Had a hip or knee replacement? The surgeon said I did not need physio after the operation?
Getting advice on exercises and checking for any long term strength and balance deficits after surgery is critical to ensure that your recovery is as good as it can be.
Hip and knee replacements are one of the most common and effective orthopaedic surgeries available. They are both relatively safe and effective at reducing some of the pain associated with osteoarthritis of the hip and knee. However, pain is not the only factor when an individual seeks help with their hip or knee. They may have had more functional problems. Perhaps not able to get out of a low chair or not being able to balance putting on pants. They may have the sensation of limping while walking or be too stiff to bend to tie shoes or pick things up from the floor. The above factors are of course, more related to weaknesses, reduced balance or stiffness rather than necessarily pain.
In some instances, the pain associated with the arthritis causes the muscle weakness, stiffness or walking problems. However, muscle imbalances or weaknesses can be the cause of the initial joint deterioration and resulting stiffness and pain.
Regardless of which of these are the first symptom, it is clear that all must be addressed to get the most out of your hip or knee post-op quickly and for the future of your joints. The new joint replaces bones and cartilage but it does not replace muscle and other soft tissue. In fact, these tissues naturally deteriorate further due to the immediate pain and stiffness associated with the trauma of surgery.
This is where rehabilitation comes in.
A generic set of exercises handed to you on the day of discharge from hospital is not going to ensure that you get the most out of your hip or knee over the subsequent six to twelve months.
This is where physio comes in. The initial exercises that you should at least be given on discharge from hospital can help you get off crutches etc. But if you want to address any underlying muscle weaknesses and stiffness which may have existed prior to surgery, and if you aim to get back to more than just walking without an aid, e.g. gardening, shopping, returning to work, looking after children and travelling, then clearly your rehab will need to get progressed at a pace that you will improve at.
Research has shown that many people’s activity expectations are lower after total hip replacement (THR) and total knee replacement (TKR). As physios we know this does not have to be the case. Surely having had such an intervention you should be able to do more never mind less. Although many are happy with some pain relief, this does not have to be all. And as mentioned previously, if the pain is originally caused by some weakness, then any relief could be short-lived without appropriate, progressive rehab. Studies have shown that many people, despite having less pain after a THR, are less active with a resulting decrease in cardiovascular and aerobic fitness. A physio can help you identify your own goals from rehab and give you feedback on what is realistic and achievable.
I will discuss some more specific TKR and then THR rehab later on. Before this, I will identify some other benefits of post-op physio rehab for either type of replacement.
We can offer hydrotherapy. This is where you do movement in water. The therapeutic advantages of water are its buoyancy and ability to offer multi-directional resistance. The reduced sense of weight you feel in the water which, can be enhanced by flotation devices, can be used to practice your walking without over-taxing your new joint. Those who still require walking aids on land often do not need any in the water. Other strengthening exercise can be performed in the water that cannot easily be done on land.
Physios have lots of tips they can offer depending on what issues arise during your rehab. Advice may include recommendations on dressing, sleeping and negotiating stairs as you wean off walking aids.
Physio TKR (Total Knee Replacement) Rehab
One of the most important outcomes to achieve post-TKR is good knee flexion. This is how much bend you get back in your knee. Time is of the essence here. Major milestone is 90 degrees flexion. This is because, typically, we find that people who achieve 90 degrees flexion tend to improve steadily after this. On the other hand, if flexion slows or plateaus at a range much less than this, then over 90 degrees flexion may never be achieved without manipulation under anesthetic.
On the contrary, those who achieve 90-100 degrees are able to commence full rotations on a bike and walk with less of a limp, making further increases more readily. We often see people present to physio with discharge from hospital letters reporting 85 or 90 degrees flexion achieved. However, on measurement at physio their flexion is often much less. This may be due to regression in the interim period, it may be due to reduced pain medications or not doing the exercises effectively. Other times they may not have been measured correctly on discharge.
It is essential for physio to be given the chance to pick up on this and we can use a variety of techniques to work on increasing the very important knee bend. This could include different types of manual therapy, soft tissue work or different exercises.
Post TKR swelling is something that needs to be monitored and controlled. If too much remains and it does not settle quickly enough, it can affect pain levels, flexion capacity and strength regain. Physios have a barrage of techniques and experience in dealing with this. Muscles atrophy (wasting) of the quadriceps, hamstrings and calves are commonly seen in post-op TKR patients. If it is the first time we have seen this person it is never clear to what degree the wastage has occurred post-op and how much was preexisting.
To achieve a good outcome it is very important to regain as much of this lost muscle mass as possible post-op. It is not always as simple as just trying to get back to doing what you used to do for this to occur, or even just doing lots of your initial exercises. Often these muscles have “gone to sleep” and are not readily recruited. This is more prevalent the longer the wastage/joint degeneration has existed.
It is in these instances especially, that we assess further up the limb for more widespread muscle deterioration. Often the glute muscles become wasted due to reduced use of that limb or due to maladaptive movement. Particular focus on glute activation and strengthening can be an important piece of the TKR rehab jigsaw.
Physio THR (Total Hip Replacement) Rehab
THR’s are a very successful procedure. Too often, however, I see people who could have had a much better outcome. This often stems from a fear of getting going earlier. Often restrictions are placed about what positions you can and cannot put your hip joint into post-op. Whether any restrictions are necessary is still debated but what is becoming more clear is that these restrictions, specifically hip flexion and lateral and medial rotation, do not have to be for months and months. Physios can help you negotiate this dilemma safely through your rehab ensuring you achieve a good mobile hip on which to build strength upon.
Sometimes the regular reminders in hospital of not crossing your legs and wedge pillows for chairs enshrine an element of fear and vulnerability to the patients long after it is needed.
Similar to THR maladaptive movement strategies may have been adopted long before the surgery. Even more so in hips is the infamous Trendlenburg gait where the individual leans over to the affected limb when it is weight bearing to reduce the load on the hip and its muscles. Regaining these specific muscles, most pertinently the glutes, will be an essential part of a thorough physio post-THR rehab. Again, further up the chain of the limb will be assessed for maladaptions, e.g. a stiff lumbar or thoracic spine from all the leaning/waddling.
Hopefully I have begun to highlight some of the considerations that need to be assessed and addressed over the course of a progressive rehabilitation so that you can readily maximise the true potential of these great procedures and not become one of the unprepared cohort who develop a poor outcome.
Written by Anthony Sheridan, Senior Physiotherapist at myPhysioSA Mount Barker.