Rehabilitation For The
Postsurgical Orthopedic Patient
Mitchell Goldflies, MD
Musculoskeletal Conditions
• Etiology
– Acute
– Overuse
– Degenerative
• Primary Lesions
• Secondary Lesions
–
–
–
–
–
Biomechanics
Ergomonics
Training Errors
Body Composition
Innervation-Referral Pattern
Musculoskeletal Conditions
• Evaluation Includes
–
–
–
–
–
–
–
–
–
Medical Condition
Mental Condition
Nutritional Status
Family History
Past Medical History
Litigation
Secondary Gain
Compliance
Belief System
Soft Tissue Healing Following
Trauma and Surgery
• Surgery is Controlled Trauma Produced
By a Trained Professional To Correct
Uncontrolled Trauma
• Connective Tissue Responds in a
Characteristic Way to Immobilization and
Trauma
• Connective Tissue is 16% of Body Weight
and 25% of Body Water Content
Soft Tissue Healing Following
Trauma and Surgery
• Connective Tissue
–
–
–
–
–
–
–
–
–
Ligament
Tendon
Perisoteum
Joint Capsule
Aponeurosis
Nerve
Muscle Sheath
Blood Vessel Wall
Bed and Framework of the Internal Organs
Soft Tissue Healing Following
Trauma and Surgery
• Connective Tissue Components
– Cells
– Extracellular Matrix
– Fibroblast
• Synthesizes Inert Components
–
–
–
–
Collagen
Elastin
Reticulin
Ground Substance
Soft Tissue Healing Following
Trauma and Surgery
• Connective Tissue Types
– Dense Regular: Ligaments and Tendons
– Dense Irregular: Joint Capsule, Perisoteum,
Aponeurosis
– Loose Irregular: Fascia, Muscle, Nerve
Sheath
Soft Tissue Healing Following
Trauma and Surgery
• Connective Tissue Biomechanics
– Viscoelastic
• Elastic-Temporary Deformation
• Viscous-Plastic-Permanent Deformation
– Shock Attenuation
• Immobilization
– Fibrofatty Infiltration
– Fibrous Adhesions
– Dehydration
Soft Tissue Healing Following
Trauma and Surgery
• Remobilization
– Well Ordered Collagen Along The Lines of
Force
– Reduction in Cross Links
– Production of Ground Substance
– Rehydration
– Adhesions Rupture
Bone Healing Following Trauma
And Surgery
• Stages of Healing: Overlap
– Inflammatory Phase 10%
– Repair 40%
• Removing Debris
– Remodeling 70%
– Results
•
•
•
•
Restoration of Original Tissue
Scar
Excessive Repair
Failure of Healing
Bone Healing Following Trauma
And Surgery
• Injury Variables
– Type of Injury
– Intensity and Duration of Force
– Tissues Involved
– Patient Age
– Nutritional Status
– Genetic, Systemic and Local Disease
– Smoking
Bone Healing Following Trauma
And Surgery
• Management
– Resuscitation of Patient
– Clinical Assesment
– Debridement if Open
– Reduction
• Manipulation
• Traction
• Operative Reduction
Bone Healing Following Trauma
And Surgery
• Management
– Immobilization
• Prevent Displacement or Angulation
• Prevention of Motion
– Rigid
– Controlled Motion
• Relief of Pain
Bone Healing Following Trauma
And Surgery
• Energy (High or Low)
• How Force Applied (Direct or Indirect)
• Level
– Articular
– Metaphsyeal
– Diaphsyeal
• Soft Tissue
• Bone Deficits
• Associated Conditions (Smoking, Diabetes,
PVD, Bone Disease, Steroids, NSAIDS)
Bone Healing Following Trauma
And Surgery
• Procedure
– Closed
– Percutaneous
– Limited Open
– Open
• Fixation
– Internal
– External
– Combined
Bone Healing Following Trauma
And Surgery
• Fixation
– Rigid
– Flexible
– Bioabsorable
• Graft Material
– Synthetic
– Allograft
– Autograft
– Xenograft
Bone Healing Following Trauma
And Surgery
• Bone Stimulation
– Ultrasound
– Pulsed Magnetic Field
– Implanted Direct Current
Bone Healing Following Trauma
And Surgery
• Wound
– Closed
– Drains
– Flaps
– Open
•
•
•
•
Packed
Wound Vac
Bead Pouch
Special Considerations
Rehabilitation Following
Bone Healing
• Rehabilitation is The Business of the
Entire Medical Team
• Reduction and Immobilization May Be
Unnecessary
• Rehabilitation is Always Essential
– Preserve Function During Healing
– Restore Function After Healing
Rehabilitation Following
Bone Healing
• Prime Goals of Rehabilitation
– Maintain or Restore The Range of Motion of
Joints
– Preserve Muscle Strength and Endurance
– Enhance the Rate of Fracture Healing by
Activity
– Early Return Function and Employment
Postoperative Rehabilitation
• Methods of Rehabilitation
– Active Use
– Active Exercises
– Under Supervision of a Physical Therapist
• Phases
– 1. Return to Range of Motion
– 2. Regain Muscle Strength Strength
– 3. Endurance and Functional Progression
Rehabilitation Following
Bone Healing
• Active Use
– The Patient Must Continue to Use the Injured
Part as Naturally as Possible Within The
Limitations Imposed by Necessary Treatment
– Rest May be Necessary for Days or Weeks
• Active Exercises
– Muscles
– Joints
Rehabilitation Following
Bone Healing
• Active Exercises
– Muscles
• Isometric Exercise If Immobilization Present
• Isotonic Exercise When Immobilization Removed
– Protected Range of Motion
» Direction
» Range
• Isokinetic Exercise
– Joints
• Capsular Contracture
• Capsular Laxity
• Functional Instability
Rehabilitation Following
Bone Healing
• Active Exercises
– Edema Control
– Disuse Atrophy
– Sympathetic Nervous System Dysfunction
• Complex Regional Pain Disorder
• Reflex Sympathetic Dystrophy
• Causalgia
Rehabilitation Following
Bone Healing
• Active Exercises
– Contralateral Limb Rehabilitation
– Joint Stabilization
– Joint Range of Motion
– Muscle Strength
– Balance Sense-Proprioception
– Endurance
– Activity Specific Reeducation
• Continuous Passive Motion
Rehabilitation Following
Bone Healing
• Gait Training
– Wheelchair
– Scooters
– Walker
– Crutches
– Cane
• Gait Patterns
• Weight Bearing Status
Rehabilitation Following
Bone Healing
• Modalities
– Heat
•
•
•
•
Hot Packs
Ultrasound
Diathermy
Whirlpool
– Cold
– Contrast Baths
Rehabilitation Following
Bone Healing
• Modalities
– E-Stim
– TENS
– Microcurrent
• Massage
• Orthotics
Where Surgical Services Provided:
Outpatient vs. Inpatient
• In Community (On Field)
• Emergency Room
– Monitored Bed
•
•
•
•
•
Hospital Surgical Suite
Bedside
Hospital Based Outpatient Office Center
Free Standing Ambulatory Surgery Center
Private In-Office Procedure
Arthroscopic and Endoscopic
Procedures
• Arthroscopy
– Hip
– Knee
– Ankle
– Subtalar Joint
– Great Toe MPJ
Arthroscopic and Endoscopic
Procedures
• Endoscopy
– Spine
– Carpal Tunnel
– Plantar Fascia
– Morton’s Neuroma
Upper Extremity
Shoulder
• Fracture/ Dislocation
– Clavicle/ A-C Joint
– Glenohumeral Joint
– Surgical Neck Humerus
• Repair/ Reconstruction
– Acromio-clavicular Joint
– Rotator Cuff
• Impingement
• Tear
Shoulder
• Repair/ Reconstruction
– Glenohumeral Joint
• Capsule
• Labrum
• Long Head Biceps
• Prosthesis
– Hemiarthroplasy
– Total Shoulder Arthroplasty
Shoulder
• First 3 Weeks After Surgery
– Control Postoperative Inflammation and Pain
– Protect Healing Soft Tissue
– Minimize Effects of Immobilization
• Cervical, Elbow and Wrist Motion
• 3 to 6 Weeks After Surgery
– Muscle Strengthening
• Scapular Stabilizers
• Rotator Cuff
Shoulder
• 9 to 12 Weeks After Surgery
– Enhance Kinesthesia and Joint Position
Sense
– Build Endurance
– Strength Scapular Stabilizers
– Work or Sports Specific Tasks
Elbow
• Fracture/Dislocation
– Humerus
– Radial Head and Neck
– Olecranon
– Elbow Dislocation
• Repair/ Reconstruction
– Distal Biceps Tendon
– Ulnar Collateral Ligament
– Tennis/ Golfers Elbow (Epicondylitis)
Elbow & Wrist
• Nerve Decompression
– Elbow
• Radial Nerve at Arcade of Froshe
• Ulnar Nerve at Cubital Tunnel
– Wrist
• Median Nerve at Carpal Tunnel
• Ulnar Nerve in Guyon’s Canal
Elbow Rehabilitation
• 1-14 Days After Surgery
– Achieve Range of Motion of Adjacent Joints
• Passive
• Active
• Active Assisted
– Promote Wound Healing
– Control Edema
– Control Pain
– Retard Muscle Atrophy
Elbow Rehabilitation
• 15-45 Days After Surgery
– Control Edema and Pain
– Achieve Full Range of Motion-Passive
– Maintain Full Range of Motion of Adjacent
Joints
– Promote Mobility of Scar Tissue
Elbow Rehabilitation
• 4-6 Weeks After Surgery
– Control Pain
– Maintain Full Elbow and Forearm Range of
Motion
– Strengthen Upper Extremity
– Regain Normal Forearm Flexibility
Wrist and Hand
• Fracture/ Dislocation/ Sprain/ Strain
– Wrist
•
•
•
•
Colles
Smith
Barton’s
Scaphoid
– Hand
• Metacarpal (Boxer, Bennett’s)
• Finger (Crush, Mallet, Jersey, Volar Plate)
Hand and Wrist Rehabilitation
• Weeks 1-3: Inflammatory Phase
– Decrease Pain
– Manage Edema
– Improve Active Range of Motion of Upper
Extremity
– Initiate Self Management and Patient
Education
Hand and Wrist Rehabilitation
• Weeks 4-6: Proliferation Phase
– Self Management of Symptoms
– Return to Work Activities
• After 6 weeks Following Surgery
– Remodeling and Maturation of Scar
Spine
• Fracture/ Subluxation
– Osteoporotic Compression Fracture
– Pars Fracture (Spondylolysis)
– Spondylolithesis
• Reconstruction
– Discectomy
– Fusion
– IDET/ Endoscopic Spine
Spine Rehabilitation
• Weeks 1-3: Protective Phase
– Protect Surgical Site to Promote Wound
Healing
– Maintain Nerve Root Mobility
– Reduce Pain and Inflammation
– Educate Patient
• Body Mechanics
• ADL
• Self Care
Spine Rehabilitation
• Weeks 4-6: Functional Recovery Phase
– Educate in Neutral Spine Concept
– Cardiovascular Conditioning
– Increase Trunk Strength
– Increase Soft Tissue Mobility
– Increase Lower Extremity Flexibility &
Strength
– Maintain Nerve Root Mobility
Spine Rehabilitation
• Weeks 7-12: Resistive Training Phase
– Independent in ADL and Self Care
– Increase Activity Tolerance
– Return to Normal Functional Level
Lower Extremity
Pelvis and Hip
• Fracture/Dislocation
– Pelvis
• Ring
• Acetabulum
– Hip
• Intracapsular
• Extracapsular
Hip and Knee
•
Joint Reconstruction
– Osteotomy
– Fusion
•
Joint Arthroplasty
–
–
–
–
Resection (Girdlestone)
Resurfacing
Hemiarthroplasty
Total Joint Replacement
Hip and Pelvis Rehabilitation
• Preoperative Training
– Gait Training
– Transfer Techniques
Hip and Pelvis Rehabilitation
• Postoperative Days 1-2
– Prevent Complications
– Increase Muscle Contraction and Control
– Positioning Precautions
– Up in Chair
– Transfers
– Ambulation
Hip and Pelvis Rehabilitation
• Postoperative Days 3-7
– Prevent Complications
– Positioning Precautions
– Promote Transfers
– Gait Independence
– Discharge to Rehab or Home
Hip and Pelvis Rehabilitation
• Postoperative Weeks 1-6
– Positioning Precautions
– Improve Hip & Lower Extremity
• ROM
• Strength
• Balance
Hip and Pelvis Rehabilitation
• Postoperative Weeks 1-6
– Increase Independence In
• Transfers
• Gait
– Plan Return to
• Home
• Work
• Previous Activities
Knee
• Fracture
– Supracondylar Femur
– Patella
– Tibial Plateau
Knee
• Acute Dislocation/ Sprain/ Strain
– Ligament
• Collateral
• Cruciate
– Meniscus
• Degenerative
– Meniscus
– Patello-Femoral
– Femoral/ Tibial
Knee Rehabilitation
• Preoperative Training
– Gait Training
– Attempt to Resolve
• Inflammation
• Swelling
• Pain
– Exercise to Regain
• Rom
• Strength
• Balance Sense (Proprioception)
Knee Rehabilitation
• Acute Phase: Post-op 1-2 Weeks
– Decrease Pain
– Manage Edema
– Increase Weight Bearing Activities
– Facilitate Quad and Hamstring Contraction
– Full Knee Extension
– Increase Passive & Active ROM
– Joint Mobilization
Knee Rehabilitation
• Acute Phase: Post-op 1-2 Weeks
– Decrease Pain
– Manage Edema
– Increase Weight Bearing Activities
– Facilitate Quad and Hamstring Contraction
– Full Knee Extension
– Increase Passive & Active ROM
– Joint Mobilization
Knee Rehabilitation
• Subacute Phase: Post-op 3-4 Weeks
– Decrease Pain
– Manage Edema
– Increase Weight Bearing Activities
• Stand to Sit
– Facilitate Quad and Hamstring Contraction
– Full Knee Extension
– Increase Active ROM
– Joint Mobilization and Stabilization
Knee Rehabilitation
• Advanced Phase: Post-op 5-6 Weeks
– Decrease Pain
– Manage Edema
– Increase Weight Bearing Activities
• Gait Training
• Reduce Reliance on Ambulatory Aids
– Joint Mobilization and Stabilization
– Progress Exercise Program
Knee Rehabilitation
• Upgrade Phase: Post-op >7 Weeks
– Progress Exercise Program
– Return to Activities
– Ongoing Training Program
Foot and Ankle
• Trauma (Acute and Overuse)
– Sprains and Strains
• Achilles
• Lateral Ankle
• Plantar Fascia
Foot and Ankle
• Fractures/ Dislocations
•
•
•
•
•
•
Ankle
Os Calcis
5th Metatarsal Base
Lisfrac Fracture/Dislocation
Metatarsal Stress Fracture
Toe crush and fracture
Foot and Ankle Rehabilitation
• Post-op Initial Immobilization 4-6 Weeks
– Gait Training
– Contralateral Lower Extremity Rehab
– Cardiovascular Training
Foot and Ankle Rehabilitation
• Phase 1 Rehab 2-6 weeks Post-op
– Decrease Pain & Swelling
– Restore Joint and Soft Tissue Mobility
– Protected ROM
• Bracing
–
–
–
–
–
Increase Strength in Lower Extremity
Increase Proprioception
Normalize Gait
Maintain Cardiovascular Fitness
Patient Education
Foot and Ankle Rehabilitation
• Phase 2 Rehab 6-8 weeks Post-op
– Decrease Pain & Swelling
– Restore Normal Joint ROM
– Increase Strength in Lower Extremity
• Intrinsic and Extrinsic Foot & Ankle Muscles
– Increase Proprioception
– Normalize Gait
– Maintain Cardiovascular Fitness
– Bracing
Foot and Ankle Rehabilitation
• Phase 3 Rehab 8-10 weeks Post-op
– Prevent Pain & Swelling
– Maintain Normal Joint ROM
• Mobilization
• Passive Stretching
– Increase Strength and Endurance
– Increase Balance & Proprioception
– Focus Training on Return to Work and Sports
– Bracing/ Orthotics
Foot and Ankle Rehabilitation
• Phase 4 Rehab >10 weeks Post-op
– Maintain Joint ROM
– Increase Strength and Endurance
– Increase Balance & Proprioception
– Return to Work & Sports Activities
– Bracing/ Orthotics
Thank You