Anneke was invited to the winter meeting of the GOTS (Gesellschaft für Orthopädisch-Traumatologische-Sportmedizin) and gave a presentation on physiotherapy treatment options following cartilage surgery. The audience consisted of specialists from various disciplines throughout Switzerland. More information about the event here: GOTS – Society for Orthopaedic-Traumatologic Sports Medicine (gots-schweiz.ch)

Cartilage

Cartilage is a form of connective tissue that is highly resistant to tearing and elastic under pressure. There are three different types of cartilage in our body: hyaline cartilage, elastic cartilage and fibrocartilage. In this article, we are referring to hyaline cartilage, which is found in our joints. It does not contain any vessels of its own, i.e. no blood vessels, lymph vessels or nerves. If it is not supplied with blood, it therefore has no healing potential of its own after an injury. Due to the lack of nerves, the pain we feel does not come from the cartilage but from neighboring, possibly inflamed tissue. Cartilage is nourished by the surrounding synovial fluid and cartilage membrane, which is formed, among other things, through adequate movement, which we supply from the outside. In a joint, the cartilage serves as a support and shock absorber between the bones and joint surfaces.

Treatment – surgery?

Cartilage can be damaged as a result of trauma, for example impact trauma (fall) or twisting, or can also develop as a result of prolonged incorrect or excessive strain. Accompanying injuries can occur, for example a rupture of the cruciate ligament or meniscus in the knee joint. The indication for surgical or conservative treatment of cartilage injuries is discussed with the treating doctor. Many factors must be taken into account: Age, concomitant injuries, location of the cartilage injury, size of the lesion, requirement profile and goals of the injured person, and many more.

Aftercare – Physiotherapy

If the cartilage injury required surgery, direct physiotherapy treatment is essential. A physiotherapist will find out which surgical method was used, which part of the joint and cartilage was affected and which restrictions are recommended by the doctor for the initial period. It can be helpful if these documents are brought to the first physiotherapy appointment.

It may be that the knee joint cannot yet be flexed to its full extent, which is why a splint limits this. You are often given sticks and are not allowed to walk fully for the first few weeks. All these measures can take 2-6 weeks, depending on the operation. We distinguish between three phases in the follow-up treatment:

• The first phase, the protection phase, lasts from week 1-6,
• the second, functional and active phase, weeks 6-12,
• The final phase can last up to over a year and includes the return to sport until the previous performance level has been reached.

Phase 1

The aims of the first phase are to promote wound healing and slightly activate the muscles and joint. The operated area is often swollen and painful at the beginning. As only partial weight-bearing on sticks is permitted at the beginning, physiotherapy checks that the foot is being rolled correctly. A splint is often worn which, depending on the operation, restricts movement so as not to interfere with healing. Early mobilization of the joint, flexion and extension of the knee are very important from day 1 of the operation. The muscles can also be activated without strain and trained as the operation progresses. Less is still more in this phase, but increasing weight-bearing will soon become very important.

Phase 2

The aim of the second phase is to restore full mobility to the joint and enable full weight-bearing without sticks and braces. During the second phase, the difference in strength between the sides (left and right leg) should be as small as possible, which must be achieved through various exercises. The physiotherapist should check the exercises as often as possible, as much as necessary, and instruct constant adjustments. The focus should already be on the patient’s requirements in everyday life, at work and during sport, so that the right choice of exercises is made. It can help to record the exercises with a video so that the patient can see any possible incorrect strain, but also to be able to watch the correct execution again and again at home. Training is becoming increasingly complex and functional and should include the components of strength, coordination, balance, leg axis stability, speed and flexibility .

Phase 3

For many patients, returning to sport and their previous level of performance is the most important long-term goal of the entire rehabilitation process. Both are also possible after cartilage surgery, but can take up to 18 months, or even less than a year depending on the operation. In this case, treatment is always individualized and agreed upon in consultation with the operating doctor, trainer, nutritional therapist, sports psychologist and others. Questionnaires, strength tests and functional test batteries (e.g. the Orthelligent Pro) should help to decide whether the operated leg and the patient are ready to return to sport and later complete the therapy.

Summary and guidance

Physiotherapeutic follow-up treatment following cartilage surgery is important. It may be possible to attend a few physiotherapy sessions before the operation in order to receive important instructions on gait, mobilization and muscle activation and to keep pain and signs of inflammation at an appropriate level. The treatment should be individualized and constantly adapted as the procedure progresses.

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References:

1.Bannuru, R.R. et al. (2019) “OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis,” Osteoarthritis and Cartilage, 27(11), pp. 1578-1589.

2.Crecelius CR, et al. (2020) Postoperative Management for Articular Cartilage Surgery in the Knee. J Knee Surg. 2021 Jan;34(1):20-29.

3.Hurley ET, et al (2019). Return-to-play and rehabilitation protocols following cartilage restoration procedures of the knee: A systematic review. Cartilage.

4.Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. (2009) Return to sports participation after articular cartilage repair in theknee: scientific evidence. Am J Sports Med. 2009 Nov;37 Suppl 1:167S-76S.

5.Nehrer Stefan et al. (2019) “Cartilage and osteoarthritis in sport”, GOTS expert meeting Krems (Donau) Austria

6.Stop X – rehabilitation & prevention of knee injuries (2022) Stop X – rehabilitation & prevention of knee injuries.

7.Stone, J. and Schaal, R. (2012) “Postoperative management of patients with articular cartilage repair,” Journal of Knee Surgery, 25(03), pp. 207-212.

8.Valle, C. et al. (2019) Prehabilitation and rehabilitation after cartilage regenerative surgery. Arthroscopy 32, 199-204.

9.Vogt, S. et al. (2012) “Practice in rehabilitation after cartilage therapy: An expert survey,” Archives of Orthopaedic and Trauma Surgery, 133(3), pp. 311-320.

10.Wagner, K.R. et al. (2022) “Rehabilitation, restrictions, and return to sport after cartilage procedures,” Arthroscopy, Sports Medicine, and Rehabilitation, 4(1).