Physiotherapy

Physiotherapy is the single most important thing you can do to improve your recovery. Performing the exercises  as directed by your physiotherapist routinely and persisting with your exercise protocol will help your recovery be better, and less complicated, and much faster . It will also reduce chance of complications and different forms of long-term damage.

Physiotherapy after a TPF has te main objective of helping you heal. Throughout the recovery process there are many smaller objectives for the specific exercise you will be performing. The objective and thus the exercises will be changing over time. Some of the benefits and objectives of physiotherapy are improved range of movement, gaining and improving stability of the knee and the body, , prevention of adhesions, improving motor control, gaining muscle mass and more.

Physiotherapy might start as early as a few days following your surgery or injury, and sometimes even on the same day. It is very important that you start early, and are in tough with a trained physiotherapist from the very beginning. This will have a dramatic effect later on, so if your O/S has not yet discussed this with you, consider asking him about physiotherapy.

At first the exercises will probably be performed at home, later on at a physical rehabilitation center and at some point you might be referred to your local gym to continue exercising there. In some cases several of the exercises may be performed in a pool but this is not at all mandatory. While performing the exercises a good remember that the exercises can be uncomfortable and can also be lightly painful, but should not hurt a lot. If you are in serious pain from the exercises consider slowing down and doing things more gently. Also, try not to do the exercises under heavy painkiller medications (of course, during the first several weeks this is unlikely), as these might mask the fact that you are over-straining your leg. Remember – pain is your friend, helping you know when something is wrong (but unfortunately will probably also prove to be an enemy).

The main objectives of the exercises are:
knee stability –  Strengthening the smaller supporting muscles around the knee will contribute to a more stable movement as the knee bends and bears weight in the future.

Range of motion –  The knee will be losing ROM due to the surgery and adhesions which form thereafter. Part of the exercise routine is aimed at constantly increasing the ROM though gentle bending, going a little further every week. It is unfortunately unlikely that you will regain 100% full range of motion, but with early and constant exercise you can get a very good result, at almost full range of motion.

Motor control –  Some of the exercises will focus on regaining good motor control of the knee and leg muscles. This includes gentle movement exercises as well general stability exercises at a later stage.

Gaining muscle mass –  Leg muscle mass is lost in a moment and takes forever to ragain.  Many of the exercises will be focused on regaining muscle mass in the main and smaller muscle of the leg.

Below is the description of the different “periods” of physiotherapy:

First Week

During the first week or so exercise will concentrate mainly around “recovering” from the effects of the surgery. This means, for example – icing and leg elevation to reduce inflammation and pain, regaining initial knee range of motion and motor control (the ability to bend your knee), and getting used to getting around on crutches. You should not be alarmed if at the very start you can hardly bend your knee at all. This is quite a standard post-surgery symptom, and will soon improve drastically. Your ROM (range-of-motion) will continue to improve for months to come. Some exercises you can be performing during this time are:

  • gentle bending of the knee in the brace, as far as you can go with no pain, many repetitions at a time (tens of repetitions)
  • moving you ankle in circles in both directions.
  • putting a towel under the knee of a straight leg, and trying to press down on it- straightening the leg

NWB Period

During the NWB period the goal is to gain as much ROM as possible, prevent the formation of permanent adhesions, reduce muscle wastage and build leg muscle. All of this has to be done gently, without putting too much pressure on the leg, and therefore include gentle exercises. These exercises can be done solo, with the help of another person and with the help of accessories(link). Exercises should be performed every day, multiple times daily or as directed by your physiotherapist. A few exercises that can be performed at this stage are:

  • Continue with moving your foot in circles by the ankle. after a few weeks pass, use a stretch band (link) as a contradicting force to make the ankle work harder, by putting the middle of the band around your foot, and holding the ends stretched with your hands. Be very gentle as this is a form of putting some weight on the leg and you don’t want to do that too early.
  • lying on your back, try to bend your leg, moving the foot towards you while touching the bed, then straighten the leg and repeat.
  • lying on your back, try to bring your knee to your chest (obviously you wont be able to, but as close as your can), return and repeat. use your hands to help you go a little further.
  • Sit on a couch or the side of a bed, let the leg fall to the floor as much as possible, stretching the ROM. Do this gently, possibly with a pillow on the floor under the foot and/or your hands holding on to the end of your brace, and allow the leg to down so that you feel a stretch and possibly light pain but no more. Lift the leg with the help of your hands and/or stretch band and repeat.
  • While performing the previous exercise, try to force the leg to “fall” more slowly by holding it with your hamstring muscles (the top part of your leg). Also, try to straighten the leg from a bent position by lifting the foot and straightening the leg (you probably won’t succeed at first, you can use your hands to help).When you are able to lift your foot without any help (approx 3 weeks), continue with these exercises:
  • straighten it and hold it at a straight position for 5 seconds, let drop and repeat.
  • Use a stretch band to add resistance to all previous exercises.
  • Ankle alphabet – Sit on a chair with your foot dangling in the air or on a bed with your foot hanging off the edge, and draw the alphabet on the floor with your toe acting as a pencil, letter by letter (draw ‘A’, then draw ‘B’ etc..)
  • Try to pick up marbles or towels off the floor by flexing your toes and grabbing the towel with your foot.
  • stretch and flex your heels and toes against stretch bands and against your hands
  • Patellar mobilization – Twice a day, use your hands to gently push your kneecap up and down, and left and right. It is best if this is done under the supervision of a trained physiotherapist
  • Leg Stretches
  • Lie on your back, bend the leg and hold the stretch band with both your hands so that the middle is above the foot. Try to straighten your leg in the air so that it resists the bend and stretches it (a bit logistically complicated)
  • Hold the band stretched around the foot, try to bring your knee close to your chest and then push it back out, stretching the band.
  • Hold the band stretched around the foot, flex and stretch your ankle as if standing on your toes.
  • perform some exercises for the core body muscles as well if possible. These are the stomach and back muscles as well as all the muscles in those areas. This will not directly help the leg, but all of these muscles will also be weakening from inactivity and exercising them could prevent extra pains and strains.
  • When possible, begin stationary bike training

More Coming soon..

Initial WB Period

This stage starts around 6-8 weeks During this period you will be putting partial weight on your leg, learning to walk again and slowly raising the amount of strain put on your leg. Generally speaking, at this point in time you will be in less danger of harming or reopening the fracture, but still need to take things slowly and carefully. Some exercises are:

  • Continue all previous exercises, adding resistance and stationary bike exercises if possible
  • Move from two crutches and tiptoeing to one crutch to a walking stick and eventually unaided walking within 4 -6 more weeks.
  • possible.practice very slow, mindful walking, focusing on walking form.
  • Use weight machines and ankle weights (link) to strengthen all the muscles of the leg. Practice both legs separately when possible, but don’t forget to train both legs and not only the injured one. Also, make sure train all muscles of the leg
  • Stretch often and especially after weight training
  • To gain stability and strengthen small muscles stand on a stability board (link) or bosu ball (link), at first with both legs. Try to stay stable while standing. When this is easy make it harded for yourself by bouncing a ball, leaning left and right or light squats. When this is also easy, try standing on just one leg.
  • Leg press, heel raises, hamstring curls, Squats (one and two legs), lunges, knee extensions
  • When you are able to walk, make sure you walk as much as possible
  • Perform advanced Rom exercises such as trying to sit with your buttocks on your feet or using your hands
  • A continuous passive motion machine may also be used if available in your physical rehabilitation center.
  • Consider trying Aphostherapy (link) to help prevent the onset of osteoarthritis.

Moving Forward

You will need to continue strengthening the leg, improving ROM and stability and performing other exercises for a while. A full year of training and Physiotherapy to some extent is not unlikely, and it might be longer. take in to account that as time goes by Physiotherapy will start to feel more like a Gym session then rehabilitation and you will be able to combine your exercise schedule with cardiovascular training such as stationary or regular bike riding.

Some good exercises are:

 

  • Elliptical trainer
  • Weight training
  • Leg press, heel raises, hamstring curls, Squats (one and two legs), lunges, knee extensions
  • Treadmill walking
  • walking in a pool
  • continue ROM exercises
  • Try to avoid impact exercise (running) as much as possible. Consult your Physiotherapist about when to start

Coming soon..

206 thoughts on “Physiotherapy

  1. Thank you all who are posting your questions and experiences. My surgery was June 1, so I am just starting down this road. My biggest physical issue right now is acute soreness/pain in the affected leg’s calf muscle. Work on flexing foot to stretch it and rub (gently!) arnica cream on it, but oh, my it hurts!

  2. My injury occurred 4-30-17, surgery on 5-1-17, open reduction with fixation of plate with six screws. Have just today, 6-15-17
    Started partial weight bearing….30 pound limit on injuries leg.
    Walking with a walker. Have been allowed strengthening and flexion exercises with water therapy for the last 3 weeks.
    Flexion up to 82 degees can be pushed (by PT) to 90 degrees.
    Extension to 1 degree. Questions: 1.my foot and toes have been numb or feels like it’s asleep since surgery. Now as I put pressure on it, it stings…will this get better? 2. I’m 64 years old,
    In good shape, active and according to my Orthopedist, I have good bones…is it realistic to think I’ll get back to my normal ROM? The recovery and the injury is amazingly difficult.
    Any suggestion or thoughts will be greatly appreciated.
    Will exercisers twice a day if pain free, be sufficient?

    Thx. Susie

    • I was a couple of years older than you when I had my injury 2-1/2 years ago, and I also had open reduction with a plate and six screws (still in there). My whole lower leg was numb on one side, and my foot felt weird, and it wouldn’t go flat on the floor the way the other one did. My doctor said all of that was because nerves were disrupted of necessity by the surgery. My leg is still numb on part of its surface, which is an odd combination with the extreme sensitivity under the skin where the plate is. But, it is manageable — I just have to be careful not to bump things. My foot came back to almost normal — my big toe still has a slight angle but probably I am the only one noticing. Quite soon I was able to wear my regular shoes again.

      As for your ROM, I have only myself to go by, but mine came back well during my time in PT. I still need to do stretching exercises because otherwise it will be stiff. As for your exercises, do them faithfully! I can’t advise on the painfulness part — some exercises I had in PT were quite painful but the therapists said that was okay — especially while you are not fully weight bearing. I would ask your doctor. You don’t want to reinjure it if you are not fully healed (mine would not let me be weight bearing at all until x-rays showed that I was completely healed: 14 weeks after surgery). Good luck!

  3. My injury occurred on February 18,2017 I spent three weeks in the hospital and then went to a rehab for 3 more weeks. This is a long healing process and can really test your patience. almost 14 weeks and I have only regained rom of 60 degrees. I’m walking with a Cain and hope to be walking unaided in the next 2 or 3 weeks. I plan to return to work at that point in my recovery process. I will have to continue my physical therapy on my own because insurance will not cover more than 2 months. It’s a long road to recovery if you are recovering from this kind of injury I wish you all the best and encourage you to keep fighting the good fight.

  4. Hi All,
    I fell skiing April 8th and had surgery a few days later. I have multiple screws and a plate 3/4 of the way down my shin. Boy is this a tough injury! I was a very athletic 39 year old at the time of injury, hiker, runner, skier and now I’m resigned to be a swimmer and golfer. I’m 7 weeks post-op and at about 85 degrees flexion. I’ve been working to get to 90 for 4 weeks now and feel like I’m just treading water, every night it tightens up and every day I fight to get it to 85 degrees. I am now going to outpatient PT and have a great therapist who pushes ROM. (I had in home PT for the first 4 weeks which was pretty mediocre and more about getting around the home safely and introduction to some exercises.) I get partial weight bearing in 3 weeks and full weight bearing as tolerated July 4th.

    I really like reading all your stories so please keep posting!

    I’m especially interested in how quickly folks went from FWB to basically ‘normal’ daily activity. I have a college reunion with some girlfriends 3 weeks after FWB and if I go, I’ll have to get on a plane. Any bets on whether this will be possible?

    Keep posting!!
    Katie

    • Katie, I would not be so quick to think you won’t be able to resume all of your accustomed activities. I’m a few decades older than you are, and I’ve managed to do almost everything again. I had no PT after I left the rehab center (3 weeks there) until I was cleared for FWB 14 weeks after surgery (it was mid-April by then). I regained function very quickly. It only took a couple of weeks to get out of my wheelchair (crutches not being feasible in my house), and then I spent a few more weeks with a walker. I graduated to a cane after that, and I was able to retire that by the end of the summer.

      I’m sure you will be able to get on that plane, with a walker or a cane, and a year from now I’ll bet you will be back out there on the trails. Do the exercises and stay optimistic! You may always need to do some stretching on the injured leg, but that’s no deal-breaker.

    • Katie,

      I can totally relate to your struggle! I am also a fairly active person, and had recently moved to Germany and was so excited to hike, bike and travel! My TPF occurred skiing on 20 Dec 16. It took me FOREVER to get to 90 degrees, and then when I was at 110 (at 14 weeks) something happened and I went back to 90…argh! I finally measured 120–that magic number–at 23 weeks! I was NWB for 14 weeks, which really took a toll on my muscles–quad and hamstring, as expected, but also glutes and calf. It took me 2 weeks to really start walking, and I used one forearm crutch for a couple weeks, but I still wasn’t allowed to drive (and only short distances, and not on the Autobahn) until 20 weeks!

      That said, we went on a family vacation at about 12 weeks post op that included a 4-hr plane ride. I was still NWB, so I used a wheelchair at the airports (security was a breeze!) and my forearm crutches on the plane. That was a little tricky, but you should be able to use just one crutch or cane by the time you travel which should be a lot easier. Just make sure you stretch out that leg and rotate your ankle/flex the foot while in flight.

      I was allowed to walk in a pool even before I was allowed to bear weight. I think that helped with ROM and with regular walking once allowed. Another tip, try cycling. Believe it or not, I was cleared to ride my bike before driving and it is easier than walking again. I also found that it helped with ROM–it was my favorite warm-up at PT and I could mark my ROM progress by how I was able to get the pedal all the way around–cheating at first and with the seat high, but eventually no cheating and seat lowered. I have now progressed to the elliptical (pain-free) for warm up and at 24 weeks post op just yesterday went on a 3.3 mile hike in the woods near my home! So in just 8 weeks there has been great improvement.

      Hopefully my experience will be of help to you. Enjoy the time with your college friends and all the best with your recovery!

    • Dear Katie,

      I broke my R leg – tibia plateau 30/11/14! I have just had the plate and screws removed by the same surgeon. All was well with my leg but I still was not fully weight-bearing and could not climb the stairs. I hope that with the hardwear is out that I shall really have as good as leg as possible. I did not realize how long it had been since I had the injury. In the meantime I trapped the sciatic nerve, same leg, of course. That was very painful for a few months, in fact the level of pain that I had to tolerate was such that I did not realize when I broke the fibula until an x-ray showed I had been walking, using elbow crutches, or up to the previons 6 months!

      Now R leg has a total hip implant, no plate or screws. Some of the nerves of the lower leg are still numb and I still do Physio, but I have been flying short and long haul using a zimmer or crutches. No more dog walking but by the end of this week I shall be swimming again, the scars should be dry enough, I was told. The wound is dry and looks good, but now I can only do the doggy paddle which I find is getting better.

      So remember, at least that is my advice to me, things could be worse. My surgeon said the break was Schwartzkat (sp. ?) 7-8, so I suppose they could just just taken off the leg! I am now 65, if that is significant and hope I won’t break any more bones!

      Good luck with you and the leg.

      Gaya

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