The First 7 Days After Knee Surgery

by Mitch Hauschildt, MA, ATC, CSCS

Over the past 20 or so years of working with athletes and active individuals, I have performed post operative rehab on hundreds, if not thousands of athletes.  This includes simple surgical procedures such as a mild debridement, as well as ACL and ALL reconstructions, osteotomies and even joint replacements.  If it can be done on an athletic knee, I have likely been a part of the rehab process.  

One thing that I have learned is that what happens in the first 2-3 weeks after surgery has a HUGE impact on the rest of their rehab.  Unfortunately, many surgeons and clinicians have taken the approach that their patients should simply hang out, perform a few home exercises, let scar tissue form and start the rehab process 6-8 weeks later.  I believe that this approach is a big mistake and increases timelines to full return to play, as well as decreases their ability to perform at a high level when they do return.

I have a discussion with every one of my post surgical rehab patients to make sure that they understand that if they are willing to put in some long days and tolerate some discomfort in the first 2-3 weeks, then the rest of their rehab process will be a breeze.  If they aren’t willing to do that, then we will be in it for the long haul.  Most people are good with that and motivated to start, so it works well.  

So, what kinds of things should we be doing in the first couple of weeks following any knee surgery?  Here is a list of all of the things that I at least attempt to perform in the first 7-10 days.  That isn’t to say that do all of these things every day, but they all at least get introduced if at all possible.  This list is long and makes for some long days, but it is in the best interest of the patient and their overall recovery.

• Incision site soft tissue mobilization:  This is always a bit controversial with clinicians that I work with because of a fear of infection or breaking open an incision.  Immediately after surgery I begin manually massaging (lightly) and mobilizing the tissue on or around the incision.  It takes a light touch and shouldn’t be painful.  The goal is to move the tissue to prevent excessive scarring from taking place.  If you can intervene early on, then it won’t be an issue later on.  
• Effusion control:  Swelling is enemy #1 for the post surgical patient.  Swelling limits range of motion, muscle function and pain.  The sooner you can get rid of it, the better off everyone will be.  I typically use a combination of kinesiology tape, manual massage, IASTM, and sequential compression devices to eliminate effusion quickly.
• Patellar mobilization:  This is more important for ACL reconstruction and joint replacement patients than other procedures, but it is good practice to mobilize the patella for pretty much all knee surgical cases.  This allows the knee to function properly when they are able to bear weight.  Without proper patellar mobility, it will get “stuck”, changing the kinematics of the knee joint.
• Grade 1-2 joint mobilization:  Joint mobilizations should be introduced early and often to prevent shortening of the joint capsule.  This is especially important for the posterior and posterior medial aspects of the joint capsule which can quickly shorten and cause an extension lag.  Everyone wants to improve knee flexion after surgery but the honest truth is that knee flexion will come around at some point with normal activities.  If they have an extension lag that persists, it will become very problematic long term.
• Bridging with core activation:  Glute work is imperative for lower extremity control.  This is nothing new, but I prefer to include some sort of core activation to keep the lumbar extensors from doing the job of the glutes.  When you activate the core during a bridge, you ensure that the glutes are actually doing what they are supposed to be doing.
• Weight shifting progression:  Weight shifting is the predecessor to gait training.  It involves getting people upright and at least partially weightbearing in a controlled manner and shifting weight side to side or forward and back.   
• Gait training:  Early gait training is important to maintaining the neuro pathways that existed prior to surgery.  Realizing that some procedures will necessitate non or partial weightbearing status, the clinician should be creative to find ways to move through the gait cycle so that way when they are able to bear weight, the motor learning process will be quick and easy.
• Hip hinge progression: Hip hinging is a basic fundamental movement pattern and one that can be performed immediately after surgery.  This is because it doesn’t necessitate knee flexion and can also be regressed to a seated position for non weightbearing patients so that you can train proper mechanics for femoral-acetabular dissociation.
• Heel raise progression: The Gastroc/Soleus complex is also important for knee stability so training it early can assist with activation strategies, gait, etc.
• Multisegmental rolling progression:  Training neurodevelopmental sequences will assist with all levels of motor learning and recovery.  Rolling patterns are great for trunk stability training, rotational training and motor learning and are non weightbearing, making this a good fit for post op knee patients.
• High-tension planking progression:  Proximal stability leads to distal mobility.  Many of the range of motion restrictions that are seen in surgical patients are due to poor threat management and poor proximal stability.  If you can improve stability proximally, you see very nice improvements in distal range of motion with very little effort.  
• Single leg stance with trunk activation:  Using a band or TRX to activate the trunk during a single leg stance is a great way to improve stability and perform gait training.  Using the upper extremity for core activation during a single leg stance is also a safe way to introduce balance training with a lifeline, making it safe and comfortable.  
• Turkish get up progression:  The Turkish Get Up is a complex movement that requires a lot of stability and mobility throughout the entire kinetic chain.  It also takes a lot of coaching, so if you aren’t comfortable teaching it or familiar with the movement, you may want to steer clear of this one.  If you are able to teach the TGU, start small and controlled with the parts of the movement that can be performed given the patient’s restrictions.  
• Active Straight Leg Raise (ASLR) progression:  The ASLR is another way of teaching the hip hinge.  The ASLR is an open chain version while most traditional hip hinging exercises are closed chain.  It is non weightbearing and a simple way of teaching femoral acetabular dissociation. 

There are other items that can also be included depending on who the patient is and what procedure they have had, but this is my general checklist of items that I perform early and often.  It usually leads to longer rehab sessions (90+ minutes) which may not be welcomed in some settings, but my opinion is that doing right by our patients is the most important thing and will pay off in the future, even if we can’t bill for every single thing that we do.