Anatomy

Ligaments are tough bands of tissue that connect the ends of bones. The posterior cruciate ligament (PCL) is located in the center of the knee joint. It connects the front of the femur (thighbone) and crosses to the back of the tibia (shinbone). The PCL is the primary stabilizer of the knee and the main controller of how far back the tibia moves under the femur. If the tibia moves too far back, the PCL can rupture.

The PCL is made of two thick bands of tissue bundled together. One part of the ligament tightens when the knee is bent; the other part tightens as the knee straightens. This is the reason the PCL is sometimes injured along with the ACL when the knee is forced to straighten too far, or hyperextend.

Causes

The most common way for the PCL to be injured is from a direct blow to the front of the knee while the knee is bent. The PCL controls how far backward the tibia moves in relation to the femur. If the tibia moves too far, the PCL can rupture.

Symptoms

The symptoms following a PCL tear can vary. Unlike an ACL tear, swelling is minimal with PCL injuries. The knee may also feel like it is giving way.

The pain and moderate swelling from the initial injury will usually go away after two to four weeks, but the knee may still feel unstable requiring treatment. If left untreated, long-term instability can lead to arthritis of the knee.

Diagnosis

The history of the knee and physical examination is probably the most important tool in diagnosing a ruptured or deficient PCL. During the physical examination, the surgeon will check to see if the tibia moves too far back on the femur. Tests are also done to see if other knee ligaments or joint cartilage have been injured.

The doctor may order X-rays to rule out a fracture. Ligaments and tendons do not show up on X-rays. Magnetic resonance imaging (MRI) is probably the most accurate test without actually looking into the knee. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. The pictures show the anatomy, and any injuries, very clearly. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis. Arthroscopy is a type of operation where a small fiber-optic TV camera is placed into the knee joint, allowing the orthopedic surgeon to look at the structures inside the joint directly. The vast majority of PCL tears are diagnosed without resorting to this type of surgery, though arthroscopy is sometimes used to repair a torn PCL.

Treatment

Non-Surgical Treatment

Initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications, such as acetaminophen, can help decrease these symptoms. A long-leg brace and crutches may be used initially to limit pain. Your doctor may allow you to put a normal amount of weight down while walking.

In less serious cases, PCL tears are usually treated with a progressive rehabilitation program. If you are returning to high-demand activities a knee brace may be needed. These braces are designed to replace knee stability when the PCL doesn’t function properly.

You most likely will receive physical therapy treatments after a PCL injury. Therapists treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

Exercises are used to help you regain normal movement of joints and muscles.
Range of motion exercises should be started right away to help you regain full movement in your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the therapist.

Exercises also improve the strength of the quadriceps muscles on the front of the thigh. As your symptoms ease and strength improves, you will be guided in specialized exercises to improve knee stability.

Surgery

If the PCL alone is injured, conservative treatment may be all that is necessary. When other structures in the knee are injured, surgery may be necessary.

The goal of surgery is to keep the tibia from moving too far back under the femur bone and to get the knee functioning normally again. Even when surgery is needed, most doctors will have you attend physical therapy for several visits before the surgery. Physical therapy before surgery helps reduce swelling, makes sure you can straighten your knee completely and can reduce the chances of scarring inside the joint. It can also help speed up recovery time after surgery.

Most surgeons now favor reconstruction of the PCL using a piece of tendon or ligament, called a graft, to replace the torn PCL. This surgery is often done using the arthroscope. Incisions are usually required around the knee, but the surgeon does not have to open the joint. The arthroscope is used to perform the work needed on the inside of the knee joint. Most PCL surgeries are done on an outpatient basis, and normally patients stay either one night in the hospital, or they go home the same day as the surgery.

In a typical surgical reconstruction, the torn ends of the PCL must first be removed. Once this has been done, the type of graft that will be used is determined. One of the most common tendons used for the graft material is the patellar tendon. This tendon connects the kneecap (patella) to the tibia.

Another very common graft involves using two of the hamstring muscle tendons that attach to the tibia just below the knee joint–the gracilis tendon and the semitendinosus tendon. By arranging the hamstring tendon into four strips, the graft has nearly the same strength as a patellar tendon graft.

If the patellar tendon is used, about one third of it is removed, with a plug of bone at either end. The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to place sutures (strong stitches) that will pull the graft into place.

Holes are then drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original PCL. The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

In some cases, an allograft is used. An allograft is tissue that comes from someone else. This tissue is harvested from tissue and organ donors at the time of death and sent to a tissue bank. The tissue is checked for any type of infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the physician and used to replace the torn PCL. The advantage of using an allograft is that the surgeon does not have to disturb or remove any of the normal tissue from your knee to use as a graft. The operation usually takes less time because the graft does not need to be harvested from your knee.

Rehabilitation

Conservative treatment of an injured PCL will typically last six to eight weeks. You will be able to return to your activities when your quadriceps muscles are close to their normal strength, your knee stops swelling intermittently, and you no longer have problems with the knee giving way.

If you have surgery, you may use a continuous passive motion (CPM) machine immediately after your operation to help the knee begin to move and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This “continuous” motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Your doctor may have you wear a protective knee brace for two to three weeks after surgery, in addition to using crutches to keep your knee safe. You will most likely be instructed to put a limited amount of weight down while you’re walking.

You may also take part in formal physical therapy after PCL reconstruction. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery.

Therapists will begin to focus on range of motion exercises within three weeks. They take care to avoid letting the tibia sag back under the femur, as this can put strain on the healing graft.

Strengthening exercises for the quadriceps muscle are safe to begin right away. Muscle stimulation and biofeedback, which both involve placing electrodes over the quadriceps muscle, may be needed to stimulate the muscle and help retrain it.

When you regain full knee movement, reduced swelling, and improved strength, you’ll gradually be able to return to your daily activities. Some doctors prescribe the use of a functional brace for athletes who intend to return quickly to their sport.

You will probably be involved in a progressive rehabilitation program for four to nine months after surgery to ensure the best result from your PCL reconstruction. In the first six weeks following surgery, expect to see the physical therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see your therapist every few weeks over the four to six month period.

Anatomy

Ligaments are tough bands of tissue that connect the ends of bones together. The collateral ligaments, located on either side of the knee, limit side to side motion of the knee. The medial collateral ligament (MCL) is found on the side of the knee closest to the other knee. The lateral collateral ligament (LCL) is found on the opposite side of the knee.

If an injury causes these ligaments to stretch too far, they may tear. The tear may occur in the middle of the ligament, or where the collateral ligament attaches to the bone. If the force from the injury is great enough, other ligaments may also be torn. The most common combination is a tear of the MCL and a tear of the anterior cruciate ligament (ACL). The ACL runs through the center of the knee and controls how far forward the shinbone moves in relation to the thighbone.

While MCL tears are more common, a torn LCL has a higher chance of causing knee instability. One reason for this is that the top of the shinbone forms a deeper socket on the side nearest the MCL. On the other side, near the LCL, the surface of the tibia is flatter, and the end of the shinbone can potentially slide around more. This difference means that the side of the knee joint where the LCL is found is more likely to become unstable as a result of a collateral ligament injury.

Causes

The collateral ligaments can be torn in sporting activities, such as skiing or football. This usually occurs when the lower leg is forced sideways–either toward the other knee (medially) or away from the other knee (laterally). A blow to the outside of the knee while the foot is planted can stress the MCL and result in a tear of the ligament. Slipping on ice can cause the foot to move outward, taking the lower leg with it. The body weight pushing down causes an awkward and unnatural force on the whole leg. As a result, the MCL may be torn because the force hinges the knee open, putting stress on the MCL.

The LCL is most often injured when the knee is forced to hinge outward away from the body. It can also be torn if the knee gets snapped backward too far (hyper extended).

Symptoms

An injury severe enough to actually tear one of the collateral ligaments causes significant damage to the soft tissues around the knee. There is usually bleeding into the tissues around the knee, swelling of the tissues, and perhaps bleeding into the knee joint itself. As the initial stiffness and pain subsides the knee joint may feel unstable, and the knee may give way and not support your body weight.

Chronic, or long-term, instability due to an old injury to the collateral ligaments is a common problem. If a torn ligament heals but is not tight enough to support the knee, a feeling of instability will persist. The knee will give way at times and may be painful with heavy use.

Diagnosis

History and Physical Exam

The initial physical examination usually gives a very good indication of which ligaments have been torn in and around the knee. In some cases, there is too much pain and muscle spasm to completely tell what is damaged in your knee. Your physician may suggest a period of rest with a knee splint and then reexamine the knee in five to seven days.

Radiological Tests

X-rays may be required to rule out the possibility that any bones have been damaged. Stress X-rays may be useful to confirm that one of the collateral ligaments has been torn. Stress X-rays are plain X-rays taken with someone attempting to open the side of the joint that is suspected of being unstable. The X-rays will show a widening of the joint space on that side if instability is present.

Magnetic resonance imaging (MRI) may be ordered if there is evidence that multiple injuries have occurred, including injury to the ACL or cartilage in the knee joint (also called the meniscus). The MRI machine uses magnetic waves rather than X-rays to create pictures that look like slices of the knee. Usually this test is done to look for injuries, such as tears in the meniscus or ligaments of the knee.

This test does not require any needles or special dye and is painless. If there is uncertainty in the diagnosis following the history and physical examination, or if other injuries in addition to the collateral ligament tear are suspected, an MRI scan may be suggested.

Treatment

Non-Surgical Treatment

An isolated injury to the LCL or MCL rarely requires surgery. Significant tears to the LCL are usually treated by holding the knee straight in a cast or brace for three weeks. Most doctors opt not to immobilize the knee in a cast when the MCL is torn. Some doctors prefer to issue their patients a knee brace after the injury if there is significant pain and instability.

Initial treatments for a collateral ligament injury focus on decreasing pain and swelling in the knee. Rest and anti-inflammatory medications, such as aspirin, can help decrease these symptoms. You may need to use crutches until you can walk without a limp.

Physical therapy treatments are common for collateral ligament injuries. Therapists may treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

Exercises are used to help you regain normal movement of joints and muscles. Range of motion exercises should be started right away to help you regain full movement of your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the joint by the therapist.

When you regain full knee movement and improved strength, gradually you’ll be able to return to work and activities. Some doctors prescribe the use of a functional brace for athletes who intend to return quickly to their sport. These braces give support and help the knee work better after an injury.

Surgery

If other structures in the knee are injured, surgery may be required. Some surgeons feel that a combination of an ACL tear and an MCL tear should be treated surgically. Others disagree and feel that the MCL tear should be treated conservatively first and the ACL reconstructed later.

Repair of a recently torn collateral ligament usually requires the surgeon to make an incision through the skin over the area where the tear in the ligament has occurred. If the ligament has been pulled from its attachment on the bone, the ligament is reattached to the bone with either large sutures (strong stitches) or a special metal bone staple. Tears to the middle areas of the ligament are usually repaired by sewing the ends together.

Chronic swelling or instability caused by a collateral ligament injury may require a surgical reconstruction. Reconstruction differs from repair of the ligaments, described earlier. A reconstruction operation usually works by either tightening up the loose ligaments or replacing the loose ligament with a tendon graft.

In the tightening procedure, your doctor will use the remaining ligament tissue and take up the slack. This is usually done by detaching one end of the ligament from its place on the bone and moving it so that it becomes tighter. The ligament is then reattached to the bone in the new place and held with metal staples or sutures.

If a tendon graft is needed to replace the loose ligament, it is usually taken from somewhere else in the same knee. Taking tissue from your own body is called an autograft. A common autograft that is used is one of the hamstring tendons called the semitendinosus tendon. Studies have shown that this tendon can be removed without affecting the strength of the leg. In this operation, your doctor will use the tendon graft to replace the damaged ligament. The ends of the tendon graft are attached to the bone using large sutures or metal staples.

Another way to replace a badly torn collateral ligament is with an allograft. For this procedure, the surgeon gets graft tissue from a tissue bank. This tissue is usually removed from an organ donor at the time of death and sent to a tissue bank. There the tissue is checked for infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the physician and used to replace the torn ligament.

Rehabilitation

Minor sprains of either the MCL or LCL should heal within four to six weeks. Moderate tears should rehabilitate within two months and severe MCL tears require up to three months. If patients are still having problems after three months, they will likely need surgery. Treatment for severe tears or ruptures of the LCL are the challenging, because they tend to leave the knee joint unstable, and patients with this condition typically don’t do well with non-surgical care.

Rehabilitation proceeds cautiously after surgery of the collateral ligaments, and treatments will vary depending on the type of surgical procedure that was used. Some doctors have their patients use a continuous passive motion (CPM) machine after surgery to help the knee begin to move and to alleviate joint stiffness. Most patients are prescribed a hinged knee brace to wear when they are up and about. Doctors occasionally cast the leg after reconstruction surgery of the LCL.

You are strongly advised to follow the recommendations about how much weight your knee can bear while standing or walking. After a ligament repair, you will be instructed to put little or no weight on their foot when standing or walking for up to six weeks. Weight bearing may be restricted for up to twelve weeks after a ligament reconstruction.

You usually take part in formal physical therapy after collateral ligament surgery. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. The goal is to help you regain full knee motion as soon as possible. Physical therapists will also work with you to make sure you are using crutches safely and only bearing the recommended amount of weight while standing or walking.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function. Ideally, you will be able to resume their previous lifestyle activities. You may be encouraged to modify their activity choices, especially if an allograft procedure was used.

The physical therapist’s goal is to help you keep your pain under control, ensure only a safe amount of weight is placed on the knee, and improve their range of motion and strength. When patients are well underway, regular visits to the therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Introduction

The anterior cruciate ligament (ACL) is the most commonly injured ligament of the knee, and it is most frequently injured during an athletic activity. Sports are becoming an increasingly important part of day-to-day life in the United States, increasing the number of ACL injuries. This injury has received a great deal of attention from orthopedic surgeons over the past 15 years, and very successful operations have been developed to reconstruct the torn anterior cruciate ligament.

Anatomy

The ACL controls how far forward the tibia moves in relation to the femur. If the tibia moves too far, the ACL can rupture. The ACL is also the first ligament that becomes tight when the knee is straight. If the knee is forced past this point, or hyperextended, the ACL can also be torn.

This tearing of the ligament results in a loud pop and a feeling of instability in the knee. The ACL may not be the only ligament injured when the knee is twisted violently, such as in a clipping injury in football. It is not uncommon to see both the medial collateral ligament (MCL) and the ACL injured.

Causes

The major cause of injury to the ACL is sports related. Numerous types of sports-related activities have been associated with ACL tears. Those sports requiring the foot to be planted and the body to change direction rapidly (such as basketball) carry a high incidence of injury. Football is frequently the source of an ACL tear because it combines the activity of planting the foot and rapidly changing direction with the threat of bodily contact. Downhill skiing is another frequent source of injury, especially since the introduction of ski boots that extend higher up the calf. These boots move the forces caused by a fall to the knee rather than the ankle or lower leg. The ACL injury usually occurs when the knee is forcefully twisted or hyperextended. Many patients recall hearing a loud pop when the ligament tears and feeling the knee give out.

There has been a dramatic increase in the number of females who suffer ACL tears. This is in part due to the rise in women’s athletics, but studies have shown that female athletes are more likely to suffer this injury then their male counterparts. It is uncertain why this is the case. Initially, it was thought that females were at higher risk because of differences in training intensity. But more evidence suggests that there may be a difference in the anatomy of the female knee, or the female ligament may not be as strong due to the effects of the female hormone estrogen. These factors may lead to a higher risk of ACL injury for the female athlete.

Symptoms

The symptoms following a tear of the ACL vary in different people. Usually, swelling of the knee occurs within a short time following the injury. This is due to bleeding into the knee joint from torn blood vessels in the damaged ligament.

The instability caused by the torn ligament leads to a feeling of insecurity and weakness of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to bend too far backwards.

The pain and swelling from the initial injury will usually be gone after two to four weeks, but the instability remains. The symptom of instability and the inability for the patient to trust the knee for support is what requires treatment.

Also important in making decisions on how to treat the knee is the growing realization by orthopaedic surgeons that long-term instability leads to early arthritis of the knee. Many orthopaedic surgeons feel that by treating the instability and performing a reconstruction of the ligament, the risk of developing wear and tear arthritis in the knee can be reduced.

Diagnosis

The history and physical examination is probably the most important tool in diagnosing a ruptured or deficient ACL. In an acute injury, the swelling is a good indicator. Any intense swelling that occurs within two hours of a knee injury usually means blood in the joint, or a hemarthrosis. If the swelling occurs the next day, the fluid is probably from the inflammatory response. Placing a needle in the swollen joint and draining as much fluid as possible gives relief from the swelling and provides useful information to your doctor. If blood is found when draining the knee, there is a 70 percent chance it came from a torn ACL. X-rays of the knee may also be ordered on the initial examination to rule out a fracture. Ligaments and tendons do not show up on x-rays. However, bleeding into the joint also occurs when a fracture through the knee joint is present, or when portions of the joint surface are chipped off.

The most accurate of the noninvasive tests for the knee is the MRI scan. The MRI (magnetic resonance imaging) machine uses magnetic waves rather than x- rays, to show the soft tissues of the body. With this machine, we are able to “slice” through the area we are interested in and see the anatomy and injuries very clearly. This test does not require any needles or special dye and is painless.

If there is a question about what is causing the knee problem, arthroscopy may be used to make the definitive diagnosis. Arthroscopy is an operation where a small fiber optic TV camera is placed into the knee joint, allowing the orthopaedic surgeon to look at the structures inside the knee joint directly. The vast majority of ACL tears are diagnosed without resorting to surgery, and arthroscopy is usually reserved to treat the problems identified by other means.

Treatment

Initial treatment for ACL injury includes crutches and rest until the swelling resolves. The knee joint may be aspirated to remove the blood in the joint. The word “aspiration” means to remove fluid from the body. The knee is aspirated by inserting a needle into the joint and drawing out the blood.

Once the initial pain and swelling begins to resolve, physical therapy will probably be initiated to regain as much of the normal range of motion as possible. One of the problems with a torn ACL is that small proprioceptive nerve endings in the ligament are torn as well. These nerves are there to give the brain information about where the body is in 3D space. These nerves are what make it possible for you to touch your nose with your eyes closed.

The joints rely on these nerves to fine tune the muscles’ actions to allow the joint to function properly. A good physical therapy program will help retrain these nerves and strengthen other muscles that will take over some of the functions of stabilizing the knee joint from the loss of the ACL.

To help replace the stability of the knee, an ACL brace may be suggested. These braces are fairly effective at preventing the knee from giving way during strenuous activity. Most of these braces must be fitted by a certified orthotist, a physical therapist, or physician. They are not the type you can buy at the drugstore. Most orthopaedists will recommend wearing a brace for at least one year after a reconstruction. So even if surgery is performed, a brace is a good investment.

If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. Most surgeons now favor reconstruction of the ACL using a piece of tendon or ligament to replace the torn ACL. Today, this surgery is most often done using the arthroscope. Incisions are usually required around the knee, but the joint itself is not opened. The arthroscope is used to perform the work needed on the inside of the knee joint. Most patients can expect at least one night in the hospital, although more and more surgeries are being done on an outpatient basis.

In the typical surgical reconstruction, the torn ends of the ACL must first be removed. Once this has been done, the type of graft that will be used is determined. One of the most common tendons used for the graft material is the patellar tendon. This tendon connects the knee cap (patella) to the lower leg bone (tibia). Another very common graft combines two of the hamstring muscle tendons that attach to the tibia just below the knee joint — the gacilis tendon and the semitendinosis tendon. Studies have shown that these two tendons can be removed without affecting the strength of the leg. There are other hamstring muscles that can take over the function of the two tendons that are removed.

If it is used for graft material, about one third of the patellar tendon is removed, with a plug of bone at either end.

The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to hold sutures that will pull the graft into place. The next procedure prepares the knee to receive the graft.

The intracondylar notch is enlarged so that there is no rubbing on the graft. This process is referred to as a notchplasty. Once this is done, holes are drilled in the tibia and the femur to place the graft.

These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL. The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

Other types of materials are also used to replace the torn ACL. In some cases, an allograft is used. An allograft is tissue that comes from someone else. This tissue is harvested from tissue and organ donors at the time of death and sent to a tissue bank. There the tissue is checked for any type of infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the physician and used to replace the torn ACL. The advantage of using allograft is that the surgeon does not have to disturb or remove any of the normal tissue from the knee to use as a graft. The operation also usually takes less time because the graft does not need to be harvested from the knee.

After surgery, a physical therapist will be contacted to begin a rehabilitation program. Some type of rehabilitation will likely be required for six months after surgery to ensure the best result from the ACL reconstruction. Most patients see the physical therapist about three times a week the first six weeks following surgery. Following the initial period, a home program may be initiated and monitored by the therapist.

As with all major surgical procedures, complications can occur. some of the most common complications following knee replacement are thrombophlebitis, infection, stiffness and loosening. This is not intended to be complete list of the possible complications, but these are the most common complications.

Thromboplebitis

Thrombophlebitis, sometimes called Deep Venous Thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots within the veins. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they get lodged in the capillaries of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary = lung, embolism = fragment of something traveling through the vascular system). Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible! Some of the commonly used preventative measures include pressure stockings to keep the blood in the legs moving and taking medications that thin the blood and prevent blood clots from forming.

Infection

Infection can be a very serious complication following an artificial joint replacement surgery. The chance of getting an infection following artificial knee replacement is probably somewhere around 1%. Some infections may show up very early – before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

Stiffness

In some cases, the ability to bend the knee does not return to normal after an artificial knee replacement. Many orthopaedic surgeons are now using a machine known as a CPM machine (continuous passive motion) immediately after surgery to try and increase the range of motion following artificial knee replacement. Other orthopaedic surgeons rely on physical therapy beginning immediately after the surgery to regain the motion. It is not clear which is the best approach. Both approaches have benefits and risks, and the choice is usually made by the surgeon based on his experience and preferences. To be able to use the leg effectively to rise from a chair, the knee must bend at least to 90 degrees. A desirable range of motion should be greater than 110 degrees. Balancing the ligaments and soft tissues (during surgery) is the most important determining factor in regaining an adequate range of motion following knee replacement, but sometimes increasing scarring after surgery can lead to an increasingly stiff knee. If this occurs, your surgeon may recommend taking you back to the operating room, placing you under anesthesia once again, and forcefully manipulating the knee to regain motion. Basically, this allows the surgeon to breakup and stretch the scar tissue without you feeling it. The goal is to increase the motion in the knee without injuring the joint.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. There have been great advances in extending how long an artificial joint will last, but all will eventually loosen and require a revision. A loose prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the knee replacement.

Activity Immediately Following Surgery

The amount of weight you can put through your knee after surgery will depend on your doctor and the procedure itself. If a cemented procedure was performed, your doctor may approve for you to place a comfortable amount of weight through your operated leg after surgery using your walking aid. If the surgery was done without cement, you may be directed to limit the amount of weight through the operated leg to only a “toe touch” amount of weight for four to six weeks after surgery. There are different ways to surgically reconstruct knees, so the instructions you are to follow after surgery will depend on your doctor and the way the surgery was done.

Precautions: Follow your instructions for the amount of weight you can put through your operated knee. Avoid activities that put a strain on the surgical area. During your activities, let pain guide your decisions. If you feel pain with any activity, stop or alter what you are doing because pain at this stage is an indicator of strain or irritation.

Exercises: Any exercises you do should be done only by the direction of your doctor or therapist. The choices of exercise used after surgery will be gauged by the type of procedure used. You may be given a few exercises that you can do for your ankle and foot. Gently bending and straightening your ankle can keep your calf muscle flexible while “pumping” away excess swelling. Some exercises are used to help control pain and help with movement in the knee. Low grade exercises for the thigh muscles can usually begin right away. Extra pain felt after these or other exercises gives an idea if you are overdoing it. You may need to change the number of repetitions, the amount of pressure, or the how often you are doing the exercises.

Inpatient Physical Therapy

Some doctors will put your knee in a machine right after surgery that slowly and gently bends and straightens your knee. This is called continuous passive motion or CPM. It is often used along with a form of cold treatment that may include a flow of cold water that circulates through hoses and pads around your knee.

Your physical therapist may schedule to see you in the hospital on the same or next day after surgery. The first visit gives your PT an idea of how well your knee is moving, how well you can move in bed, your safety when getting up and sitting on the edge of the bed, and whether you can begin to walk using a walking aid and putting the right amount of weight through your foot. As you gain more confidence and endurance with walking, your therapist will begin to train you how to go up and down stairs using your walking aid.

You may also begin doing a few exercises in your hospital room during the first visit. Gentle range of motion exercises can be used to help begin to restore knee movement. You could begin a series of strengthening exercises for the thigh and leg muscles too. As your condition improves, you may be transported by wheelchair to the physical therapy gym for your treatment sessions.

While you are an inpatient, your therapist may see you for therapy up to two times each day. You can expect to stay in the hospital at least three to four days after surgery. You may be released to go home when you can get in and out of bed safely, walk with the right amount of weight on your foot using a walking aid, go up and down stairs safely, and do your exercises by yourself.

After You Leave the Hospital

Once discharged from the hospital, you may be seen in the home for treatment. This is to make sure you are safe in and around your home. You could be seen for at least one home visit for the safety check and to review your exercise program.

Outpatient Physical Therapy

On your first outpatient visit, your physical therapist will want to gather some more information about the history of your condition. You may be given a questionnaire that helps you tell about the day-to-day problems you are having because of your condition. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your therapist gauge how much pain you have now and how your pain and symptoms change once you’ve had treatment. Your therapist will probably ask some more questions about your condition to get an idea how your knee has been feeling since your surgery:

• How is your knee feeling since the surgery?
• Where do you feel your pain now?
• Do you have any popping or clicking in the knee?
• Are you getting any more swelling?

Physical therapy Evaluation

Once all this information has been gathered, your condition will be evaluated. The main parts of the evaluation are listed below and may be done in the order chosen by your therapist.
Posture/observation: Your physical therapist will check your overall posture, including the alignment of your low back, pelvis, and your knees and ankles. These have a significant role in the health of your knee. Your therapist will also check the surgical area to make sure the incisions are healing. By comparing each side, your therapist can determine if there is extra swelling, bruising, or a loss in the size of your muscles.

Gait analysis: By watching you walk back and forth, your therapist can make sure your walking aid is adjusted for you and that you are using it safely. The amount of weight you put through your leg will depend on your doctor and the type of procedure done (cemented or not).

Range of motion (ROM): Your therapist will check the ROM in your knee. This is a measurement of how far you can move your knee forward and back (flexion/extension). You may have pain and limited movement in both directions. Movement of the knee cap (patella) is also checked to see that it is moving freely. Your ROM is written down to compare how much improvement you are making with the treatments.

Strength: Your therapist will test the strength of your muscles. You could be asked to hold against resistance as your therapist tests the muscles around the knee. Other muscles that may be checked include the hip, buttocks, and calf muscles. These measurements are compared to your other side. Weakness in key muscles will be addressed with a strengthening program.

Girth: Using a tape measure, your therapist may compare the circumference of your thigh, knee, and calf. This can give an indication of swelling or whether your muscles have lost size (atrophied) from a lack of use or from having pain.

Manual examination: You may be given a manual examination of the knee. Your therapist will carefully move your leg in different positions to make sure that the knee and other joints are moving smoothly. Your therapist will also look at the flexibility of the muscles and tendons around your knee. This type of exam can help guide your therapist to know which type of treatments will help you the most.

Palpation: Palpation is when your therapist feels the soft tissues around the sore area. This is done to check the skin for changes in temperature, to see how much swelling you have, to pin-point areas of soreness, and to see if there are tender points or spasm in the muscles around the knee joints. This can help your therapist get a good idea about which treatments will help you the most.

Treatment Plan: Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. The plan also lists the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.

Using Physical Therapy to Ease Pain

Your therapist may choose from one or more of the following tools, or modalities, to help control the symptoms you may have from your knee surgery.

Rest: Rest is an important part of treatment after surgery. If you are having pain with an activity or movement, it should be a signal that there is still irritation going on. You should try to avoid all movements and activities that increase your pain. Be sure to use your crutches as assigned by your doctor, and put only the amount of weight on your leg as approved by your doctor.

Ice: Ice makes the blood vessels in the sore area become more narrow, called vasoconstriction. This helps control inflammation that is causing pain and can easily be done as part of a home program. Some ways to put ice on include cold packs, ice bags, or ice massage. Cold packs or ice bags are generally put on the sore area for 10 to 15 minutes.

Heat: Heat makes blood vessels get larger, which is called vasodilation. This action helps to flush away chemicals that are making your knee hurt. It also helps to bring in nutrients and oxygen which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin doesn’t overheat and burn. It’s also not a good idea to sleep with an electric hot pad at night.

Swelling control: Massage, cold whirlpool treatment, or compression therapy may be used to control swelling by flushing the extra fluid away from the area. The use of cold, compression, and elevation are a beneficial combination for reducing swelling.

Electrical stimulation: This treatment stimulates nerves by sending an electrical current gently through your skin. In the acute treatment after meniscal surgery, the stimulation can ease pain and help remove swelling. It is often used in combination with ice in the early stages and heat in the later stages of recovery. This treatment stimulates nerves by sending an electrical current gently through your skin. Some people say it feels like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort.

Improving range of motion (ROM): To improve your ROM, your therapist can use graded joint mobilization, manual stretching, and select exercises. The swelling and irritation from a knee surgery can cause movement problems in the knee cap. Getting your knee cap moving will help with your overall knee ROM. Active movement and stretching as part of a home program can also help restore movement.

Gait Training: Once you are safe to put full weight through your operated leg, your therapist will work with you to “fine tune” your gait. Retraining may be needed if you’ve developed a limp, which may be due to apprehension of pain or simply from a habit you’ve developed since your injury or surgery. Getting a normal walking pattern starts with shifting your weight when you walk. If you can visualize the way competitive speed skaters sway their hips when they skate, you’ll get the picture of what it means to shift your weight. When you place your sore-side foot down and prepare to step through with the opposite foot, you may be hesitant to shift the weight of your hip over your planted foot. This leads to an antalic gait–better known as a limp. Practicing this part of the walking cycle may be all that is needed to help you “remember” how to walk without a limp. Your therapist will also make sure that your steps are equal in width and length.

Aquatic therapy: By doing exercise in a pool, the properties of buoyancy and warmth let you exercise with ease of movement. The buoyancy of the pool can be used to make exercise easier, to give resistance with some of the exercise, and to help you begin walking with less stress on your new knee. The warmth can help muscles relax, improve circulation, and ease soreness; letting you move easier. If your therapist works with you in the pool, a few visits are usually all that is needed before you get into a regular program on land. If you are getting good benefits in the pool, you will probably want to get a membership to the pool so your other visits can be used to work on strengthening, walking, and getting you back to doing the activities you enjoy.

Strengthening and Exercise

After a knee surgery, you can expect that your leg muscles will be weak. When muscles weaken from pain or disuse, other muscles overpower the weaker ones. This leads to an imbalance where the weaker muscles become longer and the stronger muscles become shorter. These imbalances change the way the joints usually work. The swelling and pain from your knee pain and surgery can lead to weakened muscles around the knee. The quadriceps muscle usually is affected. Exercises can be chosen to help regain the strength in the muscles around the knee.

Biofeedback: Muscle control is the basis for strength. Using biofeedback can help you get back the contol of the quadriceps muscle. The biofeedback unit has surface electrodes that are put on the skin over the muscle that needs help. As you practice working the muscle, the machine will give you “feedback” to let you see and hear how the weak muscle is performing. The biofeedback unit can also be set to alert you if other muscles are overpowering the weak muscle. Biofeedback can be used while you do your exercise program so you’ll know if you’re actually working the right muscle.

Functional Electrical Stimulation (FES): This is a way to use electrical stimulation to help retrain a weakened or deconditioned muscle. Electrodes are placed over the muscle that is to be retrained. The electrical current passes through the skin and stimulates the motor nerve of the muscle causing it to tighten for a set time without your conscious effort. The machine is usually set to go on for about 10 to 15 seconds and then off for 15 to 30 seconds. Once you get the idea of how the muscle feels when it tightens, you can begin tightening the muscle when the current comes on again. After you get a good contraction going, you should be able to sucessfully tighten the muscle without the use of the current.

Progressive Resistive Exercises (PREs): Many choices of PREs are now used in rehabilitation. Some of these choices include pulley systems, free weights, rubber tubing, manual resistance, and computerized exercise devices. Using PREs is a way to apply graded resistance to muscle groups to gradually help them gain endurance and strength. These exercises typically start with lighter weights with lots of repetitions, and as endurance increases, more weight is gradually used with fewer repetitions.

Exercise Precautions: First, avoid “overdoing” it. If you find that your knee swells up late in the day, it may be a sign you may doing too much too quickly. Second, avoid pain. Pain is an indicator that something isn’t right. You may feel some discomfort with your exercises, but this should be “reasonable” discomfort. If pain is excessive or lasts more than one hour after exercise, inform your therapist at your next visit. You may need to change the number of repetitions, the amount of pressure, or the how often you are doing the exercises.

Progressive Exercise: Exercises will be given to help improve motion, strength, and endurance in the knee. Your program will also address key muscle groups of the buttocks, thigh, and calf. Other exercises can be used to simulate day-to-day activities like stair climbing, pivoting, and squatting, depending on which phase you have completed. Following are some types of exercises that may be used to help your condition.

Closed Kinetic Chain (CKC) Exercises: These are exercises in which the foot is kept on the ground while movement and resistance take place in the joints and muscles above. These types of exercises are important because they are so much like the activities we do every day. For example, a partial squat exercise is the same action as lowering yourself onto a chair or couch. A leg press is a lot like the action of going up a stair or step. These exercises add strength and stability around the muscles and joints of the hip and leg.

Proprioceptive Exercises: These are exercises that help retrain your position sense, also called “joint sense.” If you close your eyes and hold up your hand, you know what your hand is doing, even though you don’t “see” it. We get position sense by way of our vision, middle ear balance, and from tiny receptors in the ligaments and joints. When we close our eyes, we rely on middle ear balance and these special receptors to keep us upright. If there has been swelling or injury in or around a joint, these tiny receptors get injured and do not recover. You can do certain exercises to get the other receptors to do more, regaining what was lost with the damaged receptors. The loss of position sense puts the joint at further risk of injury because the joint loses stability, like having loose lug nuts on a wheel of a car. Special exercises, called proprioceptive or neuromuscular exercises, help protect the knee by “tightening the lug nuts.” You can think of these exercises like balance training. Examples include balancing on one leg with your eyes open/closed, walking on uneven or soft surfaces, or practicing on a special balance board. Some therapists use special manual exercises to get the other receptors working better.

Home Program

As your condition keeps getting better, you will be given advanced exercises to do at home or in a gym setting. You will recheck with your therapist at regular intervals to make sure you are doing these exercises routinely and safely. During these rechecks, you may be given additional exercises to work on over the next few weeks. Eventually you will be progressed to a final home program. Once you’ve been released to full activity, you may be instructed to follow up with a few visits over the next few months. This will give a comparison of strength and function of the operated knee and to make sure you are performing at peak levels. Before you are completely done with therapy, more measurements will be taken to see how well you’re doing now compared to when you first started in therapy.

What do your joints have to do with your teeth? Quite a bit, if you have a joint replacement. Patients with joint replacements should be sure to mention their new joint replacement to their dentist before undergoing any procedures.

Why? Because certain dental procedures could cause bacteria found in the mouth to travel through the bloodstream and settle in your artificial joint. This increases your risk of contracting an infection, according to the American Dental Association (“Receiving antibiotics before dental treatment. JADA , Nov 2003).

“Any time you work in the mouth, there is a possibility of bleeding,? said Matthew L. Creech, DDS, of Fort Wayne Dental Group in Indiana. ?If bleeding occurs, germs can enter the bloodstream and travel to the newly replaced joint area,? Dr. Creech said.

Dental procedures carrying a higher risk of bleeding or producing high levels of bacteria in the blood include tooth extraction, periodontal treatment, dental implant placement, some root canal work, initial placement of orthodontic bands, certain specialized local anesthetic injections, and regular dental cleanings, if bleeding is anticipated.

Preventative antibiotics can be prescribed for you to help decrease the chances of getting an infection after your dental work. ?Pre-medication with an antibiotic is recommended for a period of time after a joint replacement,” Dr. Creech said. The American Dental Association and the American Academy of Orthopaedic Surgeons agree that for the first two years after a joint replacement, you may need antibiotic therapy for dental procedures. After that, only high-risk patients may require antibiotics for certain dental treatments.

According to the American Academy of Orthopaedic Surgeons, you should also get preventive antibiotics before dental procedures if:

• You have an inflammatory type of arthritis such as rheumatoid arthritis or systemic lupus erythematosis
• Your immune system has been weakened by disease, radiation or drugs
• You have insulin-dependent (Type I) diabetes
• You are undernourished or malnourished
• You have hemophilia

Also, be sure to talk with your dentist about any new or different medicine you may have started taking since your last dentist appointment.