A main concern for any of us working with post-op TKA is lack of ROM, especially knee extension. We know the patient should obtain full extension as soon as possible for proper gait & arthrokinematics of the tibiofemoral joint. Not only for short term for long term control to help prevent hip and back problems in the future.
The debate may go on forever on the other factors that will affect this: vitality of the knee from the length and amount of contracture before surgery, how early rehab is implemented post-op, the type of intervention and just overall patient’s general activity level and adherence to therapy. Hindsight is 20-20, lets look into the solution…or lack of an adequate solution.
Contracture is defined as the shortening of connective tissue. Lack of knee extension can be tightening of biceps femoris, ligaments and mostly the posterior capsule. This does not respond to pounding on the joint with our body weight, but to daily low-load, long-duration stretch and in my opinion, consistent knee extension moment maneuvers. The key here is daily and not aggressive pounding of the joint.
We have many avenues to address this but one that I just do not like is when the therapist uses excessive force mobilizing the knee into extension. I have seen general A/P gliding as if the therapist wanted to break it the prosthesis to literally sitting on the knee. Is this really needed? Wouldn’t you think guarding, rebounding and just plain ol’ patient resistance would make this ineffective? If you see a 2 degree change afterwards in the clinic, is this really functional and what is the carry-over?I’m not sure if being so aggressive makes us feel authoritative, powerful or just want to make a statement. Needless to say, it is ridiculous. We don’t do this with other surgeries, why the knee?
My solution? Well, I don’t do what is described above. I feel graded grade 2-3 mobilizations in both anterior/posterior and posterior/anterior (more pain relieving) is very effective. Even IR of tibia on femur is very responsive. Most surgeons don’t address the mechanical fault, just take out arthritic joint. See past post on this topic. Theoretically, am I taking the joint into the “end-range” with grade 2-3? No, but does it have to be? Would the patient respond better to pain-relieving manual therapy (even at late stages in post-op) than painful, not-looking-forward-to-any-physical-therapy-again approach?
My Top 5 Approaches:
1. Mobilizations per description above and picture below. NOT brutality and war with the knee.
2. Knee Extension Moment Exercises. See pictures below for a few examples.
3. Low-load, long-duration stretch. Weight on knee with moist heat seated seems to be more effective than prone knee extension hanging from plinth. We know what this looks like.
4. Dynamic splinting. A good case report here. Main reason this is not picked earlier is because I have not seen it personally.
5. NOT sitting on knee.
What is your approach to this condition? Is myofascial releases your agenda? Have you been exposed to dynamic splinting and if so, is it effective? What products do you use?