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Rehabilitation guidelines for patients undergoing knee arthroscopy

At the RNOH, our emphasis is patient specific, which encourages recognition of those who may progress slower then others. We also want to encourage clinical reasoning.

Milestone driven
These are milestone driven guidelines designed to provide an equitable rehabilitation service to all our patients. They will also limit unnecessary visits to the Outpatient Clinic at RNOH by helping the patient and therapist identify when specialist review is required.

Team:
Professor Briggs’ secretary: Mr Pollock’s secretary: Mr Carrington’s secretary: Mr Miles’ secretary: Mr Skinner’s secretary: Physiotherapy department: 020 8909 5573 020 8909 5677 020 8909 5618 020 8909 5831 020 8909 5621 020 8909 5820/5519

Indications for surgery:
• • • • • • • • Meniscal tears Damage to the articular cartilage of the joint Debridement Loose body within the knee Synovectomy Ligament reconstruction Repairing certain joint fractures Biopsy

Incision:
A knee arthroscopy is a procedure that involves making two or three small incisions, or portals, usually in front of the knee. A small arthroscope (three to five millimetres in diameter) is inserted into the knee allowing the surgeon to see and operate inside the joint. Knee arthroscopy is usually carried out under a general anaesthesia, either as a day case or in some instances as an overnight stay in hospital.

Possible complications of surgery:
• • • • • • Accidental damage to the knee joint Bleeding Nerve damage Deep Vein Thrombosis Pulmonary embolism Persistent/recurrent pain

Knee arthroscopy Guidelines 2010

Review 2012

ACL deficient/rupture). swelling. Teach protection.e. compression and elevation (PRICE) Post-operative management explained. including walking aids. and advise what to do if concerned. the following assessed: • • • • • • • Current functional levels General health Social/work/hobbies Functional range of movement Gait/mobility. No further physiotherapy treatment should be necessary. The medical team will refer for outpatient physiotherapy if appropriate. icing. Exercises as should be commenced as per Appendix A. Knee arthroscopy Guidelines 2010 Review 2012 . circulation. rest. Patient discharged unless indications to be seen post-operatively. Post-operatively Patients are not routinely seen post operatively unless requested by the medical team (i. with consent. colour. orthoses Muscle power and range of movement Post-operative expectations Treatment: • • • • • • • Patient information leaflet issued Swelling management Exercises: taught as per handout (see Appendix A) Gait re-education: ensure safe and independently mobile with appropriate walking aid/s Mobility: ensure patient is independently mobile. especially self-management at home after discharge Patient treatment plan completed and filed in medical notes.• Infection Pre-operatively: Where possible the patient will be seen pre-operatively and. temperature. including stairs if necessary Advice/education: teach how to monitor sensation. The patient should mobilise FWB (unless stated otherwise) once they have had something to eat and drink.

Driving Patients should not return to driving until their knee is pain free and they have full knee flexion. the patient should contact the ward. • The wound should be kept clean and dry to prevent infection • If there is excessive bleeding through the dressing. usually 2-3 days. They may use crutches until the knee becomes more comfortable. They MUST be able to perform an emergency stop. If their job is physically demanding and involves heavy manual work or standing for long periods then 1-2 weeks off work may be necessary. Otherwise the patient should have been advised what to do by the ward staff. Mobility The patient can mobilise FWB immediately post operatively. and should inform their insurance company about the surgery to ensure their cover is valid. GP or local A&E department for advice Knee arthroscopy Guidelines 2010 Review 2012 . Wound care The stitches or steristrips will be removed at clinic if the patient is seen 2 weeks or less post operatively.Recovery rehabilitation phase: 0 weeks – 2 weeks Return to work If patients’ job involves sitting for the majority of the day they can return after 3 days.

then consider the following: Possible problem Swelling Pain Breakdown of wound e. Should continue isometric work at all times • If persists. monitor closely • If does not decrease over a few days. but inform surgical team and refer back if deteriorates or if concerned Knee arthroscopy Guidelines 2010 Review 2012 .Failure to progress If a patient is failing to progress. inflammation. monitor closely. Should continue isometric work at all times • If decreases overnight.g. refer back to surgical team • Decrease activity • Ensure adequate analgesia • Elevate regularly • Decrease weight bearing and use walking aids as appropriate • Pacing • Modify exercise programme as appropriate. refer back to surgical team • Refer to surgical team • • • • • • • Numbness/altered sensation Refer back to surgical team Ensure exercise progressions are at suitable level for patient Address core stability Review immediate post-operative status if possible Ensure swelling under control If new onset or increasing refer back to surgical team If static. bleeding. infection Recurrent instability Action • Ensure elevating leg regularly • Use ice as appropriate if normal skin sensation and no contraindications • Decrease amount of time on feet • Pacing • Use walking aids • Circulatory exercises • Modify exercise programme as appropriate.

Repeat 15 times. Exercise your operated leg by pulling your foot and toes up. Sitting on a chair or the edge of the bed with your foot on a sliding board. Hold for 5 seconds and slowly relax your leg. Hold 5 seconds . Bend your ankles and push your knees down firmly into the bed.Exercises to be started immediately after your knee arthroscopy 2. 3-4 times daily Knee arthroscopy Guidelines 2010 Review 2012 . 1. Bend your knee as much as possible. Repeat 15 times. Hold approx. Lying on your back or sitting up in bed with legs straight. Bend and straighten your hip and knee by sliding your foot up and down the board. Keep your kneecap and foot facing the ceiling throughout. Repeat 20 times. Lying on your back or sitting up in bed. Lying on your back with a sliding board under your leg. 3-4 times daily 2.relax Repeat 20 times. 3-4 times daily 3. tightening your thigh muscle and straightening the knee (keep knee on roll). 3-4 times daily 4. Put a roll under your operated leg. 5 seconds and slowly relax.

Repeat 20 times. 3-4 times per day 4. Hold for 5 seconds. Lying on your back with one leg straight and the other leg bent (you can vary the exercise by having your foot pointing either upwards. 5 seconds and slowly relax your leg. Hold approx. You can do the exercise with a 5kg weight or rubber exercise band around the ankle. Sit on a chair or on the edge of the bed. Hold approx 5 seconds. 3-4 times daily 2. 3-4 times daily 3. Repeat 20 times. Bend your knee back as much as possible. Hold approx. straightening the knee and lifting the leg 20cm off the bed. inwards and outwards). 5 seconds. Pull your toes up. tighten your thigh muscle and straighten your knee.Exercises to be started 3 days after your knee arthroscopy 1. Exercise your straight leg by pulling the toes up. List 3-4 times daily Knee arthroscopy Guidelines 2010 Review 2012 . Bend your knee as far as possible keeping the hip straight and ankle flexed.slowly relax Reference Repeat 15 times. Repeat 20 times. Sit on a chair or edge of the bed with your feet on the floor. Lying face down with your hips straight and knees together.

‘Risk of deep vein thrombosis in patients undergoing knee arthroscopy. tables/charts) ISSN: 1940-7041 CINAHL AN: 2010473193 8. ‘Physical therapy after arthroscopic partial meniscectomy: is it effective?’ Exerc Sport Sci Rev. 2003 Apr. Knee arthroscopy Guidelines 2010 Review 2012 .org. ‘Rehabilitation after arthroscopic meniscectomy: a critical review of the clinical trials. 20 (6): 665-8 (journal article . with or without debridement. NHS Choices ‘Knee Arthroscopy’ 25/08/2009 http://www. The Knee. 2005 Fall. NICE Guidelines (2006) ‘Interventional procedure overview of arthroscopic knee washout.’ American Journal of Physical Medicine & Rehabilitation (AM J PHYS MED REHABIL). patients. volume 16. Arroll B.Elsevier In select young and healthy population with few co morbidities supervised physical therapy is no more beneficial than a home exercise program following relatively simple knee surgical procedures (arthroscopic meniscectomy).’ Int J Technol Assess Health Care. SM Coppola & SM Collins. and society. International Orthopaedics’. CONCLUSIONS: Clinicbased physiotherapy after knee arthroscopic partial meniscectomy surgery is costly and evidence is needed that its effectiveness is high enough to support its use. One study found that physiotherapy was beneficial for retaining muscle strength and had a positive effect on pain assessment. but no more costly to society than when not providing it and does not result in reduced contact with the NHS. simple analgesics in the first 1 to 2 days following surgery and a wellplanned home-based exercise programme should be sufficient for recovery. ‘Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review’.Summary of evidence for physiotherapy guidelines 1. Rodriguez Moreno HA et al. 24(6): 350-353 In most cases.nhs.nice. Goodwin PC & Morrissey MC. but this did not translate into functional improvement. 2006 Jun. 2. 2009 Nov-Dec.uk/IPG230 7. Goodyear-Smith F.aspx 6. Goodwin et al. 2001. Pages 171-175 (June 2009) .uk/conditions/Arthroscopy/Pages/Introduction. Studies reviewed in this paper show there is little evidence that formal physical therapy is necessary to return patients to their normal receiving this care. 5. 85(6): 490-501 Quick recovery occurs in these patients when only a home exercise program is given. issue 3. Morrissey et al. 3. ‘Physiotherapy after arthroscopic partial meniscectomy surgery: an assessment of costs to the National Health Service.PMID: 16262967 Providing clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is more costly to the NHS and patient. research. for the treatment of osteoarthritis’ http://www.31(2):85-90.21(4):452-8. ‘Evaluating treatment effectiveness: benchmarks for rehabilitation after partial meniscectomy knee arthroscopy.’ 4.equations & formulas. Current Orthopaedic Practice.