Wellness & Lifestyles Australia

KNEE ARTHROSCOPY REHABILITATION E-BOOK

Prepared by: Daniella Kittel

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE .................................................................................................................1 INTRODUCTION ......................................................................................................................2 KNEE ANATOMY ......................................................................................................................3 KNEE ARTHROSCOPY ................................................................................................................4

Indications for surgery:................................................................................................... 4 The procedure: ............................................................................................................ 4

AFTER YOUR KNEE ARTHROSCOPY ................................................................................................6 Advice and information:.................................................................................................. 6 Walking...................................................................................................................... 7 Recovery .................................................................................................................... 7

REHABILITATION AFTER KNEE ARTHROSCOPY STAGE 1........................................................................8 REHABILITATION AFTER KNEE ARTHROSCOPY STAGE 2...................................................................... 11 SUMMARY ........................................................................................................................... 15 RESOURCES ......................................................................................................................... 16 CONTACT US ....................................................................................................................... 17

MANUAL LAST MODIFIED 23/08/2011

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION Welcome to the W&L series of e-Books. You have chosen the edition on knee arthroscopy. This resource will be beneficial to:

Anyone who is interested in the anatomy and biomechanics of the knee joint Anyone who is considering a knee arthroscopy and is wondering what the procedure involves Anyone who would like a guide to knee rehabilitation after surgery

The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.

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KNEE ANATOMY

Diagram taken from: The Center for Orthopaedics & Sports Medicine (2003), Torn Cartilage (Meniscus), viewed 15th April 2011

http://www.arthroscopy.com/sp05005.htm The knee joint has two parts, the patellofemoral and the tibiofemoral joints. The patellofemoral joint is between the knee cap (patella) and the femur bone. The femur has a groove at the front which the patella sits in and is able to slide up and down when the knee bends and straightens. The main knee joint is between the femur and tibia. The joint surface of the tibia (the shin bone) is relatively flat and has articular cartilage and menisci covering the bone. The femur (thigh bone) is rounded to allow for a rolling movement on the flat tibia and also has articular cartilage. There are large muscles and ligaments surrounding the knee joint to keep the joint secure and transmit weight through the tibiofemoral joint evenly.

1. The menisci and articular cartilage act to absorb force in your knee. If they become worn and rough with degeneration or injury, they can cause catching, locking giving way and/or pain in your knee. Alternately, if the structures around the knee cap are tight then they can pull the knee cap off to one side when the knee is bending or straightening, resulting in pain, discomfort and degeneration.

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KNEE ARTHROSCOPY

Indications for surgery: Knee arthroscopies can be performed in order to examine and repair the knee after a variety of injuries. The three main scenarios presented in this e-book are

Lateral release Meniscal repair, trimming or removal of loose body Removal of bony loose bodies, resurfacing of degenerated bony surfaces

Lateral release This is done when there are tight structures on the outer aspect of the kneecap pulling it over to the outer part of the knee. Meniscal repair This is required when the meniscus has been torn, needs to be repaired or torn/loose fragments removed. Chondroplasty and Osteoplasty This is done when there is degeneration in the bony joint surfaces or loose fragments within the joint which need to be repaired or removed.

The procedure:

Arthroscopy involves keyhole surgery where a small incision of less than 1cm is made, the joint is irrigated with a sterile solution to enlarge the surgical space and a tiny fibre optic camera (the arthroscope) is guided into the knee and the image displayed on a monitor allowing the tissues and bony surfaces to be examined. In some cases, the arthroscope is exploratory only and no further action is required (this has been recently supercede by the use of MRI). If an issue is identified, other keyholes are then created for the appropriate probes and cauterising tools to be utilised - surgical treatment can then be performed as required. This can usually be done under a local anaesthetic as this procedure is not particularly invasive. The recovery is usually quicker than an open procedure as there is less trauma to the connective tissues, less scarring because of the smaller incisions A lateral release involves making an incision along the structures out to the side of your knee cap (the lateral retinaculum). The retinaculum is then severed from its joint capsule and fascial attachment.

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Surface anatomy of the knee showing the retinaculum

Diagram taken from: American Academy of Family Physicians (2007), Management of Patellofemoral Pain Syndrome, viewed 18th April 2011

http://www.aafp.org/afp/2007/0115/p194.html

Chondroplasty, osteoplasty and meniscal repairs are performed deep inside the knee joint to smooth out joint surfaces. Torn menisci are trimmed with a scissor like probe, the fragments can then be suctioned or ablated. Meniscal repair is undertaken by utilising sutures or tacks. Repair is only possible for tears in the outer 30% or vascular region of the meniscus. If the tear extends any deeper, due to poor vascularity, any repair attempt will fail and excision is the preferred option.

Diagrammatic representation of Trimming of a Meniscal Tear

Diagram taken from: The Center for Orthopaedics & Sports Medicine (2003), Torn Cartilage (Meniscus), viewed 15th April 2011

http://www.arthroscopy.com/sp05005.htm

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AFTER YOUR KNEE ARTHROSCOPY

Advice and information: Ask your doctor and surgeon about pain management plans. Once the anaesthetic wears off from the operation and as you are trying to use your knee more, you may experience an increase in pain. There will be a bandage wrapped around your knee after surgery. Remove the bandage the morning after the surgery with your shower but keep the bandaids on, trying to keep them dry. Follow the RICE regime below to minimise pain, swelling and inflammation.

R Rest: Be cautious about walking with weight through your leg at first. Limit activity levels with consideration to the amount of swelling and pain.

I Ice: Use ice packs or ice wrapped in moistened cloth on your operated knee for 10 minutes on, 30 minutes. Continue until the knee is no longer swollen by the end of the day.

C Compression: Keep tubigrip bandage (like an open sock of bandage) around your knee until your knee no longer swells.

E Elevation: Keep the knee resting on a chair or cushion so that it is elevated above the level of the hip to reduce swelling pooling at the knee.

Commence exercises the day after your surgery but be mindful of your symptoms. Do not push through pain or cause excessive swelling.

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Walking Commonly you will be requested to use crutches after your arthroscopy to protect you knee post surgery. The time the crutches are required for will be detailed by your surgeon. Your physiotherapist will ensure you are using them safely before you are discharged. Once you no longer require crutches, it is important to practice a normal, symmetrical walking pattern. This ensures undue strain on your injured knee is avoided, as well as protecting other joints which may become overloaded with an altered walking pattern. Do not spend prolonged periods on your feet when you knee is still swollen. When your swelling and pain have reduced, you can challenge your walking by going in different directions (sideways and backwards) and in circles (both clockwise and anticlockwise).

Recovery It will usually take at least 3 weeks to return to normal activities. However, swelling and other symptoms may persist for months. Caution should be given to commencing new or strenuous activities for 3 months while the knee heals completely. Driving will depend on the type of car and the type of surgery you underwent. This will need to be assessed by your surgeon before you recommence driving. Do not be tempted to drive without the surgeons approval as there are legal and insurance ramifications if an accident were to occur. Before going out onto the roads, practice doing quick braking movements and do not attempt driving until this can be done without pain. Another factor to consider is that reaction speeds are usually decreased for about one to three weeks post operatively and will effect your safety to drive. Returning to sport will also need to be discussed with your surgeon but in general, swimming and cycling can be low impact ways of maintaining fitness until full training can be resumed.

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REHABILITATION AFTER KNEE ARTHROSCOPY STAGE 1 Commence exercises the day after your surgery. Perform this program in consultation with a therapist so that they can prescribe these exercises specific to your needs. Do not perform exercises by pushing into pain, slowly build up the exercises. Static quads Sit with knee extended, attempt to push your knee downward to straighten your knee further. Your quadriceps or thigh muscle should tense up as you do so. Inner range quadriceps exercise Using a rolled up towel under your knee, contract your quadriceps muscle to lift your foot off the bed. Ensure that your leg is straight and you are pushing the back of your knee into the rolled up towel. Gently lower again and repeat 10 times.

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Straight leg raise With the rolled towel under your foot, contract your quadriceps muscle to lock the knee into a straight position and raise your whole leg off of the rolled up towel and hold for 3 seconds. Gently lower again and repeat 10 times.

Knee flexion Use your hands to help slide your heel towards your bottom until you start to feel an increase in pain. Stop and hold this position for 20 seconds and repeat 10 times.

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Knee bending on chair While sitting on a chair try to bend your knee as much as possible, using your other foot to help push it under and hold for 20 seconds. Relax your leg and repeat 10 times.

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REHABILITATION AFTER KNEE ARTHROSCOPY STAGE 2 When the exercises in stage 1 feel easy to complete, progress to the following set of exercises. Standing While standing focus on holding yourself tall with symmetry. Keep feet parallel, contract your quadriceps and buttock muscles to control your lower half and raise your chest to make yourself tall. Hold this posture for 2 minutes, especially after youve been sitting down for a while.

Quadriceps stretch in standing place your operated leg behind you on a chair so that the knee is bent approximately 90. Ensure you keep support at hand so you dont over balance and slowly squat with your other leg to increase the bend in your operated knee. Hold 30 seconds, repeat 3 times.

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Knee bending stepping on a chair Step your foot onto a chair and lean forward so that you bend your knee and feel a stretch. Hold for 30 seconds, lean back to release the stretch and repeat 10 times.

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Knee straightening over chairs While sitting on a chair, rest your ankles on another chair. Place a book over your knee to help straighten it and relax, holding your knee out straight for as long as possible. Aim to build up to 10 minutes at a time.

Quarter squats Stand tall with feet shoulder width apart and pointing forwards, do a small squat so that your knee bends about 45 and straighten back up again. Progress to doing a squat on your operated leg when pain allows.

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Sitting on haunches kneel on a bed or sofa with your operated leg against the floor. Gently sit back onto your bad leg only until you start to feel pain in your knee. If desired, use one or more pillows between your bottom and leg until you are able to reach lower. When comfortable, you can perform this exercise with both legs against the floor. Hold for 30 seconds and repeat 3 times a day.

After 6-8 weeks, you should be back to most physical activities (unless arthroscopic ligament repair has occurred). Work closely with your physiotherapist to fine tune a program specific to your activity requirements. If in doubt, work closely with your surgeon, medical officer and physiotherapist to ensure you address any issues that arise.

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SUMMARY In summary, knee arthroscopies are a relatively non-invasive surgery which can be done to examine and repair the knee after a variety of injuries or degenerative processes. After surgery there is a large focus on reducing pain and swelling by using the RICE protocol. Early rehabilitation will increase knee movement and strength but it is important to be sensitive to pain and swelling. Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist. All the best for a speedy recovery, The W&L Team

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RESOURCES Sports Med booklets on knee arthroscopies (patient information, post operative management, lateral release, chondroplasty/osteoplasty and meniscal tear) were referred to for the content of this e-book. Medibank Private: Knee Arthroscopy What To Expect (2008) http://www.medibank.com.au/Client/Documents/Pdfs/Knee-Arthroscopy.pdf, Accessed: 11th April, 2011 Knee Arthroscopy, American Academy of Orthopaedic Surgeons (2010) http://orthoinfo.aaos.org/topic.cfm?topic=A00299, Accessed: 11th April, 2011 Subluxed Patella, Left Knee with Arthroscopic Lateral Release - Medical Illustration, Human Anatomy Drawing, Nucleaus Medical Media (2011), http://catalog.nucleusinc.com/generateexhibit.php?ID=10786, Accessed: 11th April 2011 Meniscus Repair - Surgical Repair of Torn Cartilage. Cluett, J (2010) http://orthopedics.about.com/cs/meniscusinjuries1/a/meniscusrepair.htm, Accessed: 11th April 2011 Torn Cartilage (Meniscus) (2003), http://www.arthroscopy.com/sp05005.htm, Accessed: 4th April 2011 Management of Patellofemoral Pain Syndrome, Dixit S, Difiori J, Burton M and B Mines (2007) Am Fam Physician. Jan 15;75(2):194-202, http://www.aafp.org/afp/2007/0115/p194.html, Accessed: 11th April 2011

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