Knee Replacement

Question:

A couple of my clients have had knee replacement operations. They have been mobile for many months now. One is very active, cycles 40 miles every weekend and is confident to try things on his knee. However, the other is a woman who is very protective and limps on hers because she is scared of damaging it. The guy’s knee surgeon told him not to do any impact stuff on the knee, which I understand; however, he included Swiss ball squats and squats in general in this. I found this a bit odd since I want to build the quad muscles surrounding the knee. Just wondering what you would suggest as good exercises for both clients. I have been using the "step blocks" a lot as a result of this.

Answer:

Often, physicians give these instructions without regard to activities of daily living. I had the same issue with a client in the past and asked him to come into my office. When he did, I told him to have a seat and then said, “Oh, I'm sorry. Please stand up. Now, please have a seat. Oh, please stand up.” After the second time, the person got the idea that he was squatting. I then asked if he ever sat down when going to the rest room. Squatting is a natural movement pattern that the lower extremity must do. It is important for you to determine your clients' range of motion and functional capacity. Often, when a joint replacement has been done, adjacent joints become limited in motion due to the compensations that have developed. Of course, you must ascertain what the affected joint’s condition is (i.e,. edema, discomfort, range of motion, etc.).

If all is acceptable in this case, I would work to keep the hip and ankle mobile and try modified lunges in the sagittal plane. When doing this, I would then add lateral and medial arm reaches at chest to waist height. The rationale for this is to create the chain reaction from the foot into the hip. The lateral reach will cause the foot to invert the calcaneus, externally rotating the leg. Your client may be able to gain some motion this way. The medial reach will cause calcaneal eversion, increased dorsiflexion and tibial, femoral and pelvic internal rotation. This will activate the calf, lower extremity and gluteal complex. Without seeing your client, I cannot advise which may be better, but one should be successful. Also, I would try Wallbangers (see Figure 1 below). Lastly, Wall Patterns are good to gain tri-plane mobility and eccentric loading and to inherently gain some strength. These are especially good for deconditioned clients and those that are very tentative toward exercise. This too can be applied in a very stable, secure environment.

As far as program design, start with three to five repetitions for two sets and progress to eight to 10 reps for two to three sets. These are conservative, general guidelines. In addition, the Wallbangers can be done near a countertop or pole or anything stable that will give your tentative client a more secure feeling. Once she starts to feel confident, she may want to explore other movement patterns in a more open space.

I hope this helps. Good luck!

Wallbangers

1. Stand in the “stand tall” position, abdominals drawn in, with the feet about shoulder width apart. Feet are pointed forward.
2. Stand about six to 12 inches away from the wall. The distance will vary among clients depending upon their range of motion through rotation, and strength of their lateral gluteals.
3. With the right shoulder closest to the wall, reach out to the left. Be sure the client rotates the hips toward the left foot, flexes the knees, drops the hips and maintains a neutral lumbar spine.
4. As the client reaches to the left, the natural reaction is for the right hip to move toward the wall. Let the client’s right hip “bang” into the wall and immediately return to the starting position. It is critical the client does NOT hold the reaching position as this removes the elastic recoil tendency of the muscle and thereby removes the eccentric loading required in this movement pattern. (The range of motion and rotation will vary depending upon the client’s ability to eccentrically load through the transverse and frontal planes. This action will become greater as the person improves range of motion, which will inherently and functionally improve strength.)
5. Return to the start position by rotating the hips back to the left and then to the upright position.
6. Perform eight repetitions and progress to three sets of 15 reps.
7. Repeat with the left shoulder closest to the wall and the action requires reaching to the right.

Sagittal Plane Lunge w/Lateral Reach to Knee Height

1. Stand with the feet approximately shoulder width apart, knees slightly flexed and abdominals in the drawn-in position.
2. Side step to the 12 o’clock position until the client feels the tension in the gluteals and lower extremities. If desired, a spinal flexion moment can be integrated into the movement pattern.
3. Immediately return to the start position.
4. Perform five to eight repetitions, building to 15 repetitions as the individual gains strength (to develop the supinators of the loading leg).
5. To develop strength of the erectors, spinal rotators and parascapular musculature, perform the above steps with a contralateral (opposite sided) reach. Depending upon the range of motion of the person’s thoracic spine, external hip rotators and opposite or weight loading glutes, the reach will be somewhat varied. This range will become greater as more flexibility in these structures is acquired. This movement pattern will add emphasis of the peroneal group of the loading leg. This is due to the supination that will occur as a result of the external rotation of the distal lower extremity during the reach phase.

Wall Patterns

• Level: Developmental
• Targeted Muscles: Peroneals, quadriceps, gluteals, hip adductors and abductors, spinal rotators, obliques
• Objective: This movement pattern is designed as a low-level excursion exercise to increase strength and stability of the musculature, especially through the frontal and transverse planes. Eccentric loading allows for greater energy conservation and a more forceful and efficient contraction. The eccentric phases allow the muscle to lengthen, absorb forces and slow the motion as the resistance is being lowered. The motion in this exercise requires the body to control the downward forces gravity places upon it. Additionally, the muscles along the lateral aspect of the body (i.e., peroneals, lateral gluteals, hip abductors and obliques) must lengthen to control the lateral motion and at the same time stabilize the motion along the frontal plane. When the movement pattern incorporates a rotational component, the spinal rotators and erectors decelerate motion. All aspects of the exercise are designed to increase the range of motion and concomitantly increase strength in the plane of motion.
• Rationale: Increase strength in the frontal and transverse plane of motion. Additionally, people become stronger through the implementation of this exercise and gain confidence in their ability to ambulate. Improvements in gait are also observed.

As people gain range and strength, further challenges can be added with arm reaches at different heights. This exercise pattern is excellent for the very unstable client, seniors or those with compromised frontal plane control.

Technique: Frontal plane, shoulder height reach

1. Stand with feet about shoulder width apart.
2. Shift the weight over one hip and be sure to keep the hip over the knee.
3. Reach with the same-side arm and excursion along the frontal plane until the client feels the loading of the lateral gluteals and lower extremity. The client will feel tension in the weight bearing leg, hip, and opposite oblique, and same side posterior shoulder. (Note: the range of motion is strictly dependent on the person’s ability to excursion along the frontal plane. It will vary with the elasticity of the musculature of the ankle, lateral glutes, and opposite adductors. As the structures gain range of motion, they will also gain eccentric loading of those muscles.)

Technique: Transverse plane high or low reaches

1. Follow the technique of the frontal plane reach.
2. Rotate the pelvis toward the side the client is turning toward.
3. Reach at shoulder level or above.
4. When reaching below hip level, it is essential the client lower the hips so the gluteals, quadriceps, hamstrings and calf group elongate to control the downward motion. Additionally, this will protect the lumbar spine.

All exercises and images printed with permission from “Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns.” Wolf, Chuck. 2003.