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:
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
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
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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.
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