Steps in the knee rehab cycle

Rehabilitation of the knee is not always a straight line process. Things may improve, and then seem to go backwards. Things may go well, and then a stumble and fall may set the whole process back.

By Dr Sheila Strover, Knee Guru March 26, 2008

If you get the idea of the various phases of the rehab cycle, then you will have a good idea about how to handle things until you can consult your doctor or therapist.

The wounded knee – immediate phase of the Rehab Cycle
This phase is immediately after injury or surgery. Focus is on:

  • wound management
  • protecting the limb
  • minimising inflammation and swelling
  • ensuring that nerves and blood vessels are functioning

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Circulation evaluation in the immediate phase of knee injury

After an injury or knee surgery, it is helpful to know a little bit about assessing blood circulation in the lower limb. These features suggest poor blood flow to the limb:

  • Injured lower leg is quite a lot paler than the good leg.
  • It is colder to the touch.
  • The pulse, which is usually felt on the top of the foot, in the region between the big and second toe, but about an inch away from them, is less than the other leg.

If a bandage is too tight the circulation away from the limb can be obstructed and the toes might become swollen and darker in colour. Loosening the dressing should improve blood flow.

A serious problem of circulation after knee injury, and sometimes after surgery, is 'compartment syndrome'. The calf muscles and vessels are contained within fibrous compartments, and any bleeding within a compartment may cause an increase in pressure there, causing pressure damage to the blood supply and the nerves.

Compartment syndrome is rare but is a clinical emergency. The calf will be tense, pain will be severe and constant, the limb pale and the patient will experience pins and needles.

Wound evaluation in the immediate phase after knee injury

Most people have a reasonable idea of assessing a wound, so I will just make a few points here.

  • The knee can suffer serious internal damage without there needing to be an obvious wound.
  • High-speed gravel wounds (motorcycling) need particular attention, and if there is a deep gash be mindful that gravel can penetrate into the joint cavity.
  • If any bone has penetrated the skin from an underlying fracture, this is always an emergency and one must go to hospital.
  • Occasionally, someone kneels on the carpet and has the impression of having knelt upon a sewing needle. A needle can penetrate a knee and apparently disappear. Do not be fooled—get an X-ray as soon as possible.

Neurological evaluation in the immediate phase after knee injury or surgery

Nerve damage may occur during surgery, so it is important to be mindful of areas of numbness or any tendency to 'foot drop' where it is difficult to lift up the foot.

Let your doctor know early if these occur.

The peroneal nerve is quite commonly damaged where injury or surgery affects the area around the top of the fibula on the outer side of the knee. Foot drop is the usual consequence, with numbness or pins-and-needles of the skin on the outer calf and top of the foot (but not the little toe).

To test for numbness, an examiner can prick the area gently with a pin, sometimes turning the pin to 'prick' with the blunt end. the patient needs to identify when the skin has been 'pricked' and whether it is sharp or blunt.


P = Protection. Clean and protect the wound. Splint it if there is any suspected bone break or the joint feels wobbly.
R = Rest. Rest the joint.
I = Ice. Ice the joint to decrease swelling and inflammation. See cold therapy.
C = Compression. Use a compression bandage (but be careful not to put it so tight it upsets the blood flow.
E = Elevation. Put the leg up on a chair or the sofa or bed. This helps to minimise swelling.

Managing pain in the immediate phase after knee injury or surgery

Knee pain is normal after injury or surgery, but extreme pain and swelling may indicate that there is tense bleeding within the knee that may need draining.

Acute pain may respond well to the PRICE/RICE regime as this regime reduces the swelling and inflammation that leads to pain. Simple painkillers may be used for pain and anti-inflammatory tablets for inflammation.

Pain in the knee can also be triggered when the knee is under stress by 'knots' in the muscles around the knee – so-called trigger points. Massage of these trigger points may offer considerable pain relief.

Maintaining circulation in the immediate phase after knee injury or surgery

It is important in this phase to maintain circulation. The lower leg is very dependent upon a 'muscle pump' in the calf. As one walks the muscle contraction and relaxation helps to keep the venous blood going back to the heart. If one is confined to bed or the sofa and the leg is immobilised this muscle pump is not working.

A useful exercise to stimulate the muscle pump is foot pumps.

Elevating the leg is also useful in keeping the venous blood flowing.

After surgery the surgeon may order tight TED stockings (thrombo-embolism-deterrent) which help to prevent the blood flow slowing down and forming clots in the veins (deep vein thrombosis). Anti-coagulant (anti-clotting) medication is also normal during and immediately after knee surgery.

Maintaining quads tone in the immediate phase after knee injury or surgery

When the knee is injured the quads muscles rapidly become inhibited.

An important exercise in this phase, and which can be done in bed or on the sofa, is 'static quads' (also called quad sets or isometric quads).

In bed – early phase of the Rehab Cycle
In this early phase in bed after an injury or surgery, the focus moves away from the wound and the management of critical function and towards minimising the damage that can occur from keeping the leg still for a long time in bed. Attention is on preventing leg clots, minimising swelling and maintaining range of motion.

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Limit inflammation & swelling in the early phase of the Rehab Cycle

The RICE regime is the mainstay when it comes to limiting inflammation and swelling.

If you can tackle inflammation early, and keep swelling down, then the rest of the rehabilitation process becomes easier. The joint cavity is large, and can hold as much fluid as the volume of your two fists, and when it is tense with fluid it is very hard to keep the joint moving and the knee can soon become stiff and the muscles weak.

Maintain extension during the early phase of the Rehab Cycle

When the knee has been injured or after surgery, the most comfortable position for the joint seems to be slightly bent.

This can be a problem as it is easy to lose those few degrees of extension – the quads become inhibited and weak and the hamstrings tendons at the back of the knee can shorten. It can be difficult to regain that extension if it is lost. So it is easier if you can at this stage maintain extension with a simple passive extension exercise.

Prevent adhesions during the early phase of the Rehab Cycle

When the knee has been swollen with fluid inside the joint, and some of the fluid has been resorbed, there is the potential after a while for the remaining fluid to thicken into sticky strands called adhesions.

In the early stages adhesions can easily be broken by mobilising the joint – taking it through flexion and extension and keeping the patella and structures around it mobile. But if the knee is not kept mobile, the adhesions can eventually form into strands of scar tissue and lock the joint from moving. This can be a major problem.

To avoid this complication at this early stage while you are still in bed, relevant exercises include heel slides, facilitated heel slides, short arc extensions and self patellar mobilisations.

Prevent DVT during the early phase of the Rehab Cycle

When the leg is kept still the blood flows sluggishly through the veins back to the heart. Normally when one is walking the rhythmic contraction of the muscles behind the calf aid the circulation of blood, but this cannot happen in bed if the leg is kept still.

The problem with sluggish blood flow, especially after injury or surgery, is that clots can form in the veins. This is called deep vein thrombosis - DVT. It is a potentially serious problem because such clots can break off and shoot up to the heart and into the lungs, stopping the blood flow to the lung tissue.

A number of things are useful to prevent DVT while in bed:

  • TED stockings - those very tight elasticated stockings
  • A calf muscle pump (usually only available in hospital)
  • Foot pump exercises
  • Anti-coagulant medications. Typically prescribed in the hospital, but ordinary aspirin is quite good as an anti-coagulant.

Prevent quads muscle inhibition during the early phase of the Rehab Cycle

When the quadriceps muscle is inactive for a time it can rapidly waste, and it is extremely hard to rebuild it. In this early phase in bed, a few simple exercises will help to maintain tone in the quads muscle. They can all be done in the bed - heel slides, facilitated heel slides and short arc extensions.

 Once you are mobile – early phase of the Rehab Cycle
In this phase when you first get out of bed after injury or surgery, the emphasis is on mobility. First you may need to master crutches. Then there is the challenge of showering or bathing. And this is a really critical time to regain flexion (bending) and extension (straightening) of the knee.

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Hygiene once you are mobile after knee injury or surgery

Once you are up and about, your thoughts will turn to the shower. This may not be an easy matter with crutches and slippery floors, never mind the fact that you may be wearing wound dressings or a brace. There are a number of useful bathroom aids that you will find handy:

  • plastic covers for your leg
  • shower stools
  • non-slip floor mats

Maintain muscle tone once you are mobile after knee injury or surgery

Now that you are up and out of bed, the range of exercises can widen. Exercises can now include some stretching and balancing, as well as a range of light muscle exercises:

  • mini squats
  • mini stork
  • one-legged balance
  • short arc extensions
  • step ups
  • tip toes

Maintain passive range of motion once you are mobile after knee injury or surgery

If there is still a lot of swelling, you may need competent help at this stage to regain flexion and extension. The next two exercises are:

  • assisted flexion
  • assisted passive extensions

Walking with crutches after knee injury or surgery

Crutches will need mastering if this is the first time you have been on them. The trick is to move both the bad leg and the crutches forward at the same time. Take the weight on the crutches while you swing your good leg forward.

Focusing on function – intermediate phase of the Rehab Cycle
This is a stage when things can seem to be going right, and then they suddenly go wrong. It is tempting to push the knee too far in the excitement of getting going again. But if you trigger inflammation you can push your progress backwards. You can also damage a ligament graft or a meniscus repair by not being careful at this stage.

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Maintain passive range of motion

During this intermediate phase of the Rehab Cycle, when you are getting back to tackling home and work chores again, it is easy to be a bit lax about knee rehab. But this phase is important to maintain and improve the range of motion (ROM) of the knee joint. Even if the muscles are not fully strong again, the ROM can be maintained with passive stretches including:

  • full quads stretch
  • lying wall slides
  • hamstrings stretch
  • ilio-tibial band stretch
  • piriformis stretch
  • patellar mobilisations

Increase active range of motion

The previous section discussed passive range of motion – i.e., achieving bending and straightening without muscle contraction, using the body weight to help gently stretch tight ligaments.

during this intermediate phase of the Rehab Cycle, passive range of motion exercises need to be accompanied by active range of motion exercises, building up the exercises as your muscles strengthen and the swelling reduces to take your knee through a greater and greater active range.

Exercises should include:

Start rebuilding lower limb strength

As range of motion increases during this intermediate phase of the Rehab cycle, gradually start to introduce strengthening exercises. Ankle weights can be used in progressive sizes to add challenge to the previous full arc extensions and straight leg raises. At this stage you can also add:

  • full squats (supported)
  • standing wall slides

Start strengthening trunk and upper body

After injury or surgery the gait may become affected from a combination of limping, using canes or crutches, and favouring the stronger leg. As you start to rebuild strength in the lower limb it is also important to pay attention to the hips and upper body. Here are some simple exercises to do:

  • hip exercises
  • crunch

Rebuild balance and spatial awareness

A big problem with knee injury or knee surgery is loss of proprioception – the ability of the person to know where the limb is in space. Balance loss is a consequence too. The knee needs to be re-educated using exercises such as:

  • side-stepping
  • wobble board

Learn about potential complications

Because in this phase you are probably seeing the clinical team less often, it is important to be aware of potential complications that may surface now. In particular we feel you need to pay attention to range of motion - there may be an inability to achieve full extension or full flexion. This may be due to a number of reasons, but be particularly aware of arthrofibrosis.

Getting back to normal – late phase of the Rehab Cycle
This is the phase when you start getting back to full activities. Range of motion needs to be maintained, while strength and endurance are getting back to normal. The knee needs re-educating for specific sports activities and to prevent re-injury.

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Maintain range of motion

At this late stage of the Rehab Cycle full range of motion should have been achieved. A new stretch to learn is the:

  • calf stretch

and you need to continue with stretches you have already learned:

Build strength and endurance

At this late phase of the Rehab Cycle, the cross-trainer and the treadmill can be useful for building up strength and endurance. Also longer walks, swimming and cycling are all helpful, as long as the knee is comfortable with the amount you do.

Balance the main muscle groups

There is often too much focus on the quads muscles. The muscle groups all need attention and complementary muscle groups need to be strengthened and balanced – quads/hams, adductors/abductors, trunk flexion/extension etcetera.

Start sports-specific exercises

This may include figure-of-eight running and plyometrics.

Prevent further injury

As you begin to return to sport during this late phase of the Rehab Cycle,it is important to retain awareness of the vulnerability of your knee. There may still be issues with balance and spatial awareness, and pushing things too hard may cause an inflammatory flareup. You need to remember to warm up before and ice down after. If the knee is painful, then go back and step in your rehab routine.

Source Knee Guru

Also see in Knee Guru
Objectives of rehab
Knee Rehabilitation – Principles & Exercises
A-Z of exercises
Ten excellent knee rehab web sites

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