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Author Topic: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery  (Read 15167 times)

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Offline Nick_Knack

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A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« on: February 17, 2005, 04:14:34 PM »
Hi Everyone,

I was thinking something that would be very helpful is to compile a list of various protocols for arthrofibrosis surgery rehab.

It would be great to get the protocols from all the big names in particular (e.g. Steadman, Shelbourne, Noyes, Eakin.....), but anyone who has had success would be great.

For example:

Days 1-3.  Ice 6 times per day.
CPM 5 times 30-70 degrees.  I don't know I am making this stuff up, but you get the picture.

Also, did surgeon recommend steroid treatment post op.  Was a drain used to remove blood.

Nick
Age: 35
1989 rt ACL (+25 degrees ext loss)
1994 rt ACL resection (+ 10 deg)
2001 rt ACL revision (+ 10 deg)
2003 rt med meniscus repair (+10 deg)
2004 rt LOA and post capsulotmy (zero degrees)
2005 rt LOA and tib bone plug removal (even w/ other leg)
2006 rt Fulkerson TTT & ACI Carticel

Offline QBknee

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #1 on: February 17, 2005, 04:35:48 PM »
Nick,

See my posting under soft tissue, over pressure program.  This is what I am doing under Dr. Noyes.  I think the post-op protocol would be based on the individual's main problems with scar tissue. In my case, my extension was a serious problem so the over pressure program, hanging weights, in my case 30 lbs 4-5 times per day for 10-15 minutes.  This forces the soft tissue to stretch.  I also had pretty bad flexion- 95 degress, but Noyes does did not want me doing the CPM post-op because it does not get you to your end range of motion and does not do a good job getting true extension.  The key for me was doing the PT in the hospital under epidural for 4 days.  I got to 130 degrees and hyperextension early on after surgery and I am keeping 120-125 so far.  They want me doing flexion bends while sitting 4-5 times per day as well.  I also do leg raises with 4lbs ankle weights, increasing weight every few days, calf stretches, standing leg extension with with strap around knee, leg curl with while on stomach while pulling for quad stretch, 5 sets holding for 30 seconds.  I also used the ermi machine at Dr. Noyes's office which is excellent for flexion work.

When you are at Dr. Minas's office, ask Tim for the article written by Dr. Millet and others titled Rehabbing the Arthrofibrotic Knee.  This is a good article to see a full rehab protocol for arthrofibrosis.

Dan
5/90 - Microfracture, 11/02 - ACI harvesting scope, 09/03 - Bone graft-Scar Resection -10/27/03 - Manip w scope 2/2/05- Posterior Capsular Release, Anterior Interval Release/staph infection, 3/14/05 wash out scope 12/11/06- Scar resection, lat/med releases

Offline hottubpam

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #2 on: February 17, 2005, 08:28:30 PM »
Hi Nick,

It might also be interesting to see all the "wrong" rehab procedures advocated by OS's that don't know how to treat arthrofibrosis.  My 2nd OS (listed on this BB under Knee Doctors and allegedly the best in the State) did an MUA (bad) then put me in serial casting (very bad, especially for flexion) and then wrote a script for VERY painful PT, super bad.  Needless to say with this protocol the scar tissue was back within 3 weeks.

Anyway now that I'm being treated by an OS that knows what he is doing here's what the protocol has been for me.  Besides the rehab protocol, I think one of the most important things the OS can do is LISTEN to the patient, they can then adjust the protocol appropriately.

After the LOA, LR and AIR, I was kept in hospital overnight, put on a CPM right out of surgery and the iceman.

Took CPM and iceman home with me.  Used them 8-16 hours the first week.

At 1 week post op, OS aspirated the knee (there had been some bleeding during the LOA) and gave me a cortisone shot.

Stitches remained in for 2 weeks.  PT began at 10 days post op.  Everything was to be done in the Pain Free zone and included biking with no resistance, SLR's (in 4 positions), wall slides, patellar mobs, toe raises, hamstring curls, prone hangs.  There's another thing the PT guy does to me when I'm laying on my stomach but I don't know the name of it.  Anyway he kind of pushes the leg up and down from the just below the knee and stretches the leg out.  After he does this we do wall slildes and measure the flexion.  I get my best numbers after he does this.  That's all I can remember.

I'd love to see the article that Dan cited - I tried to find it on the web, but could only find an abstract.  Apparently you have to subscribe to one of the ortho sites to get the full text.


Pam
ACLR, Menisectomy 3/04; ACL resection, Cyclops lesion removal, LOA & MUA 10/04; LOA, LR & AIR 12/29/04;#4&5 surgery on 2/9/05 & 3/2/05 debridement, irrigation & lavage, portal closure; #6  LOA, AIR, LR & other releases 12/9/05; #7 surgery 1/18/06 portal closure, lavage, debrid etc #8 skin graft 3/06

Offline QBknee

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #3 on: February 17, 2005, 08:40:08 PM »
Pam,

I would be glad to fax the article to you.  You can send me a private message if you want me to fax or mail you the article.

Dan
5/90 - Microfracture, 11/02 - ACI harvesting scope, 09/03 - Bone graft-Scar Resection -10/27/03 - Manip w scope 2/2/05- Posterior Capsular Release, Anterior Interval Release/staph infection, 3/14/05 wash out scope 12/11/06- Scar resection, lat/med releases

Offline favouritesearcher

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #4 on: February 19, 2005, 07:56:09 AM »
This is a great idea.

I think there needs to be a lot of detail or links to detail, and also something about what to expect for progress.  There's a lot of good stuff on the board but it's very hard to put it together in enough detail to be able to do it without actually going to an arthrofibrosis specialist.  Eg when to start, how long for, amount of weight to use in extension work, even the meaning of "isometric" stretches, "closed chain" exercises, even "ROM" and "extension" are things that not everyone knows about (ie I had to find out what exactly they were).  I liked Laurie's post because it puts everything in one place.

Laurie's post:
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=9077.0

Not on arthrofibrosis but the bit on quad work is something I found easy to understand:
http://www.kneeclinic.com.au/pdfdoc/exercisesheet.pdf

John
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline Heather M.

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #5 on: February 19, 2005, 09:34:27 PM »
I think it's great to get everything into one place, but not if the purpose is to set up a self-service rehab!  The rehab protocol for each arthrofibrosis is different.  It is up to the doctor to use his/her expertise to taylor the protocol for the individual patient's needs.  I certainly wouldn't recommend doing the rehab alone, and I do see a specialist!  When I first saw Dr. S., he said he wouldn't even do the scope on me unless I stayed in Vail for one month post-op.  And even then, he wouldn't release me to go back home until my Vail PT was able to vouch for the skill level of the one I had in AZ (strangely enough, they had gone to school together!!).

Anyway, that's just my two cents' worth.  I'd be happy to help compile the information here, and we can aske the KG to 'stick' this topic on the top of the soft tissue healing problems section.  But keep in mind...there are four of us (at least!) that have seen Dr. S...and we *all* had very different rehab protocols.  Really--different.  There are some basic principles that guide the rehab of each of us, but the nitty-gritty, daily tasks couldn't be more different.  It's critical to keep this in mind:  a knee with arthrofibrosis is a special knee, and it must be treated that way. 

So here are the basic guiding principles that I was given:

  • The two main guiding principles were:  NO IRRITATION and EARLY ROM.  These determined the activities.
  • No irritation:  I was 100% NWB on crutches, not allowed to so much as touch my toe to the ground.  No showers, no cooking, no nothing...being waited on hand and foot, slowly losing my mind....(not sure if that was part of the protocol, but that's certainly what happened!  I was NWB for over 10 days, then added fractions of my weight until about 7 weeks post-op when I got off crutches completely.
  • Early ROM:  Immediate use of CPM, starting on waking up from surgery.  Used the CPM 20+ hours/day.  0-70 degrees while awake, 30-70 while asleep (ugghh).  Please note that I had 135 degrees of flexion and 0 extension on the first day post-op, so that might have affected the settings I used.
  • No Irritation:  Completely NWB rehab--everything was done on a table or using a recumbent bike on 0 resistance.
  • Early ROM:  Daily exercises done 2 times/day at formal PT, plus another 3-4 times at home.  These included:  SLR's (seated at first, then lying down at about 7 weeks post-op; wall slides; patellar mobilizations (done by someone else, preferrably, as when the patient bends over to do his/her own, the hams tighten and the kneecap sinks down into the joint--ouch!); free spinning on recumbent bike at 0 resistance; a series of quad sets and hamstring stretches to gently work and lengthen the muscles;
  • No irritation:  If something causes sharp pain and/or swelling, we drop it immediately from the routine.  We only add one item to PT every couple of days, then measure the effects.  We tried to go to 25% weight-bearing, and my knee blew up--so no more putting weight on the leg, back to NWB status on crutches.  Another example--my PT did an assisted quad stretch which is pretty much pushing on my leg while I'm face-down, trying to bend it until the quad gets stretched.  The PT was reluctant, but my quad spasms were driving me nuts, so I begged...that afternoon, my knee blew up.  The PT ditched the afternoon session and we just spent time massaging, doing ultrasound, patellar mobes, and Jobst treatment to pump swelling out of the leg.
  • Early ROM:  A knee that is not swollen bends better, so we spent a lot of time doing tissue work, phonophoresis, jobst treatments, IF/e-stim with ice (NO HEAT ALLOWED!), and serious elevation (like putting my legs on the wall while the PT massaged fluid out of the joint.
  • Early ROM and No Irritation:  My past history with post-op infection was a huge concern, and was likely a major reason I had so much scar tissue reform after surgery.  So we did a very big antibiotic IV push pre-op, and kept the wounds covered for 3 weeks, no showers without a dry wrap over the wounds, and Dr. S. used very strong internal stitches to enable me to get full ROM without worrying about popping the incisions open.

I'm going to post a link to my post-op thread, where I wrote in great detail what I was doing for the first four months of rehab.

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=1434.0

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline favouritesearcher

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #6 on: February 21, 2005, 07:32:57 AM »
Forgot Heather M's kneecap and patellar tendon work ... v important, both start day 1.

Heather M's patellar mobilisations and patella tendon massage (page 1, 6/10 of the way down):
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=11244.msg78947#msg78947
(Link to original worked when it was posted but didn't just now.)

Definitely need a doctor or physio to keep an eye on muscle balance, mal-tracking, special types of massage, etc.  Having an idea of the protocol lets one ask questions about exercises (a) the physio wants to do which aren't on the protocol, and (b) which aren't being done but should be.

JDM
« Last Edit: February 25, 2005, 07:57:32 AM by favouritesearcher »
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline Janet

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #7 on: February 23, 2005, 12:34:25 AM »
I think the thing that helped me the most was the limited weight bearing post-op. I was non-weight bearing for two weeks, then gradually added weight until I was off crutches at about 6 or 7 weeks. I then used a cane for a while longer.

Before my first scar tissue surgery, I was using a cane. Following the surgery, I continued with the cane. I never used crutches at all. The scar tissue came back. I changed doctors and after my second scar tissue surgery, I used crutches for a few days, but was urged to get off them quickly. The scar tissue came back. I changed doctors again. My last surgery (the one where I was NWB) was 19 months ago, and the scar tissue has not returned. This was the biggest change in the rehab, and the one I think helped the most.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Jaci

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #8 on: June 30, 2006, 05:13:36 PM »
A link to this thread was posted elsewhere recently; I had forgotten all about it. (Thanks, Shade, for the reminder.) I'm bumping it up since it might be helpful for others.


Jaci
« Last Edit: July 01, 2006, 04:58:44 PM by Jaci »
10/03 Twist injury
12/03 Menisectomy- tears ACL, MCL, & LCL missed by OS
Arthrofibrosis ROM 38-68
3/04- 4/08 Multiple scar tissue procedures:
6 scopes w/LOA, AIR, LR, chondroplasty, synovectomy, bone spur & plica removal
3 insufflations, many injections
Chronic AF, patella infera, IPCS

Offline Jaci

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #9 on: April 23, 2007, 02:08:31 AM »
Bump.

 :)
10/03 Twist injury
12/03 Menisectomy- tears ACL, MCL, & LCL missed by OS
Arthrofibrosis ROM 38-68
3/04- 4/08 Multiple scar tissue procedures:
6 scopes w/LOA, AIR, LR, chondroplasty, synovectomy, bone spur & plica removal
3 insufflations, many injections
Chronic AF, patella infera, IPCS

Offline rjs1956

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #10 on: April 23, 2007, 02:23:56 AM »
Every case is very different.  I had an LOA at Steadman-Hawkins in Greenville SC and I was told to go full weight-bearing as soon as I could the day after surgery.  Swelling has not been my problem, tight muscles and tendons are.  I went into surgery with ROM about 3 - 18.  Almost two weeks post-op I am now 0 - 60 - that's 60 degrees with the therpaist holding my leg down with my wincing.  My PT is ankle pumps, tissue massage, patella mobilization, quad flexes, straight leg raises "around the world", clams, wall slides, and calf stretches straight back to get the hamstrings to stretch as well. 
1970 patella dislocation
1/1/07 stage 4 petallfemoral osteoarthritis bone-on-bone
1/1/07 petallfemoral bone bruises "kissing lesions" quarter-sized
1/2/07 bruises bleeding into knee cavity, swollen, immobile
1/18/07 surgery to remove blood, swollen immobile, fibrosis starts
4/9/07 LOA Dr Folk

Offline ermintham

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #11 on: May 22, 2007, 04:19:10 AM »
bump
28/6/06 motorbike accident
31/8/06 scope to clean up the knee
16/11/06 ACLR
12/05/07 Diagnosed mild baja, ACL rupture due to malpositioned graft
1/6/07 ACLR revision

Post-op Diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=36990.0

Offline apple

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #12 on: May 25, 2007, 05:48:34 AM »
I just posted a "so far" success story last night, and I had a couple of different things, as well as the common ice and CPM.  I had the cryocuff on for six days (with small breaks in between) while in hospital and then took it home for two more weeks.  I was kept under an epidural, so as to"trick" my body into thinking that I had not experienced trauma to the joint.  CPM was for 24 hours constantly and then for five days alternated with a bolster under my ankle as extension was my main concern.  On my bolster while under epidural, my calf actually touched the bed (large Coffee can bolster)!  The CPM wouldn't take me much past 0 degrees and I need to be at 12 hyperextension.  At PT now, I am at 2-4 degrees (hyperextended) and 10ish when lying on my stomach.  After 2 and half years my atrophy has caused some difficulty, with a 10-15 degree lag, but it is improving every day.  Previously, I had my original ACL patellar Recon. and then two scopes and a MUA.  None helped with my extension before.  My protocol after recon, was wait 2 weeks before PT, and the other scopes and MUA was after 5 days.  It is clear that with arthrofibrosis, it is crucial that immediate ROM is absolutely necessary and the epridural helped with pain management, and the ice helped the swelling.  So far, so good...

Offline vbmom

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #13 on: May 25, 2007, 05:17:27 PM »
I know that this will probably not be a popular suggestion but........  My daughter had a major extension problem after ACL recon/lateral release, then a MUA, and then finally another scope to remove scar tissue.  They put her in a dynasplint in February and she still is wearing it.  She finally went flat 2 weeks ago and I have to think the dynasplint helped.  It never bothered her one bit like most posts implied (she is a tough kid though).  Now we are afraid to quit wearing it for fear of losing the extension.  It has been a long haul and we are finally getting close to seeing the light at the end.  Swimming was also amazing for her with kickboards etc.

vbmom

Offline Laurie

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Re: A Compilation Of Protocols For Rehab Post Arthrofibrosis Surgery
« Reply #14 on: May 27, 2007, 04:58:02 AM »
I come back to this board periodically and it's interesting to see so many people still fighting with something pertiaining to Arthrofibrosis.

In hindsight I would say that the 0 (zero) irritation and early ROM are the absolute.  What you do to achieve that is different for everyone.  But zero swelling and full range of motion are what you are after prior to any strength training.  It took me years to get my knee back.  It was over a year for the swelling and irritation to stop.  I did nothing.  I layed around with my leg elevated above my heart.  Iced.  and gentile ROM excersizes, i.e. wall slides, bike with no resistance and #1 was patellar mobilizations.  I think time is a factor.  Most people rush and want results.  Go slow.  Don't let yourself get too depressed.  (it's only normal)  Don't accept failure.

It can be done.

Laurie :)
Laurie :)















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