Therapeutic Exercise:

Foundation & Techniques

Resource person: Dr. Rahat Ayub PT
SHS.326.Lec.17
 Review
• HYPOMOBILITIES
• OPERATIVE & NON OPERATIVE MX
• Ligamentous injuries
 OUTLINES
• Miniscal injuries
• Knee tests
• THR / THA
 Meniscus Tears: Nonoperative
Management
• Mechanisms of Injury
• The medial meniscus is injured more
frequently than the lateral meniscus
• Insult may occur when the foot is fixed on the
ground and the femur is rotated internally, as
when pivoting, getting out of a car, or
receiving a clipping injury
• An ACL injury often accompanies a medial
meniscus tear
• Lateral rotation of the femur on a fixed tibia
may tear the lateral meniscus. Simple
squatting or trauma may also cause a tear
 Common Structural and Functional
Impairments
• acute locking of the knee
• Pain during forced hyperextension or maximum
flexion occurs along the joint line
• joint swelling and some degree of quadriceps
atrophy
• springy end feel when passive extension is attempted
• slight limitation of flexion or extension
• McMurray test or Apley’s compression/distraction
test may be positive
• When the meniscal tear is acute, the patient
may be unable to bear weight on the involved
side.
• Unexpected locking or giving way during
ambulation often occurs, causing safety
problems.
 Management
• Often the patient can actively move the leg to
“unlock” the knee, or the unlocking happens
spontaneously
• Passive manipulative reduction of the medial
meniscus may unlock the knee
• Patient position and procedure: Supine.
Passively flex the involved knee and hip, and
simultaneously rotate the tibia internally and
externally. When the knee is fully flexed,
externally rotate the tibia and apply a valgus
stress at the knee. Hold the tibia in this
position, and extend the knee. The meniscus
may click into place.
• After this treat the joint as if it is an acute
lesion.
• exercises should be performed in open- and
closed-chain positions to improve strength
and endurance
Apley's compression & distraction test for
meniscal injuries
Mcmurray test for meniscal injuries
• https://
www.youtube.com/watch?v=XCvfIhequOc
• https://www.youtube.com/watch?v=UdpQZZs
RtnU
Total Hip Arthroplasty
 Indications for Surgery

 Severe hip pain with motion and weight bearing

 Joint deterioration and loss of articular cartilage
 Osteoarthritis
 Rheumatoid or traumatic arthritis
 Ankylosing spondylitis
 Osteonecrosis (avascular necrosis)
 Nonunion fracture
 Bone tumors
 Failure of conservative management or previous joint
reconstruction procedures
 Contraindications to Total
Hip Arthroplasty
 Absolute
1. Active joint infection
2. Systemic infection
3. Chronic osteomyelitis
4. Significant loss of bone
5. Neuropathic hip joint
6. Severe paralysis of the muscle
 Relative
1. Localized infection
2. Progressive neurological disorder
 Standard surgical approaches
 Posterolateral approach
• Most frequently use
• Preserves the integrity of the gluteus medius and vastus lateralis
• Trochanteric osteotomy is not necessary
• Disadvantage
• Postoperative joint instability
• Risk of postoperative
• dislocation,
 Standard surgical approaches
 Direct lateral approach
• Release proximal insertion of the gluteus medius
• Longitudinal splitting of the vastus lateralis
• Detachment of gluteus minimus
• Trochanteric osteotomy is not necessary
Disadvantage
• Postoperative weakness
• Gait abnormalities
 Standard surgical approaches

 Anterolateral approach
• Involves complex reconstruction
• Indicated for patients with muscle imbalances
• Osteotomy of the greater trochanter
• Soft tissues disturbed
 Conventional hip replacement

Healthy hip Cuts Implant components Implanted

Cemented or Cement less
 Cemented versus cementless fixation

Cemented Fixation
• Acrylic cement allow early postoperative weight
bearing
Disadvantage
• Aseptic (biomechanical) loosening
• of the prosthetic components at the
• bone–cement interface in younger,
• physically active patients
 Procedures
Cemented versus cementless fixation

 Cementless (biological) fixation

• porous-coated prostheses
• cementless press-fit technique
• Smooth (nonporous) femoral components with cementless arthroplasty
• Coating of a bioactive compound
called hydroxyapatite
• Under 60 year of age

Disadvantage
• Late weight bearing
 Operative approaches
Minimally invasive approaches
 Step 1: Incision

• Removal of
osteophytes
• Avoid transverse
Ref: Desert Orthopaedic Center
http://www.desertorthopedic.com/mini.asp

acetabular ligament

Ref: http://www.bonecement.com/application/totalhip.html
Step 2: Removal of Femoral Head

• Femoral head
dislocated
• Femoral head
removed at neck
 Step 3: Prepare Acetabulum

• Drill and reamer used

to remove cartilage
and create cup shape
• Anchorage holes
made (cemented case)
• Remove debris with
brush
 Step 4: Insertion of Acetabular Component

• Held in place by
friction, screws or
cement
• Pressurization carried
out in cemented case

See Reference Section

Step 5: Preparation of Femoral Canal

• Straight reamer
creates hole
• Remove debris
• Insert distal plug

See Reference Section

 Step 6: Insertion of Femoral Stem

• Friction fit or cement

• If cement used
pressurize cement to
create an even
cement mantle

See Reference Section

Step 7: Attachment of Femoral Head

• Attach femoral head

to stem (by Morse
taper)

See Reference Section

 Step 8: Insertion of Head into Acetabular
Component

• Femoral head is
located into
acetabular liner
• Range of motion is
verified

See Reference Section

 Features of Minimally Invasive Total
Hip Arthroplasty

Incision location and muscles disturbed

• Posterior approach
– 7- to 10-cm posterior incision
– the abductor mechanism consistently is left intact
• Anterior approach
– 10 cm incision beginning just lateral and distal of the anterior
superior iliac spine
– leaves all muscles intact
– no postopertive precautions
• Lateral approach
– least commonly used
– leaves the posterior capsule intact
– eliminating the need to postoperative precautions
 Postoperative Management

Immobilization
• After THA there is no
need for immobilization
• The operated must be
kept in a position of
• slight abduction and
neutral rotation when
the patient is lying in
bed in the supine
position.
 Early Postoperative Weight-Bearing Restrictions After Total Hip Arthroplasty

Method of Fixation

Cemented: Cementless and hybrid

• Immediate At least 6 weeks
postoperative weight from partial weight
bearing as tolerated bearing to full
weight bearing
Early Postoperative Weight-Bearing Restrictions
After Total Hip Arthroplasty

Surgical Approach

Standard
Restricted immediately after surgery
Minimally invasive
Weight bearing as tolerated immediately
after surgery
 Exercise: Maximum Protection
• Goals and interventions.
• Prevent vascular and pulmonary complications.( ankle pumps
and deep breathing ex)
• Prevent postoperative dislocation or subluxation of the
operated hip.(educate care taker)
• Achieve independent functional mobility prior
to discharge(perform adl, ambulatory devices, ascend stairs)
• Maintain strength and endurance in the upper extremities
and unoperated lower extremity(active resistive ex)
• Prevent reflex inhibition and atrophy of musculature(muscle
setting ex)
• Regain active mobility and control of the operated
extremity(codman, active knee flexion, ex, abduction etc)
• Prevent a flexion contracture of the operated hip(don’t use
the pillow under the knee)
 Exercise: Moderate and Minimum
Protection Phases
Goals and interventions
• Regain strength and muscular endurance.(bilateral
and unilateral closed chain ex, resistive ex)
• Improve cardiopulmonary endurance.(cycling,
swimming, water aerobics)
• Reduce contractures while adhering to motion
precautions(rom ex)
• Improve postural stability, balance, and gait.(gait
training, treadmill, practice on uneven surfaces )
• Prepare for a full level of functional activities.
 Accelerated Rehabilitation After
Minimally Invasive THA

Immediate postoperative therapy.(5 to 6 hours after surgery)

• Postoperative bed and chair transfers
• Ambulation with crutches
• Ascending and descending stairs
Criteria for hospital discharge.
• Transfer in and out of bed
• Stand up from and sit down in a stand
• Walk 100 feet
• Ascend and descend a flight of stairs
 Operative procedure

 A posterolateral approach is most

commonly used
 After removing the head of the femur, the
metal-stemmed prosthesis is inserted into
the shaft of the proximal femur
 Exercise: Maximum Protection
Goals and interventions.
• Prevent vascular and pulmonary complications.
• Prevent postoperative dislocation or subluxation of the
operated hip.
• Achieve independent functional mobility prior
• to discharge
• Maintain strength and endurance in the upper
extremities and unoperated lower extremity
• Prevent reflex inhibition and atrophy of musculature
• Regain active mobility and control of the operated
extremity
• Prevent a flexion contracture of the operated hip.
Question
 Summary
• Ligamentous injuries
• Knee tests
• THR / THA