Outpatient Total Knee Rehabilitation

I have seen most patients coming to me for outpatient total knee rehabilitation doing quite well after their initial stints in Acute Rehab or Home Health.  I find that my biggest role is to make sure people understand what the next 12 months will be like and to help them manage independently.  Here are my main guidelines:

1) Pain Science Education: Yes, you went through pretty severe trauma, so pain is ok, don’t be afraid of it, it definitely doesn’t indicate anything is wrong, you’re just healing from a surgery where someone took a saw and cut off the ends of two of your bones and hammered in metal parts (not to mention any soft tissue lacerations to see the bones).  It’s ok to be in pain.  Use meds as needed and remember the pain will get better.

2) When your knee is warm, it is moldable.  I use a warm metal analogy.  A blacksmith can mold metal if it is hot, and your knee can gain or lose range of motion if it is warm.  This assessment is really easy, compare the temperature of your knees, the surgical one is probably warmer.  Keep stretching every day until it cools down (this will probably be 4-6 months post op).

3) Don’t manually stretch knees.  Get someone on a bike, have them start at a high seat where they can go around easily.  Pedal there for a minute, then lower the seat level.  Every minute you should lower it a little more.  You’ll find flexion improves pretty quickly.  For extension, elevate the leg on a block / cushion at the heel and put weight on the knee.  Tell the person to stay there as long as they can tolerate it.  Shoot for 5-10 minutes, 2x/day.  Use any other pain modulating manual therapy techniques to ease these motions.  But with both of these, the patient is in control and can have a successful outcome.  I’ve seen a couple of nightmare joints where the patient clearly didn’t have control during stretching and the result was a knee that didn’t bend ideally and had long term residual spasm.

4) Strengthen the knee as much as possible with closed chain activities (this applies to everyone).  Sit to stand, step ups, floor transfers.  Then progress to more aggressive strengthening if they want to do it.

Infraspinatus pain or trigger points?

Are you struggling with infraspinatus trigger points, tightness or pain?  You might also have trigger points in your levator scapula and pec minor.  I  have a theory that this is a result of poor use of your upward rotation force couple neuro tag.  Serratus anterior, upper trap, and low trap should be working properly to rotate your scapula upward and decrease any impingement stresses.

If this is not occurring correctly, the glenohumeral joint elevates (flexes or abducts) with the anterior delt, biceps, etc. and the body runs out of motion around 120 degrees.  As those flexors start to bunch up, the work to go much further is difficult, so the scapula starts to get pulled upward by humeral adductors that attach to the scapula (infraspinatus, teres minor, teres major, and subscapularis).   I think infraspinatus becomes the main culprit because the shoulder is usually in relative internal rotation (ask a lot of people to raise their arms overhead and note which way the palm is facing) and it is put on tension in that position.  Passively placing the scapula in this upwardly rotated position should help alleviate any tension in the posterior shoulder.
Here are a couple of great ideas for helping improve this, thank you to Eric Cressey for putting out some great free material on youtube.
I also like to visualize the serratus actively upwardly rotating the shoulder blade to initiate an overhead lifting motion with a scooping motion.  Focusing on the elbow and going bottoms up with a kettlebell seems to help as well.