Muscle Tightness Limiting Recovery of Total Knee Arthroplasty Patient’s

By: Jacob Wentworth, SPT

Abstract

Background and Purpose

Patient and Setting

Intervention

Outcomes

Discussion and Conclusion

Key Words
Background and Purpose

In the year of 2021 there were reported around 2.4 million hip and knee replacements
combined in the United States. About 54.4% of these joint replacements were total knee
arthroplasty’s (TKA). A TKA is done to help with patients that have pain or functional
impairments with their knees. There are 3 different types of knee replacements, total knee
replacement, partial knee replacement, and patellofemoral replacement. All three surgeries can
be done on a patient’s knee, depending on the severity of their knee damage.

The most common reason a person might need a knee replacement is osteoarthritis (OA). OA
can cause a person’s knee joint to become rough due to thinning of articular cartilage between
the femur and the tibial plato. When the articular cartilage in the knee joint becomes thin, the
femur and tibial plato rube together, bone on bone causing the surfaces to become rough and
painful while moving the joint. The main goal of a knee replacement is to reduce pain and
improve function of a patient’s knee.

With all surgeries, there comes some potential complications. For a TKA some of these
complications are periphrastic fracture, aseptic loosening, wound complications, periphrastic
joint infection, TKA instability, patellar clunk syndrome, stiffness, perennial nerve palsy, and
more. All these complications need to be known and understood by all the medical staff that
will be working with the patient after the surgery. When it comes to rehabilitation after a TKA,
the physical therapist (PT) must be aware of these complications and make sure the patient isn’t
developing them. The focus of a PT is to get the patient walking, decrease pain, increase
strength, and to get their range of motion in the knee back.

Many factors can play a role in a patient’s inability to get their range of motion back in their
knee. Some of these factors can be pain, excessive scar tissue, replacement dysfunctions, not a
lot of motion before surgery, stiffness, and more. This case report will describe how manual
physical therapy can improve a patients range of motion after a TKA with sever stiffness in the
knee. This case report was completed under the direction of the Department of Physical
Therapy and with oversight of the College of Graduate Studies at Central Michigan University.

Caser Description

Patient History and Review of Systems

The patient was a 69-year-old male who had a TKA done to his left knee after chronic pain. The
patient initially reported to physical therapy with a doctor’s diagnosis of primary OA of the left
knee. The patient reported having a chief complain of pain in his left knee for the past couple
years. His knee would get swollen and sore from doing activates such as walking, carrying
laundry, doing yard work, going up and down the stairs, and more. The patient would have pain
at night depending on what activates he did during the day and the pain would change
depending on the position he was in. Surgery for a TKA was set for a few days after the physical
therapy pre-evaluation.
The patient drove a pick-up truck and lived alone in a house that had stairs leading to his
basement where his laundry was and had three steps to get into his house. The floors were all
hardwood and tile with his bedroom and bathroom both on the first floor. Even though he lived
alone, that patient had a sister that lived near by and agreed to help him after the surgery. The
patient also had a two wheeled walker that he was fitted for to improve mobility post-
operation.

According to the patients’ medical records, he had a right TKA a couple years back. After
surgery, the patient was to be seen three times per week for 6 weeks, with goals to be created
with the patient at the second visit. The patient would then have a progress note complete
every 30 days to report to the doctor how his rehabilitation is going.

The projected physical therapy goals that were created at the first visit post-op, included both
short term (2-4 weeks) and long term (4-6 weeks). The short-term goals were: become
independent with initial HEP and report consistency with it; improve knee flexion to 95° to be
able to sit with feet flat on the floor and legs even; improve knee extension to 0° for improved
gait mechanics; and ambulate with a straight cane on a level surface without difficulty,
community distances. The long-term goals were: become independent with comprehensive HEP
and be independent with progressing it for maximal outcomes; improve Focus on Therapeutic
Outcomes (FOTO) score from 31/100 to 57/100 in order to demonstrate an improvement in
their overall tolerance for their daily activates; resume driving; report no difficulty sleeping in
patients bed due to pain; ambulate without an assistive device community distances without
difficulty; and be able to go up 5 stairs with hand rail alternately without difficulty.

Clinical Impression #1

Upon review of the patient and his medical history, the patient presents as a moderate
complexity case and will be a good candidate for physical therapy. When examining the patient,
the physical therapy team found that he had decreased range of motion, decreased strength,
decreased flexibility, decreased activity tolerance, gait dysfunction, and decreased weight
bearing tolerance. The patient would benefit from skilled physical therapy interventions to
address the impairments noted. Improvement of these impairments will help address the
patients’ functional limitations of sleeping at night, participating in leisure activates, standing,
walking, and stairs. Constant was obtained after the plan of therapy was reviewed and agreed
upon by the patient.

Examination

The patient’s initial examination was done a few days before his surgical date. This examination
was conducted to see where the patient was at for strength, range of motion, and functional
activity assessment before the surgery. In the examination the patient was also educated about
exercises that should be done at home after the surgery to improve his recovery. The tests that
were conducted for range of motion were both left and right knee active and passive flexion and
extension. For strength testing, the areas that were tested were both left and right hip flexion,
extension, adduction, abduction, along with knee flexion and extension, and ankle dorsiflexion
and plantarflexion. As for the functional activity assessments, these consisted of assistive device
demonstration, gait pattern demonstration, sit/stand, and squat.

Place figure 1 here

Clinical Impression #2

Based upon the initial examination, the patient continues to be a moderate complexity case and
a good candidate for physical therapy. The patient demonstrated decreased strength, decreased
range of motion, and decreased independence with functional activities. The involvement of
regular physical therapy three times per week for 6 weeks will enhance the patient’s recovery.
Treatment will begin after surgery, starting with more tests and measures to determine the new
strength and range of motion of the patient post-surgery. Along with tests and measure, the
patient will go through interventions that follow the protocol for patients post TKA. With the
plan for this patient to be seen 3 times per week for 6 weeks, goals were established to see
improvement through the patient’s recovery. The patients’ goals were separated into two
groups, short term (2-4 weeks) and long term (4-6 weeks). The short-term goals were: become
independent with initial HEP and report consistency with it; improve knee flexion to 95° to be
able to sit with feet flat on the floor and legs even; improve knee extension to 0° for improved
gait mechanics; and ambulate with a straight cane on a level surface without difficulty,
community distances. The long-term goals were: independent with comprehensive HEP and be
independent with progressing it for maximal outcomes; improve FOTO score from 31/100 to
57/100 in order to demonstrate an improvement in their overall tolerance for their daily
activates; resume driving; report no difficulty sleeping in patients bed due to pain; ambulate
without an assistive device community distances without difficulty; and be able to go up 5 stairs
with hand rail alternately without difficulty.

Interventions

The patient was seen in physical therapy 20 times across a month and a half time frame. Each
visit was around 45 minutes of interventions 2 to 3 times per week to improve the patient’s
strength, range of motion, and functional activates. The physical therapy team also worked on
address complaints of the patient’s, such as pain and stiffness in the knee. These complaints
were managed by implementing manual therapy to the affected areas. Each physical therapy
session was directed around the protocol for a TKA and how the patient was feeling at each
session.

The first treatment session after surgery forced on following the protocol. For TKA patients, the
main goal at first is to get them moving on the knee and start improving the range of motion
and strength. For this patient the physical therapy team focused on therapeutic exercise and a
little bit of manual therapy. To get the patient’s tissue warmed up, the patient started on a
NuStep bike, level 1 intensity, and did this for 8 minutes. The patient was informed to use his
arms on the bike to help bring the knee up into as much flexion as he could. The next exercise
that was completed was heel slides for two sets of ten. This exercise focused on the patients
range of motion and getting him into as much flexion and extension as he could. Straight leg
raise was then done to help strengthen the patient’s core and hip. This was done for one set of
ten repetitions. The next intervention for this patient was short arch quads, to work on
strengthening the quads and help improve knee extension. This was performed for two sets of
ten. Glute contraction was then done where the patient would lay supine on the table and
contract his glutes for one set of 20 repetitions. Then the final therapeutic exercise that was
performed for this treatment was one set of 10 repetitions of quad sets. Each repetition was
held for 10 seconds to strengthen the patient’s quads. After all the therapeutic exercise was
done for the session, the physical therapy team finished the treatment with manual therapy,
performing edema management with effleurage. This technique was performed for the last 10
minutes of the treatment.

At the patient’s 13th visit, was the first progress note. Treatment was performed for the patient
along with retesting and measuring the patient’s range of motion and strength. The treatment
started with exercise which consisted of a warmup on the NuStep machine, level 4 intensity, for
a total time of 8 minutes. After the warmup, the patient went into therapeutic exercise and
started with 8-inch step ups with each leg for one set of 15 repetitions. The next exercise was 6-
inch step downs with each leg for one set of 15 repetitions. After that, the patient went to the
leg press machine where he did 2 sets of 15 repetitions with 15 pounds of resistance. Moving to
the next machine, the patient did leg extensions for 2 sets of 12 repetitions with 10 pounds of
resistance. Then to finished up the therapeutic exercise part of the patient’s treatment, the
patient did seat leg curls with 25 pounds of resistance for 2 sets of 12 repetitions. After the
therapeutic exercise portion of the treatment was completed, the physical therapy team
performed manual therapy of stretching to the patient’s quad and iliopsoas. The patient was in
the supine position with his surgical leg off the edge of the bed. The physical therapy team
provided overpressure to the patient’s leg to stretch the quad and iliopsoas. This technique was
performed for 9 sets of 10 seconds at a time to get to a total end range time of 90 seconds for
max elongation of the muscles. Once the treatment was completed, the retesting and
measuring was conducted to see how much the patient has been improving in therapy.
Comparing to the patient’s initial test and measures, the patient demonstrated to have the
ability to walk without an assistive device, he demonstrated an increase in overall strength and
range of motion of his knee. The patient also had a decrease in pain in his knee.

Place figure 2 here

In the patients last treatment where I was a part of the physical therapy team, a normal
treatment session was performed with the patient. The treatment primarily focused on getting
the patient more knee flexion. A week prior to this treatment a progress notes was performed
and sent to the patients doctor to look over and see if the patient was ready for discharge. The
doctor wanted to see more knee flexion for the patient and reported wanting the patient to
continue with physical therapy to improve with more knee flexion. For this treatment, the
patient started out with a warmup on the upright bike with a level 3 intensity, for 8 minutes.
Some therapeutic exercise was then performed such as forward lung on step stretch for 10
repetitions, being help for 5 seconds each, and body weight squats at the squad bar for support
for 10 repetitions. Once those were completed, manual therapy was performed on the patient’s
knee. The manual therapy started with a functional massage on the distal quad will the patient
was in a seated position. This was done for a total time of 3 minutes to the patient’s knee. Next
was scare tissue management with cupping, soft tissue message, and deep tissue massage.
Once this was completed, functional stretching with cupping on the knee into flexion was
performed for 5 minutes. Then to finish the therapy session, the patient was supine on the table
with his affected leg hanging off the edge to stretch the quad and iliopsoas. This stretch took
place for a total of 90 seconds with 9 sets of 10 seconds holds. In this treatment session the
patient had a lot of pain during the manual therapy to elongate the patient’s tissue that was
limiting the patient’s ability to go into further knee flexion.

Outcomes

The patient was seen for a total of 20 visits in the amount of time I was a part of the physical
therapy team. The patient progressed in the aspect of increased range of motion, strength,
functional activates, and decreased pain. For range of motion, the patient improved left knee
active flexion of 65° to 108°. For left knee active extension, the patient improved from -5° to 0°.
When it comes to strength, the patient improved in all areas. Left hip flexion went from a 4-/5
to 4+/5, left hip extension improved from a 3+/5 to 5/5, left hip abduction improved from a 4-/5
to 5/5, left hip adduction improved from a 4-/5 to 5/5, left knee flexion improved from a 4-/5 to
5/5, left knee extension improved from a 4-/5 to 5/5, and left ankle plantarflexion improved
from a 3/5 to a 5/5. As for functional activates, the patient was walking independently, able to
go up and down stairs, and had an observed normal gait pattern. The patient’s pain was also
lower, improving from an 8/10 pain at worst to a 5/10 pain at worst, and only at nights.

By the last treatment session, I was a part of, the patient had met most of his long-term goals
for physical therapy. These goals consisted of: being independent with a comprehensive HEP
and be independent with progressing it for maximal outcomes; improve FOTO score from
31/100 to 57/100 in order to demonstrate an improvement in their overall tolerance for their
daily activates; resume driving; report no difficulty sleeping in patients bed due to pain;
ambulate without an assistive device community distances without difficulty; and be able to go
up 5 stairs with hand rail alternately without difficulty. The only two that the patient hadn’t met
yet but was close to meeting was the no difficulty sleeping in his own bed due to pain, and
ability to go up and down 5 stairs without difficulty. With some of the patients’ goals not being
met, the patient’s doctor wanted him to stay in therapy to work on these goals and improve his
knee flexion to at least 110°.

Discussion

This case report outlined the physical therapy interventions and clinical reasoning performed for
a patient with a TKA in an outpatient orthopedic clinic. The patient in this case report was able
to meet almost all his goals and requirements to be discharged from physical therapy but was
held up by muscle tightness and meeting the 110° of active knee flexion goal. For patient’s
recovering from a TKA, it is normal for the patient to reach 110° of active knee flexion by the
end of physical therapy. Getting to 110° of active knee flexion will help improve functional
abilities for the patient’s everyday living.

With the current findings in this case, the patient had typical progression of events. The patient
had been progressing well throughout therapy with strength, pain, most range of motions, and
most functional activates. Further knowledge past the patient’s 20th visit is unknown due to
time constraints. This would be considered a limitation for this case report. The whole story of
the patient’s rehabilitation is not complete and the number of visits it took for the physical
therapy team to achieve the goal of getting the patient to 110° of active knee flexion is
unknown. With more research on muscle tightness limiting the recovery of TKA patients,
treatment could be quicker and more effective.
References

Siddiqi A, Levine BR, Springer BD. Highlights of the 2021 American Joint Replacement
Registry Annual Report. Arthroplast Today. 2022 Jan 29;13:205-207. doi:
10.1016/j.artd.2022.01.020.

Archunan M, Swamy G, Ramasamy A. Stiffness After Total Knee Arthroplasty: Prevalence

and Treatment Outcome. Cureus. 2021 Sep 25;13(9):e18271. doi:10.7759/cureus.18271.

Poboży T, Wojciech K, Hordowicz M. TKA With Retained Hardware Guided By

Intraoperative Ultrasonography - a case report. BMC Surg. 2019 Sep 2;19(1):126. doi:
10.1186/s12893-019-0585-6.

Canovas F, Dagneaux L. Quality of Life After Total Knee Arthroplasty. Orthop Traumatol
Surg Res. 2018 Feb;104(1S):S41-S46. doi: 10.1016/j.otsr.2017.04.017.

Han HS, Kim JS, Lee B, Won S, Lee MC. A High Degree of Knee Flexion After TKA
Promotes the Ability to Perform High-flexion Activities and Patient Satisfaction in Asian
Population. BMC Musculoskelet Disord. 2021 Jun 21;22(1):565. doi: 10.1186/s12891-
021-04369-4.

Berryman Reese N. Muscle and Sensory Testing, 4th ed. St. Louis, MO: Elsevier; 2020.

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