Round 2 orthopedics (inpatient)

Knee arthroplasty
‫دي العناوٌن االساسٌة اللً اتقالت فً الراوند‬

 Introduction:-
 Arthroplasty = joint replacement, knee arthroplasty = knee replacement.

 The knee consists of 3 major components:

1. Patellofemoral component (articulation between patella and femur)
2. Medial tibiofemoral component (articulation between medial tibial plateau and
medial femoral condyle)
3. Lateral tibiofemoral component (articulation between lateral tibial plateau and
lateral femoral condyle)

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 Indications:-
 Severe arthritis (causing severe pain, inability to stand or bear weight + failure of
conservative treatment) (‫)المرٌض مش قادر ٌقف على رجله‬
 Severe valgus or varus deformity (frontal plane deformity) (usually in case of valgus or
varus deformity, high tibial osteotomy is performed. But knee replacement is indicated in
case of degeneration. For example:
o If the valgus deformity is so severe that it caused narrowing of lateral joint space
thus causing degeneration of lateral tibiofemoral joint.
o Or if the varus deformity is so severe that it caused narrowing of medial joint space
thus causing degeneration of medial tibiofemoral joint.
 Failure of previous arthroplasty (if the patient didn't follow the precautions or if the life
span of the implant ended [maximum 20 years]) (a revision arthroplasty should be
performed in this case where the surgeon either changes part of the joint or the entire
joint according to the degree of damage)
 In case of local infection (the body is treating the implant as a foreign body thus causing
infection. If the infection isn't controlled by a course of antibiotics then the surgeon
removes the implant then treat the infection (debridement, drainage and antibiotics) then
wait for the infection to be completely over then insert the new implant) (can't insert an
implant on active infection(

‫ ٌبقى خالص‬degeneration ‫ وٌبدأ المفصل ٌتآكل وٌحصله‬joint space ‫ قللت ال‬severe valgus or varus deformity ً‫لو ف‬
‫ ولو المرٌض كان مغٌر مفصل قبل كدا‬.high tibial osteotomy ‫ والزم اغٌر المفصل بدل ماعمل‬joint‫ بوظت ال‬deformity ‫ال‬
‫ او وقع او عمل حاجة غلط او ان صالحٌة المفصل خلصت فالمفصل ٌحصله حاجة او ٌتكسر او ٌتخلع‬precausions ‫ومالتزمش بال‬
‫ النه جسم‬implant ‫ او لو الجسم هاجم ال‬.‫ اللً حاصل‬damage ‫ٌبقى الجراح هٌدخل ٌغٌر المفصل كله او جزء منه على حسب ال‬
infection ‫ وٌنضف ال‬implant ‫ وماقدرناش نتحكم فٌها بالمضادات الحٌوٌة فساعتها الجراح هٌشٌل ال‬infection ‫غرٌب فعمل‬
.‫ وبعدها ٌركب مفصل جدٌد‬active infection ً‫وٌستنً تروح خالص وماٌبقاش ف‬

 Classifications:-
1) According to component:
Tri-compartmental Uni-compartmental
Bi- compartmental arthroplasty
arthroplasty arthroplasty

(Total knee arthroplasty) Replacement of only 2

components of the knee joint
- Replacement of all 3
(patellofemoral component + Replacement of only 1
components of the knee
medial tibiofemoral component of the knee
joint.
component) joint
‫ حصل‬compartments 3‫لو ال‬
‫ دول‬compartements 2 ‫(فً االغلب ال‬
degeneration ‫فٌهم‬
)‫اكٌد بٌبقو متؤثرٌن‬

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 Tri-compartmental Bi-compartmental Uni-compartmental

N.B.:
 There is a special criteria that surgeons consider while deciding which surgery option is
suitable for the patient condition (it's not only dependent on the number of compartments
affected. for example only 1 or 2 compartments are affected but the surgeon decided to
perform a total knee replacement)

 For example bi-compartmental arthroplasty is performed if:

• 2 compartments are affected
• No frontal plane deformity (valgus or varus deformity) above 15 o
• No flexion contracture above 15o
• Intact normal ligaments.
• Age less than 60 years and not overweight. (‫)بس فً ناس بٌقولو ممكن دول ماٌؤثروش‬

‫ المتؤثرة ٌعنً عشان‬compartments‫ محددة بٌقرر بٌها الجراح هٌعمل انهً عملٌة مش بس عدد ال‬criteria ً‫ٌعنً ف‬
varus ‫ او‬valgus ً‫ متؤثرٌن أل كمان الزم ماٌبقاش ف‬2 compartments ‫ مش بس‬bi-compartmental ‫ٌعمل ال‬
.‫ سلٌمة‬ligaments ‫ درجة والزم تكون ال‬15 ‫ اعلى من‬flexion contracture ‫ درجة او‬15 ‫اعلى من‬

2) According to method of fixation:

 The method that we fixed the implant with into the receiving bone.
 There are 3 types of fixation methods:
i. Cemented
ii. Cementless (uncemented)
iii. Hybrid
tri- ً‫ (لو ه‬patellar ‫ وجزء‬tibial ‫ وجزء‬femoral ‫ جزء‬prosthesis ‫ او ال‬implants ‫ٌعنً عندي ال‬
patellar ‫ او ال‬tibial component‫ او ال‬femoral component ‫) ٌبقى انا ثبتت او لزقت ال‬compartmental
.receiving bone ‫ دا ازاي فً ال‬component

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 Cemented Cementless Hybrid

Fixation by acrylic Part is cemented

Fixation by bone growth (no cement)
fixation

cement and the other part

More fixed and stable than the cemented is cementless
‫ فً ال‬implant‫(لزقنا ال‬
type
)‫ باسمنت‬receiving bone
femoral ‫ٌعنً مثال ال‬
Ingrowth Ongrowth
‫ ٌبقى‬component
Pores coated Rough textured ‫ وال‬cemented
Joint surface

implant implant
The joint surface is tibial component
smooth. ( ‫السطح مافٌهوش‬ ‫ملٌانة اخرام العضم‬ ‫ او‬cementless ‫ٌبقى‬
‫)خرابٌش او اخرام‬ ‫ جوا‬ingrowth ‫ٌحصله‬ ‫السطح الخشن العضم‬ .‫العكس‬
‫ الصغٌرة (ثابت‬pores ‫ال‬ )‫ٌتكون علٌه (ثابت جدا‬
)‫جدا‬
Bone growth takes 3-6 months or more
indication

More appropriate for a

More appropriate for a physically active
physically inactive old age
patient with good quality of bone.
patient.

Not suitable for a young

Contraindication

physically active patient

as mechanical loosening Not suitable for an osteoporotic patient
of fixation would happen (no bone formation) (bad quality of bone)
causing dislocation or bone ‫ النه مافٌش‬pores ‫مافٌش عضم هٌتكون فً ال‬
failure. ‫ اصال‬formation
fixation ‫لو بٌتحرك كتٌر ال‬
‫هٌفك‬
The patient can walk from the 2nd day
The patient can walk from
weight bearing as tolerated (WBAT) with a
the 2nd day weight
Gait

walker. (weight bearing improves bone

bearing as tolerated
formation)
(WBAT) with a walker.
)‫(زمان كنا بنمشٌه بعد شهر او شهر ونص‬

‫ هو للجراح حتى لو انت عندك معلومات كافٌة النه هو عارف‬weight bearing‫ الرأي االول واالخٌر لل‬:‫ملحوظة‬ •
‫ وانت خلٌته ٌعمل وحصلت اي مشكلة‬weight bearing‫ ماٌعملش‬patient ‫عمل اٌه فً العملٌة وعشان لو قال ان ال‬
.‫ٌبقى الغلط هٌقع علٌك‬

3) According to constraints:
 It's classified according to implant design (implant ‫ )شكل ال‬into 3 types:
o Non-constrained
o Semi-constrained
o Constrained

.‫ انواع دول‬3‫ لل‬implant ‫ٌعنً بتتقسم حسب شكل ال‬

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 Non-constrained Semi-constrained Constrained
- Crutiated retaining
(bicruciate retaining
implant) (ACL, PCL and
Other names

collaterals are present) Hinged knee replacement

- Or PCL - Partially constrained femoral compartment‫ال‬
retaining implant - Posterior stabilized ‫ االتنٌن‬femoral compartment‫وال‬
(only the PCL is ‫ زي مفصل الباب‬hinge‫بٌنهم‬
present)
‫ ٌعنً حافظنا علٌه‬Retained
.‫ماشٌلناهوش‬
Depends on the ligaments
Depends on the design of the Depends on the design of
for stability (not the design
Stability

implant but it's partially the implant for stability (not

of the implant) (prosthesis
constrained the ligaments) (prosthesis
doesn't favor stability)
‫شكل المفصل مش هو اللً بٌدي‬ ‫ٌعنً حاجة فً النص بٌن النوعٌن التانٌٌن‬
favor stability)
stability ‫ال‬

Ligaments are present Ligaments are removed

Lig

…
(‫)ماشٌلناهاش‬ (‫(شٌلناها خالص‬

It's partially constrained so it

Similar to the kinematics of
doesn't limit axial rotation in
a healthy knee (as the Cutting the ligaments affects
the same degree as the
ligaments are still present) mobility so:
constrained type (some axial
Joint mechanics

- It allows sagittal motion

- Allows mobility in sagittal
motion (flexion & extension)
- Allows axial motion (tibial
rotation) (screw home
mechanism [SHM])
Good mobility
rotation is present) (axial
(flexion & extension)
rotation is more than the
- and prevents axial motion
constrained type and less than
(rotation)
the non-constrained type)
Less mobility (but good
Prevents excessive or severe
stability)
femoral translation

N.B.:
How the semi-constrained type prevents excessive translation?
The tibial component has a post (intercondylar spine) and the femoral component has a box
(transverse cam). The post enters the box thus preventing excessive translation.
‫ ال‬.box ‫ بٌبقى فٌه‬femur‫ بتاع ال‬prosthesis‫ وال‬post ‫ بٌبقى فٌه نتوء طالع منه اسمه‬tibia‫ بتاع ال‬prosthesis‫ال‬
.excessive translation‫ فتمنع ال‬box ‫ بٌدخل فً ال‬post

.‫الفٌدٌو اللً الدكتور عرضته فً الراوند عن اشكال المفصل موجود فً البوست اللً نازل فٌه الملخص‬

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 )‫ دا للفهم ولكن الدكتورة ماشرحتوش‬SHM‫(شرح ال‬
Screw home mechanism (SHM): During the last 30 degrees of knee extension, the tibia (open
chain) or femur (closed chain) must externally or internally rotate, respectively, about 10
degrees. (This slight rotation is important for healthy knee movement)

‫ درجات او ال‬13 ً‫ حوال‬femur‫ على ال‬rotation ‫ بتعمل‬tibia ‫ ال‬knee extension ‫ درجة فً ال‬33 ‫ٌعنً اخر‬
‫ درجات‬13 ً‫ حوال‬tibia‫ على ال‬rotation ‫ تعمل‬femur

Hinged knee replacement (constrained) semi-constrained knee replacement

ً‫ عالً من فوق (اللً متحدد باالزرق ف‬box ً‫ بٌبقى ف‬posterior stabilized ‫نعرف الفرق ازاي فً االشعة؟ ال‬
pink‫ (مرسوم بال‬cruciates‫ اللً محافظ على ال‬non-constrained‫ ٌبقى دي ال‬box ‫ او‬hinge ‫االشعة) ولو مافٌش‬
)‫فً االشعة‬
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 Precautions:-
 Putting a pillow under the patient's knee is
prevented (although it's comfortable for
the patient) as it causes flexion contracture
and we won't be able to stretch the muscle
for a while (capsular pattern ً‫) وٌدخل ف‬
 The patient shouldn't get rid of the walker (or assistive device) until:
o The patient is able to control the quadriceps → his knees don't give way ( ‫ٌعنً مش‬
‫ )بتخونه‬and not in extension lag (lack of full knee extension with full contraction of
quadriceps)
o The patient has good proximal stability (trunk isn't always leaning forward)
 Abductor strengthening exercise such as straight leg raise from side lying position is
delayed for 1 or 1.5 month for patient with cementless prosthesis and delayed for 2 weeks
for patients with cemented prosthesis (the exercise is delayed to prevent valgus or varus
deformities as the patient may put his foot in angulation while raising his leg)

‫ الزم نراعً انه ماٌحطش مخدة تحت رجله مع ان دا وضع مرٌح النه‬knee arthroplasty ‫ لعٌان عامل‬rehabilitation ‫اثناء ال‬
ً‫ اللً هو قاعد فٌه وهتدخل ف‬position‫ من ال‬stretch ‫ ومش هنعرف نعملها‬flexors ‫ فً ال‬contracture ‫كدا هٌعمل‬
.capsular pattern

control ‫ اال لما ٌبقى عامل‬walker‫ونراعً انه ماٌتخلصش من ال‬

‫ ورجله مش بتخونه وهو ماشً او مش‬quadriceps ‫كوٌس على ال‬
‫ انه‬extension lag ‫ لما ٌرفع رجله (ال‬extension lag ً‫بتتاخد ف‬
‫ ركبته بتبقى متنٌة مش‬straight leg raise ً‫لما ٌجً ٌرفع رجله ف‬
‫ كوٌسة‬proximal stability ‫) وانه ٌبقى عنده‬full extension ً‫ف‬
.‫ قوي فماٌبقاش موطً على قدام‬core‫وال‬

straight leg raising from side lying ‫ونؤجل انه ٌعمل‬

ً‫ ٌطلع وه‬neutral ‫ عشان ممكن ماٌطلعش ورجله‬position
valgus or ‫ (زي الرجل اللً علٌها سهم احمر) فٌعمل‬rotated
.varus deformity

Treatment Program:-
 The treatment program consists of 3 phases:-
1. Maximum protection
2. Moderate protection
3. Minimal protection

 Each phase has a different set of exercises.

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  Maximum protection:-
 The first 4 weeks
 The patient problems in this phase includes:-
o Breathing complications (caused by: patient under anesthesia, sleeping in bed for
long time, old age)
o Pain
o Swelling (the patient is bed ridden so the patient is predisposed for swelling)
o Limited ROM
o Proprioception problems (caused by: removal of ligaments [ligaments are
responsible for proprioception], pain affects proprioception)
o Muscle weakness or inhibition (pain causes muscle inhibition and the surgery
incision itself causes muscle weakness)
o Gait problems

‫الجدول دا فٌه كل مشكلة هنعالجها او نمنعها ازاي وتحته هنتكلم عنهم بالتفصٌل‬
Problem

Cardio-
Breathing Muscle
list

Pain Swelling Limited ROM Proprioception respiratory

complications weakness
fitness

- Auto-
- Ice - Quadriceps
passive
application strength ex
exercise
- Compression - Hamstring
Intervention

(flexion + - Weight - Low

- Ice - Elevation strength ex
Breathing extension) shifting impact
application (+faradic) - Proximal
exercises - Flexibility - Closed aerobic
- TENS - Circulatory stability
exercises kinetic chain exercises
exercises - Crutch
(stretches)
- Static muscles
- SAFTE
exercises Strength ex
exercise

o Breathing complications:
Deep breathing exercises (diaphragmatic breathing):

Patient position: Semi-Fowler's position (so that the

gravity assists the diaphragm) (we put a rolled towel
between the shoulders to relax the accessory muscles
[‫)]كتافه تنزل لتحت‬

Order: take a deep breath from your nose filling your

abdomen with air (as a balloon) then expire from
your mouth slowly (if the patient isn't able to fill his abdomen with air then sniffing action
would activate and facilitate the motion of the diaphragm)

Repeat the exercise 3-4 times only to avoid hyperventilation.

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o Pain:
Ice application
o We cover the ice or icepack with towels to avoid ice burns
o We apply it for 10 minutes every 2 hours.
TENS application
o The 2020 guidelines showed that it's a good method of pain reduction in conjunction with
the rest of exercise program

o Swelling:
Ice application
Compression

Elevation (+faradic stimulation(

o Pulsed faradic stimulation on quadriceps during elevation decreases swelling.

Circulatory exercises
o Active pumping.
o Perform motion on distal joints then proximal joints
o Start unilateral then bilateral then alternate.
o Perform motions 5 times slowly then 5 times fast then 5 times slowly
o Motions include: toes flexion and extension, toes abduction and adduction, ankle plantar
flexion and dorsiflexion (‫)ٌاخد مشط رجله علٌه‬, ankle eversion and eversion, ankle
circumduction then proximal joints.
o Knee flexion and extension is allowed
)stiffness‫ اصال منعا ل‬ROM ‫ٌقدر ٌتنً ركبته من بعد العملٌة عادي والزم ٌحركها وٌعمل‬

Static exercises
o Quadriceps set maintains tone and a pumping action that reduces swelling
o Performed by pushing the knee downward on the bed (hold for 5 seconds)
.‫) طول ما هو قاعد‬quadriceps set( static quadriceps exercise ‫ طول ما هو ناٌم اخلٌه ٌعمل‬o

N.B.:
The difference between the terms (swelling – edema – effusion – hemarthrosis):
Swelling is a general term classified into:

 Extra-articular swelling: (swelling outside or away from the joint) like edema.
 Intra-articular swelling: (swelling inside the joint) classified according to the accumulated
fluid to:
 Effusion: accumulation of synovial fluid inside the joint.
 Hemarthrosis: accumulation of blood inside the joint.

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o Limited ROM:
The patient knee ROM at first is 10o-60o or less. We aim to increase ROM up to 90o in the first
month. Knee ROM is Performed actively or active assisted.
Auto-passive exercise:
o Auto passive means that the motion is performed by gravity, extra weight or the other
limb. The following exercises can be performed to increase knee ROM for patient with any
condition related to the knee (but be careful for any precautions related to the condition)
o Flexion ROM exercises:
1. Heel slide: the patient slides the heel flexing his knee (actively) or the patient pulls
his leg with a towel sliding his heel flexing the knee (active assisted)
2. The patient is in prone lying position putting his healthy leg under the affected leg
and then the healthy leg raises the affected leg in flexion (auto-passive exercise)
3. The patient is sitting with the healthy leg on the affected leg then the healthy leg
pushes the affected leg backward in flexion (auto-passive)

‫ وتمرٌن كمان‬.‫نخلٌه ٌزحلق رجله على السرٌر او ٌشدها بفوطة ونقوله ٌعملها طول ما هو ممدد ٌزحلق رجله على السرٌر‬
ً‫ وحاطط رجله السلٌمة تحت التعبانة وبعدٌن ٌتنً ركبته السلٌمة بحٌث ترفع التعبانة تاخدها ف‬prone ‫اننا نخلٌه ناٌم‬
.flexion ً‫ او ٌعمل نفس الشًء وهو قاعد وحاطط رجله السلٌمة على التعبانة وتزقها لورا ف‬.flexion

o Extension ROM exercise:

1. Prone hang exercise: (a very effective exercise) patient is sleeping in prone lying
position and his knees are at the edge of the bed (legs are hanging) and the gravity
pulls the leg downward (autopassive). Exercise progression is putting weight on the
calf then putting weight on the ankle.
2. Heel prop exercise: patient is in supine lying position with a towel rolled under the
ankle. The gravity pulls the knee in extension (autopassive).

‫ ولو عاٌزة اصعبها اركبله‬extension ً‫نخلٌه ناٌم على بطنه ورجله برا السرٌر والجاذبٌة تبقى شادة رجله لتحت ف‬
‫ وتمرٌن تانً انه ٌنام على ضهره واحط فوطة‬.ankle ‫ على ال‬weight ‫ او اصعبها اكتر احط ال‬calf ‫ على ال‬weight
.extension ً‫ واسٌب الجاذبٌة تشد ركبته ف‬ankle ‫كبٌرة تحت ال‬

N.B.:
o There is a correlation between the ROM of the patient before the surgery and after the
surgery.
‫ بعد العملٌة اكتر من اللً دخل‬limited range ‫ فهٌبقى عنده‬limited range ‫فً عالقة بٌن انه المرٌض داخل العملٌة ب‬
.‫ من االول‬ROM exercise ‫ فالزم اعمل‬.‫ احسن قبل ما ٌدخل العملٌة‬range‫ب‬
o In rehabilitation of any knee condition, it's more important to gain the extension ROM
than the flexion ROM because every 1 degree limitation in extension equals 10 degrees
limitation in flexion. Especially in ACL patients if we didn't achieve full extension in the first
week then we might not be able to achieve it later as adhesion can occur.
extension ‫ فً ال‬limitation ‫ درجات‬5 ‫ عشان لو مثال داخل ب‬flexion‫ اكتر من ال‬extension ‫ ال‬range ‫بنركز اننا نجٌب‬
.flexion ‫ فً ال‬limitation ‫ درجة‬50 ‫ٌبقى هٌكون معاها‬
| P a g e 13
Flexibility exercises (stretches):
o Gentle hamstring stretching
exercises
o The patient is in supine position with
a towel under the ankle and let the
gravity extend the knee (gravity
assisted). The therapist puts one
hand above the knee and the other
below the knee (the therapist can
gently press down with his hand.

SAFTE exercise:
o A very effective & safe exercise (a lot of researches has been done on this exercise) and it can be
done as a whole exercise program that can be done while the patient is watching TV.
o Stands for Slide And Flex, Tighten & Extend:-
o Slide and flex:
 The patient is sitting on a chair with the healthy leg over the affected leg ( ‫حاطط القدم على‬
‫ )القدم‬then the patient slides the healthy leg backward pushing the affected leg in flexion
(Auto-passive)
 Then slide the buttocks forward (this increases knee flexion) and lean his back backward.
o Tighten & extend:
 Then from the same previous position (knee flexed + back leaning backward), extend the
knees (pushing the knees downward + dorsiflex the ankle) (static quadriceps exercise)
 Then press the heel downward on the ground (static hamstring exercise)
 Then perform patellar mobilization.
o repeat the exercise for: 3 sets x 10 reps (5 sec hold for each movement)

‫ بٌعمل كذا‬.‫دا تمرٌن حلو جدا وعلٌه ابحاث كتٌر ممكن ٌتعمل كبروجرام لوحده للمرٌض ٌقدر ٌعمله وهو قاعد ٌتفرج على التلٌفزٌون‬
ً‫ االول بٌقعد على كرسً وٌحط رجله السلٌمة على التعبانة وبعدٌن ٌزق رجله التعبانة لورا برجله السلٌمة فتروح ف‬.‫حاجة مع بعض‬
)2 ‫ لقدام وٌرٌح ضهره لورا (زي الصورة السهم اللً علٌه‬buttocks‫) وبعدها ٌطلع بال‬1 ‫ (زي الصورة السهم اللً علٌه‬flexion
‫) وبعدها من نفس‬3 ‫وبعدٌن من الوضع دا ٌفرد ركبته وٌزق ركبته لتحت وٌشد مشط رجله علٌه (زي الصورة السهم اللً علٌه‬
ً‫ ٌعن‬mobilization ‫ وٌعملها‬patella ‫) وبعدها ٌمسك ال‬4 ‫الوضع ٌدوس بكعبه على االرض (زي الصورة السهم اللً علٌه‬
.‫ٌمسكها ٌحركها فوق وتحت وللجانبٌن‬

| P a g e 11
o Proprioception training:
In case of weight bearing:
o Weight shifting exercise
o The patient shifts his weight (while standing
with the walker) antero-posterior then medio-
lateral.

If weight bearing isn't allowed yet:

o Closed kinetic chain exercise
o Leg press against the wall: the patient is pushing a big ball against the wall with his legs (if
the big ball isn't available then the patient can push against
the wall directly)

‫ وهو واقف على‬weight shifting ‫ٌعنً لو المرٌض بٌحمل هاخلٌه ٌعمل‬

closed kinetic ‫ ولو مابٌحملش ٌبقى ٌعمل‬.‫ لقدام وورا وبعدها للجانبٌن‬walker‫ال‬
‫ انه ٌزق الحٌطة برجله او ٌزق كورة على الحٌطة برجله‬chain

o Muscle weakness or inhibition:-

The guidelines recommend applying resistance starting from the 7th day (and according to the
patient condition).

Quadriceps strengthening exercises:

1) Static quadriceps exercise:
 The patient pushes his knee downward against therapist hands or the bed and
dorsiflex the ankle. (repeat for 3 sets x 10 reps with 5 sec hold each)
2) Straight leg raises:
 The patient flexes the non-affected knee and
the affected knee is extended.
 The patient pushes his affected knee
downward against therapist hands and
dorsiflex the ankle then raise his leg upward
(straight leg raise with no hip abduction and
the foot in neutral position to avoid varus or
valgus deformity)
 We didn't just directly start by raising the leg
because we want to make sure that the knee
is extended and not in extension lag.

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 ‫نتنً الرجل التانٌة اللً مش شغالٌن علٌها واقوله ٌزق ركبته على اٌدي وٌاخد مشط رجله علٌه وٌرفع رجله لفوق وبعمل‬
abduction ‫ واراعً انه وهو بٌرفع ماٌعملش‬extension lag ‫كل دا عشان اتؤكد انه بٌرفع ورجله مفرودة ومافٌش‬
. valgus‫ او‬varus ‫ وٌحصل‬angulation ‫عشان ماٌعملش‬

3) Short arc extension:

 The patient extends the knee in a certain range (not full range) (50o-90o or 60o-90o)
 The patella in this range is in complete contact with the femoral condyle.
 Strain or deformation = force / surface area.
 So if the surface area = 1 cm, force = 50 N, then deformation = 50
 If the surface area = 10 cm, force = 50 N, then deformation = 5
 So in case of big contact (big surface area), deformation is the lowest.
 The last 45o is avoided (by putting the rolled towel under the knee)
‫ مع‬patella‫ بتاع ال‬contact‫ كله ٌعنً قاعد ٌفرد ركبته بزاوٌة معٌنة بٌبقى فٌها ال‬arc‫المرٌض مابٌجٌبش ال‬
‫ تحت ركبته عشان‬rolled towel ‫ فبنحط مخدة او‬deformation ‫ مناسب بحٌث ماٌحصلش‬femoral doncyle‫ال‬
.range‫نتجنب اخر ال‬

4) Multiple angle isometric:

 Contracting the quadriceps in different angles.
 Multiple pillow are put under the patient's knee (to
control the angle), therapist hand above the ankle,
then the patient press against therapist hand
upward as if he is extending his knee, then change
the angle by removing or adding a pillow and
perform the same motion.
‫بنحط كذا مخدة تحت ركبة العٌان وبعدٌن نخلٌه ٌزق اٌدي وكؤنه بٌفرد ركبته وبعدها نغٌر الزاوٌة باننا نغٌر المخدات ونكرر‬
.‫نفس الحركة‬

N.B.:
o In case of extension lag: we can use electrical stimulation to augment the muscle strength.
We can use electrical stimulation in general with the
strengthening program to aid us with gaining strength
(especially in extension lag)
electrical ‫ٌعنً لو حد ماٌعرفش ٌرفع رجله وركبته مفرودة ممكن نعمل‬
.‫ عشان تشتغل وٌفرد ركبته‬quadriceps‫ لل‬stimulation

↑ Extension lag
Hamstring strengthening exercises:
1) Hamstring set:
 Patient is in supine position. Therapist one hand is under the ankle and the other is
palpating the hamstring, then the patient presses his ankle against therapist hand.

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2) Hamstring curls:
 Patient in prone position putting a pillow or a rolled towel under foot and leg to avoid
the last degrees of extension. The patient then flexes the knee while maintaining foot
in midline to make sure we are training the entire muscle (if the foot is in medial
rotation we will be training medial hamstring only. If the foot is in lateral rotation we
will be training lateral hamstring only)

‫ زي الصورة حاطٌن مخدة او فوطة تحت رجله عشان ماٌجٌبش‬position ‫ٌعنً ٌبدأ من‬
‫ عشان نبقى بنشتغل على‬rotation ‫اخر كام درجة وبعدٌن ٌتنً ركبته من غٌر ماٌعمل‬
.‫العضلة كلها‬

3) Multiple angle isometric:

 Contracting the hamstring in different angles.
 Multiple pillow are put under the patient's knee (to control the angle), therapist hand
under the ankle, then the patient press against therapist hand downward as if he is
flexing his knee, then change the angle by removing or adding a pillow and perform
the same motion.
‫بنحط كذا مخدة تحت ركبة العٌان وبعدٌن نخلٌه ٌزق اٌدي وكؤنه بٌفرد ركبته وبعدها نغٌر الزاوٌة باننا نغٌر المخدات ونكرر‬
.‫نفس الحركة‬

Proximal stability:
o Proximal stability is crucial for distal mobility.
o If the core isn't stable (no proximal stability) and the patient is leaning forward with the
trunk then this will produce stress on the lower limbs. The causes of knee conditions aren't
always originating from the knee or the surrounding muscles. It may be a problem in
proximal stability causing stress on the knee.

‫ مش متثبت‬core ‫ من تحت الن لو ال‬distal mobilityً‫ من فوق عشان ٌبقى ف‬proximal stability ً‫الزم ٌبقى ف‬
‫كوٌس ٌبقى هاحمل زٌادة على الرجل عشان كدا فً مشاكل كتٌر فً الركبة بتبقى الركبة سلٌمة والعضالت اللً حوالٌها‬
‫ على الركبة وممكن ٌبقى حد عضالت رجله متقسمة بس مشكلته فً حاجة‬stress ‫ فٌه مشكلة فعامل‬core‫سلٌمة بس ال‬
.‫ للركبة مش فً الركبة نفسها‬proximal ‫ او‬distal

1) Core stability exercises

.core strengthening ‫ غٌر ال‬core stability‫ال‬
2) Core strengthening exercises:
i. Static abdominal and back muscles exercise: (therapist hand under the back of the
patient, ask the patient to contract the abdomen and
press his back against your
hand)
ii. Crunches (1 ‫)الصورة‬
iii. Bridges (2 ‫)الصورة‬

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3) Hip abductors strengthening exercises:
i. Delayed at first (precautions ً‫)زي ما قولنا فوق ف‬
ii. (a) Straight leg raises from side lying position:
 Patient is in side lying position with his back supported
against a wall to avoid substitution (substitution by hip
flexion) then raise the leg.
iii. (b) Clam exercise:
 Patient is in side lying position with his back supported against a wall to avoid
substitution (substitution by the pelvis)
 The patient is in hip and knee flexion then the patient abducts and externally
rotates the hip (opening his 2 legs apart like a clam or opening a book)

4) Hip extensors strengthening exercises:

i. Prone straight leg raise:
 Patient is in prone position with feet outside the plinth
 It's better to start the exercise from hip flexion so a pillow is put under the
abdomen to flex the hip, and then ask the patient to raise his leg.
 The patient can substitute the motion by moving the pelvis and flexing the knee
(knee flexion = hamstring. We want to recruit the gluteus Maximus muscle not
the hamstring)
 In order to avoid substitution, we order the patient to squeeze the buttocks then
raise the leg and make sure that the knee is extended (with the knee extended,
we recruited the hamstring to extend the knee and work on the knee only not the
hip so the gluteus Maximus is recruited to
extend the hip)

‫ ورجله برا السرٌر زي الصورة ونقوله ٌضم االلٌتٌن‬prone ‫هٌبقى ناٌم‬

gluteus ‫وبعدٌن ٌرفع رجله وهً مفرودة فبكدا ضمننا اننا شغلنا ال‬
hamstring ‫ مش ال‬Maximus

N.B.:
Good gait depends on:
 proximal stability
 Crutch muscles strengthening exercises
 Teach the patient how to walk weight bearing as tolerated (WBAT) with a walker:
o The walker then the affected limb then the non-affected limb.

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o Cardiorespiratory fitness
Low impact aerobic exercise:
o Such as walking and swimming (‫)ٌعوم لو فك الغرز‬
o Swimming is great as the muscles will be trained while the joints are unloaded.

.unloading ‫ٌعنً نخلٌه ٌتمشى او ٌعوم لو فك الغرز والسباحة حلوة عشان هٌشغل كل العضالت وهو عاملها‬

.moderate‫ وبعدها ندخل فً ال‬maximum protection phase ‫ اسابٌع بتوع ال‬4 ‫كدا خلصنا اول‬

 Moderate protection:-
After the maximum protection phase, Pain and swelling disappeared so we progress the
exercise in the previous rehabilitation phase:-

ROM exercises:
o In the maximum protection phase we achieved 90o knee flexion.
o If the surgeon confirmed that the artificial joint can allow the patient to perform 125o-
150o knee flexion then we continue the ROM exercise until we gain this range.
o If the joint only allows 90o, then we work to maintain that range.

‫ ٌبقى نشتغل معاه لحد مانجٌبها ولو ال ٌبقى نشتغل اننا‬125 ‫ فلو المفصل ٌجٌب اكتر من‬93 range‫احنا وصلنا معاه ل‬
.range‫نحافظ على ال‬

Strengthening exercises:
o Progressive resisted strengthening exercise:
o The patient performs the same exercises of the maximum protection phase but with
progression (increasing resistance or extra weight).
o Strengthening from weight bearing position (standing):
o Mini squat: the correct position for this exercise is:
 The knees doesn't surpass the toes (which means that the patient should slightly
flex the knee to about 60o) (maximum activation of muscles is at 60o flexion so
flexing the knee above 60o won't produce any extra
muscle activation and will increase joint reaction force
(JRF) causing pain so patient with knee problems should
perform the exercise 45o-60o flexion only [this is also a
better position for healthy individuals])
 During flexion the knees are in varus position (not valgus)

resistance‫ اللً فاتت ولكن نزود ال‬phase ‫ٌعنً هنخلٌه ٌعمل نفس التمارٌن فً ال‬
squat ‫ ودا‬mini squat‫وطالما المرٌض بدأ ٌحمل ٌبقى نعمله تمارٌن وهو واقف زي ال‬
maximum ‫ اللً فٌه بٌحصل‬range‫ درجة الن دا ال‬63 ‫عادي بس مابننزلش فٌه كتٌر ٌعنً بننزل بس نتنً ركبتنا‬
‫ ونزود‬joint reaction force‫ زٌادة وهنزود ال‬activation ‫ للعضلة واكتر من كدا مش هٌحصل اي‬activation
.varus ً‫ ماتدخلش ف‬knee‫ على الفاضً ونراعً ان ال‬pain‫ال‬
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Progressive proprioceptive training:
o Balance exercise using balance board
o The patient is standing on the balance board putting the knee in
semi-flexion 5o to make sure that we are training the knees not
the ankle.
o Then the patient starts to shift his weight antero-posterior then
medio-lateral.

semi- ‫ وهو عامل‬balance board ‫ اننا نوقفه على‬balance training ‫بنعمل‬

‫ لقدام‬weight shifting ‫ وبعدها نخلٌه ٌعمل‬.ankle‫ مش ال‬knee‫ عشان نبقى شغالٌن على ال‬knee‫ فً ال‬flexion
.‫وورا وبعدها للجانبٌن‬

Mobilization:
o Patellar mobilization
o Tibio-femoral mobilization (‫( )لو محتاجه‬anterior glide & posterior glide)

Progress aerobic exercise:

o Add cycling to the program. (‫)ٌركب عجل‬

.minimum protection‫ وبندخل بعدها فً ال‬moderate protection phase‫كدا خلصنا ال‬

 Minimal protection:-
Progressive resisted strengthening exercises:
o Same as the moderate protection phase but increase resistance.

Progressive balance training

Return to play training:

o If the patient is practicing any sports then we prepare him to return to this sport by
performing the basic tasks of the sport.
.‫لو بٌلعب رٌاضة ببدأ ارجعه للرٌاضة بتاعته بالتدرٌج ٌعمل الحاجات االساسٌة‬

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