITIES
• E-stim as needed
• Ice 15-20 minutes
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
GOALS OF PHASE:
• Promote healing of repaired rotator cuff
• Control pain and inflammation
• Gradual increase of ROM
• Independent in HEP
• Delay muscle atrophy
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
Phase 2: Week 6-12
ROM
• Continue all ROM from previous phases
• Initiate gentle posterior capsule stretching
• Initiate gentle IR stretching
• Initiate rope/pulley
• Initiate passive ER wand exercise
• Rope/Pulley (flex/abd/scaption)
• Wand activities in all planes
• Posterior capsule stretching
• Towel stretching
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
STRENGTH
• Continue with all strengthening from previous phases
increasing resistance and repetition
• Initiate supine AROM exercises without resistance
• Initiate UBE without resistance
• Initiate scapular stabilizer strengthening-active assisted
• Manual rhythmic stabilization exercises at 90 ° flex
• Shoulder shrugs with resistance
• Shoulder retraction with resistance
• Supine punches with resistance
• Prone shoulder extension
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
• Prone rowing
• Prone ER with abduction
• Initiate forward flexion, scaption, empty can
• Sidelying ER
• UBE for endurance training
• Initiate plyotoss at chest then progress to overhead
• Bicep/Tricep work
• Isokinetic ER/IR at neutral at week 10-12
MODALITIES
• Ice 15-20 minutes
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
GOALS OF PHASE:
Minimize pain and swelling
Reach full ROM
Improve upper extremity strength and endurance
Enhance neuromuscular control
Normalize arthrokinematics.
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
Phase 4: Week 12-24
ROM
• Continue with all ROM activities from previous phases
• Posterior capsule stretching
• Towel stretching
STRENGTH
• Progress strengthening program with increase in
resistance and high speed repetition
• Initiate IR/ER exercises at 90 ° abduction
• Progress rhythmic stabilization activities to include
standing PNF patterns with tubing
• Initiate single arm plyotoss
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
•
•
•
•
•
Initiate military press, bench press, flys, lat pulldowns
UBE for strength and endurance
Initiate sport specific drills and functional activities
Initiate interval throwing program week 16-20
Initiate light upper body plyometric program week 1620
• Progress isokinetics to 90 ° abduction at high speeds
Shoulder Surgery Protocol : RTC Lesion repair protocol
ROTATOR CUFF REPAIR PROTOCOL
MODALITIES
Ice 15-20 minutes
GOALS OF PHASE:
• Full painless ROM
• Maximize upper extremity strength and endurance
• Maximize neuromuscular control
• Initiate sports specific training/functional training
Shoulder Surgery Protocol : Total Shoulder Replacement
Brief description of the procedure:
• Total shoulder joint replacement is an option given to
patients who suffer from joint dysfunction.
• This is usually the result of osteoarthritis or rheumatoid
arthritis, but more rarely for those who have sustained
severe trauma from a shoulder fracture.
• Generally, all other modes of treatment are considered
first, such as physical therapy and medication, but total
shoulder replacement can provide pain relief and
increased mobility for those who have not experienced
relief.
Shoulder Surgery Protocol : Total Shoulder Replacement
Shoulder Surgery Protocol : Total Shoulder Replacement
• When shoulder replacement surgery is performed, the ball
is removed from the top of the humerus and replaced with a
metal implant.
• This is shaped like a half-moon and attached to a stem
inserted down the center of the arm bone.
• The socket portion of the joint is shaved clean and replaced
with a plastic socket that is cemented into the scapula.
• Just like any joint replacement the success of the surgery
depends on many factors including the advanced state of
the arthritic joint at the time of surgery, the overall health of
the patient and most importantly the dedication to the
physical therapy required after the surgery.
Shoulder Surgery Protocol : Total Shoulder Replacement
Shoulder Surgery Protocol : Total Shoulder Replacement
Variations: Hemi Arthroplasty, Reverse Shoulder Replacement
• The intent of this protocol is to provide the clinician with a
guideline of the postoperative rehabilitation course of a
patient that has undergone a total shoulder arthroplasty
(TSA) or hemi-arthroplasty (humeral head replacement,
HHR).
• It is not intended to be a substitute for appropriate clinical
decision-making regarding the progression of a patient’s
postoperative course. The actual post surgical physical
therapy management must be based on the surgical
approach, physical exam/findings, individual progress,
and/or the presence of postoperative complications. If a
clinician requires assistance in the progression of a patient
post-surgery, consult with the referring surgeon.
Shoulder Surgery Protocol : Total Shoulder Replacement
Please Note:
Patients with a concomitant repair of a rotator cuff tear
and/or a TSA/HHR secondary to fracture or cuff
arthropathy should be progressed to the next phase
based on meeting the clinical criteria (not based on the
postoperative time frames) as appropriate in
collaboration with the referring surgeon. The given time
frames are an approximate guide for progression,
achieving
Shoulder Surgery Protocol : Total Shoulder Replacement
Passive Range of Motion (PROM): PROM for all patients
having undergone a TSA should be defined as ROM that is
provided by an external source (therapist, instructed
family member, or other qualified personnel) with the
intent to gain ROM without placing undue stress on either
soft tissue structures and/or the surgical repair.
PROM is not stretching!!!!!!!
Shoulder Surgery Protocol : Total Shoulder Replacement
Phase I – Immediate Post Surgical Phase:
Goals:
• Allow healing of soft tissue
• Maintain integrity of replaced joint
• Gradually increase passive range of motion (PROM) of
shoulder; restore active range of motion (AROM) of
elbow/wrist/hand
• Reduce pain and inflammation
• Reduce muscular inhibition
• Independent with activities of daily living (ADLs) with
• modifications while maintaining the integrity of the
replaced joint.
Shoulder Surgery Protocol : Total Shoulder Replacement
Precautions:
• Sling should be worn continuously for 3-4 weeks
• While lying supine, a small pillow or towel roll should
be placed behind the elbow to avoid shoulder
hyperextension / anterior capsule stretch /
subscapularis stretch. (When lying supine patient
should be instructed to always be able to visualize
their elbow. This ensures they are not extending their
shoulder past neutral.) – This should be maintained
for 6-8 weeks post-surgically.
• Avoid shoulder AROM.
Shoulder Surgery Protocol : Total Shoulder Replacement
• No lifting of objects
• No excessive shoulder motion behind back, especially
into internal rotation (IR)
• No excessive stretching or sudden movements
(particularly external rotation (ER))
• No supporting of body weight by hand on involved side
• Keep incision clean and dry (no soaking for 2 weeks)
• No driving for 3 weeks
Shoulder Surgery Protocol : Total Shoulder Replacement
Post-Operative Day (POD) #1 (in hospital):
• Passive forward flexion in supine to tolerance
• Gentle ER in scapular plane to available PROM (as
documented in operative note) – usually around 30°
(Attention: DO NOT produce undue stress on the
anterior joint capsule, particularly with shoulder in
extension)
• Passive IR to chest
• Active distal extremity exercise (elbow, wrist, hand)
• Pendulum exercises
Shoulder Surgery Protocol : Total Shoulder Replacement
• Frequent cryotherapy for pain, swelling, and
inflammation management
• Patient education regarding proper positioning and
joint protection techniques
Early Phase I: (out of hospital)
• Continue above exercises
• Begin scapula musculature isometrics / sets (primarily
retraction)
• Continue active elbow ROM
• Continue cryotherapy as much as able for pain and
inflammation management
Shoulder Surgery Protocol : RTC Lesion repair protocol
Late Phase I:
• Continue previous exercises
• Continue to progress PROM as motion allows
• Begin assisted flexion, elevation in the plane of the
scapula, ER, IR in the scapular plane
• Progress active distal extremity exercise to
strengthening as appropriate
Shoulder Surgery Protocol : Total Shoulder Replacement
Criteria for progression to the next phase (II):
If the patient has not reached the below ROM, forceful
stretching and mobilization/manipulation is not
indicated. Continue gradual ROM and gentle
mobilization (i.e. Grade I oscillations), while respecting
soft tissue constraints.
• Tolerates PROM program
• Has achieved at least 90° PROM forward flexion and
elevation in the scapular plane.
• Has achieved at least 45° PROM ER in plane of scapula
• Has achieved at least 70° PROM IR in plane of scapula
measured at 30° of abduction
Shoulder Surgery Protocol : Total Shoulder Replacement
Phase II – Early Strengthening Phase
(Not to begin before 4-6 Weeks post-surgery to allow for
appropriate soft tissue healing):
Goals:
• Restore full passive ROM
• Gradually restore active motion
• Control pain and inflammation
• Allow continue healing of soft tissue
• Do not overstress healing tissue
• Re-establish dynamic shoulder stability
Shoulder Surgery Protocol : Total Shoulder Replacement
Precautions:
• Sling should only be used for sleeping and removed
gradually over the course of the next 2 weeks, for
periods throughout the day.
• While lying supine a small pillow or towel should be
placed behind the elbow to avoid shoulder
hyperextension / anterior capsule stretch.
• In the presence of poor shoulder mechanics avoid
repetitive shoulder AROM exercises/activity against
gravity in standing.
• No heavy lifting of objects (no heavier than coffee cup)
• No supporting of body weight by hand on involved side
• No sudden jerking motions
Shoulder Surgery Protocol : Total Shoulder Replacement
Early Phase II:
• Continue with PROM, active assisted range of motion (AAROM)
• Begin active flexion, IR, ER, elevation in the plane of the scapula
pain free ROM
• AAROM pulleys (flexion and elevation in the plane of the scapula)
– as long as greater than 90° of PROM
• Begin shoulder sub-maximal pain-free shoulder isometrics in
neutral
• Scapular strengthening exercises as appropriate
• Begin assisted horizontal adduction
• Progress distal extremity exercises with light resistance as
appropriate
• Gentle glenohumeral and scapulothoracic joint mobilizations as
indicated
• Initiate glenohumeral and scapulothoracic rhythmic stabilization
• Continue use of cryotherapy for pain and inflammation.
Shoulder Surgery Protocol : Total Shoulder Replacement
Late Phase II:
Progress scapular strengthening exercises
Criteria for progression to the next phase (III):
If the patient has not reached the below ROM, forceful
stretching and mobilization/manipulation is not
indicated. Continue gradual ROM and gentle
mobilization (i.e. Grade I oscillations), while respecting
soft tissue constraints.
• Tolerates P/AAROM, isometric program
• Has achieved at least 140° PROM forward flexion and
elevation in the scapular plane.
• Has achieved at least 60+° PROM ER in plane of scapula
• Has achieved at least 70° PROM IR in plane of scapula
measured at 30° of abduction
Shoulder Surgery Protocol : Total Shoulder Replacement
Phase III – Moderate strengthening
(Not to begin before 6 Weeks post-surgery to allow for
appropriate soft tissue healing and to ensure adequate ROM):
Goals:
• Gradual restoration of shoulder strength, power, and
endurance
• Optimize neuromuscular control
• Gradual return to functional activities with involved upper
extremity
Precautions:
• No heavy lifting of objects (no heavier than 3 kg.)
• No sudden lifting or pushing activities
• No sudden jerking motions
Shoulder Surgery Protocol : Total Shoulder Replacement
Early Phase III:
• Progress AROM exercise / activity as appropriate
• Advance PROM to stretching as appropriate
• Continue PROM as needed to maintain ROM
• Initiate assisted shoulder IR behind back stretch
• Resisted shoulder IR, ER in scapular plane
• Begin light functional activities
• Wean from sling completely
• Begin progressive supine active elevation strengthening
(anterior deltoid) with light weights (0.5-1.5 kg.) at
variable degrees of elevation
Shoulder Surgery Protocol : Total Shoulder Replacement
Late Phase III:
• Resisted flexion, elevation in the plane of the scapula,
extension (therabands / sport cords)
• Continue progressing IR, ER strengthening
• Progress IR stretch behind back from AAROM to AROM
as ROM allows (Pay particular attention as to avoid
stress on the anterior capsule.)
Shoulder Surgery Protocol : Total Shoulder Replacement
Criteria for progression to the next phase (IV):
If the patient has not reached the below ROM, forceful stretching
and mobilization/manipulation is not indicated. Continue gradual
ROM and gentle mobilization (i.e. Grade I oscillations), while
respecting soft tissue constraints.
• Tolerates AA/AROM/strengthening
• Has achieved at least 140° AROM forward flexion and elevation in
the scapular plane supine.
• Has achieved at least 60+° AROM ER in plane of scapula supine
• Has achieved at least 70° AROM IR in plane of scapula supine in
30° of abduction
• Able to actively elevate shoulder against gravity with good
mechanics to at least 120°.
Shoulder Surgery Protocol : Total Shoulder Replacement
(Not to begin before 12 Weeks to allow for appropriate
soft tissue healing and to ensure adequate ROM, and
initial strength):
Goals:
• Maintain non-painful AROM
• Enhance functional use of upper extremity
• Improve muscular strength, power, and endurance
• Gradual return to more advanced functional activities
• Progress weight bearing exercises as appropriate
Precautions:
• Avoid exercise and functional activities that put stress on the
anterior capsule and surrounding structures. (Example: no
combined ER and abduction above 80° of abduction.)
• Ensure gradual progression of strengthening
Shoulder Surgery Protocol : Total Shoulder Replacement
Early Phase IV:
• Typically patient is on a home exercise program by this point
to be performed 3-4 times per week.
• Gradually progress strengthening program
• Gradual return to moderately challenging functional
activities.
Late Phase IV (Typically 4-6 months post-op):
􀂃 Return to recreational hobbies, gardening, sports, golf,
doubles tennis
Criteria for discharge from skilled therapy:
• Patient able to maintain non-painful AROM
• Maximized functional use of upper extremity
• Maximized muscular strength, power, and endurance
• Patient has returned to advanced functional activities
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Brief description of the procedure:
• The reverse total shoulder replacement arthroplasty
enables experienced shoulder surgeons to treat
patients with conditions that previously had no
solution.
• These conditions include rotator cuff tear arthroplasty,
instability with anterosuperior escape, pseudoparalysis,
and failures of surgery for arthritis and facture
management.
• In the normal shoulder, the rotator cuff muscles,
including the supraspinatus, help balance the ball of
the arm bone (humeral head) in the socket against the
upward pull of the deltoid muscle
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
• In the normal shoulder, the rotator cuff muscles,
including the supraspinatus, help balance the ball of
the arm bone (humeral head) in the socket against the
upward pull of the deltoid muscle.
• The goal of reverse total shoulder replacement is to
restore some function to the joint destroyed as a result
of cuff tear arthropathy by providing stability and a
fulcrum against which the deltoid muscle can help
elevate the shoulder to a level where basic shoulder
functions can be performed without the risk of
dislocating the shoulder
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
• With the Reverse Shoulder Prosthesis, the anatomy, or
structure, of the healthy shoulder is reversed. The implant is
designed so that the ball portion is attached to the scapula
and the socket is placed at the upper end of the humerus.
• The Reverse Shoulder Prosthesis is mainly used for older
patients with rotator cuff tear arthropathy
• Patients see a drastic difference in their range of mobility,
and their ability to perform daily activities, such as eating,
drinking, combing their hair, etc.
• Patients who have had the procedure go from having severe
shoulder dysfunction to 90 to 100 degrees full elevation.
Shoulder Surgery Protocol : Reverse Shoulder
Replacement Protocol:
Shoulder Dislocation Precautions
• This rehabilitation protocol has been developed for the
patient following a Reverse Total Shoulder Arthroplasty.
• Precautions should be implemented for the first 16
weeks postoperatively unless surgeon specifically
advises patient or therapist differently.
• This protocol has been divided into phases. Each phase
may vary slightly based on the individual patient and
special circumstances.
• Progression to the next phase based on clinical criteria
and time frames as appropriate.
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Phase 1: Immediate Postsurgical Phase, Joint Protection (Day 1
to Week 6)
Goals:
Patient and family independent with
•
•
•
•
•
•
Joint protection
Passive range of motion (PROM) after 2 weeks
Assisting with putting on/taking off sling and clothing
Assisting with home exercise program (HEP)
Cryotherapy
Promote healing of soft tissue/maintain the integrity of the
replaced joint
• Enhance PROM after two weeks
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
• Restore active range of motion (AROM) of
elbow/wrist/hand
• Independent with activities of daily living (ADLs) with
modifications
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Precautions:
• Sling is worn for 2-3 weeks postoperatively.
• While lying supine, the distal humerus/elbow should
be supported by a pillow or towel roll to avoid shoulder
extension. Patients should be advised to “always be
able to visualize their elbow while laying supine”
• No shoulder AROM
• No lifting of objects with operative extremity
• No supporting of body weight with involved extremity
• Keep incision clean and dry (no soaking/wetting for 2
weeks); no whirlpool, Jacuzzi, ocean/lake wading for 4
weeks minimum.
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Day 14(acute care therapy)
Begin PROM in supine
• Forward flexion and elevation in the scapular plane in supine to
90°
• External rotation (ER) in scapular plane to available ROM as
indicated by operative findings, typically around 20° - 30°
• No IR range of motion (ROM)
• AROM/active assisted ROM of cervical spine, elbow, wrist, and
hand
• Begin periscapular submaximal pain-free isometrics in the
scapular plane
• Continuous cryotherapy for first 72 hrs postoperatively, then
frequent application (4-5 times a day for about 20 minutes)
cryotherapy
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Days 15 to 21
• Continue all exercises as above
• Begin submaximal pain-free deltoid isometrics in
scapular plane(avoid shoulder extension when isolating
posterior deltoid)
• Frequent (4-5 times a day for about 20 minutes)
cryotherapy
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Weeks 3 to 6
Progress exercises listed above
Progress PROM
• Forward flexion and elevation in the scapular plane in
supine to 120°
• ER in scapular plane to tolerance, respecting soft tissue
constraints
• At 6 weeks postoperatively start PROM IR to tolerance
(not to exceed 50°) in the scapular plane
• Gentle resisted exercise of elbow, wrist, and hand
• Continue frequent cryotherapy
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Criteria for progression to the next phase (phase II)
• Patient tolerates shoulder PROM and AROM program
for elbow, wrist, and hand
• Patient demonstrates the ability to isometrically
activate all components of the deltoid and periscapular
musculature in the scapular plane
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Phase II: ARAOM, Early Strengthening Phase (Weeks 6 to
12)
Goals:
• Continue progression of PROM (full PROM is not
expected)
• Gradually restore AROM
• Control pain and inflammation
• Allow continued healing of soft tissue/do not
overstress healing tissue
• Re-establish dynamic shoulder stability
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Precautions:
• Continue to avoid shoulder hyperextension
• In the presence of poor shoulder mechanics avoid
repetitive shoulder AROM exercises/activity
• Restrict Lifting of objects to no heavier than a coffee
cup
• No supporting of body weight by involved upper
extremity
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Weeks 6 to 8
• Continue with PROM program
• Begin shoulder active assisted ROM/AROM as appropriate
• Forward flexion and elevation in scapular plane in supine with
progression to sitting/standing
• ER in IR in the scapular plane in supine with progression to
sitting/standing
• Begin gentle GH IR and ER submaximal pain-free isometrics
• Initiate gentle scapulothoracic rhythmic stabilization and
alternating isometrics in supine as appropriate. Begin gentle
periscapular and deltoid submaximal pain-free isotonic
strengthening exercises, typically toward the end of the eighth
week
• Progress strengthening of elbow, wrist, and hand
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
• Gentle GH and scapulothoracic joint mobilizations as
indicated (grades I and II)
• Continue use of cryotherapy as needed
• Patient may begin to use hand of operative extremity
for feeding and light ADLs
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Weeks 9 to 12
• Continue with above exercises and functional activity
progression
• Begin AROM supine forward flexion and elevation in
the plane of the scapula with light weights of 0.5 to 1.4
kg (1 to 3 lb) at varying degrees of trunk elevation as
appropriate (ie, supine lawn chair progression with
progression to sitting/standing)
• Progress to gentle GH IR and ER isotonic strengthening
exercises
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Criteria for progression to the next phase (phase III)
• Improving function of shoulder
• Patient demonstrates the ability to isotonically activate
all components of the deltoid and periscapular
musculature and is gaining strength
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Phase III: Moderate Strengthening (Week 12+)
Goals:
• Enhance functional use of operative extremity and
advance functional activities
• Enhance shoulder mechanics, muscular strength,
power and endurance
Precautions
• No lifting of objects heavier than 2.7 kg (6lb) with the
operative upper extremity
• No sudden lifting or pushing activities
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Weeks 12 to 16
• Continue with previous program as indicated
• Progress to gentle resisted flexion, elevation in
standing as appropriate
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
Phase IV: Continued Home Program (Typically 4+ Months
Postoperative)
Typically the patient is on a HEP at this stage, to be performed
3-4 times per week, with the focus on
• Continued strength gains
• Continued progression toward a return to functional and
recreational activities within limits, as identified by progress
made during rehabilitation and outlined by surgeon and
physical therapist
Criteria for discharge from skilled therapy
Patient is able to maintain pain-free shoulder AROM,
demonstrating proper shoulder mechanics (typically 80° - 120°
of elevation, with functional ER of about 30°)
Shoulder Surgery Protocol : Reverse Shoulder
Replacement
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ACDF
TLIF
ALIF
PLIF
XLIF
References:
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