Physiotherapy after cartilage surgery in the knee

Anneke was invited to the winter meeting of the GOTS (Society for Orthopedic Traumatologic Sports Medicine) and gave a lecture on the physiotherapeutic treatment options after cartilage surgery. Audience were different disciplines from all over Switzerland. More information about the event here: GOTS – Gesellschaft für Orthopädisch-Traumatologische Sportmedizin (gots-schweiz.ch)

Cartilage

Cartilage is a form of connective tissue that has a high resistance to tearing and elasticity under pressure. There are three different types of cartilage in our body: hyaline cartilage, elastic cartilage and fibrocartilage. We refer in this article to the hyaline cartilage, which is located in our joints of the human body. It does not contain its own vessels, i.e. blood and lymph vessels and 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 cartilaginous membrane, which is formed, among other things, by adequate movement, which we supply from the outside. In a joint, cartilage serves as a support and shock absorber between the bones and joint surfaces.

Treatment - surgery?

A cartilage can happen as a result of trauma, for example impact trauma (fall) or twisting, or it can develop as a result of prolonged incorrect loading or overloading. Accompanying injuries can occur, in the knee joint for example a tear of the cruciate ligament or meniscus. The indication for surgical or conservative treatment of cartilage injuries is discussed with the treating physician. Many factors must be taken into account: Age, concomitant injuries, localization of the cartilage injury, size of the lesion, requirement profile and goals of the injured person, but also many others.

After care - physiotherapy

If the cartilage injury required surgery, direct physiotherapeutic 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 flexion in the knee joint may not yet be performed to a final degree, which is why a splint limits it. Often, you will be given canes and not allowed to step all the way for the first few weeks. All these measures can last 2-6 weeks, depending on the surgical procedure. In the aftercare we distinguish between three phases:

• the first phase, protective, lasts from week 1-6,

• the second, functional and active phase, week 6-12,

• and the last one can last up to more than a year and includes the return to sport until the previous level of performance, if requested.

The goals of the first phase relate to promoting wound healing and light activation of the muscles and joint. Often the operated area is swollen and painful at the beginning. Since only partial weight-bearing on canes is allowed at the beginning, physiotherapy checks that proper rolling of the foot is performed. Often a splint is worn, which is restricted in movement depending on the operation, so as not to interfere with healing. Very important from day 1 of the operation is the early mobilization of the joint, bending and stretching the knee. The musculature may also be activated already unloaded and trained in the course. Less is still more in this phase, but soon the increasing load becomes very important.

Phase 2

The second phase aims to restore the full mobility of the joint and to allow full loading without sticks and splint. In the course of the second phase, the strength force should be as little as possible in comparison to the healthy leg, 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 is already on the requirements of the patient in everyday life, work and sports, so that the correct exercise selection is made. It can help to record the exercises with a video in order to see possible incorrect stresses as a patient, but also to be able to watch the correct execution again and again at home. Training is becoming more complex and functional and should include the components of strength, coordination, balance, leg axis stability, speed and mobility.

Phase 3

Returning to sports and previous performance is the most important and long-term goal of overall rehabilitation for many sufferers. And both are also possible after cartilage surgery, but can take up to 18 months, or even less than 1 year, depending on the operation. Here, the treatment is always individualized and made in consultation with the operating doctor, if necessary trainer:in, nutrition therapist:in, sports psychologist:in and others. Questionnaires, strength tests and functional test batteries (e.g. Orthelligent Pro) should help to decide whether the operated leg and the patient are ready to return to sports and later to complete the therapy.

Conclusion and direction

Physiotherapy aftercare following cartilage surgery is important. If necessary, it is possible to attend a few sessions of physiotherapy before the operation in order to receive important instructions on gait, mobilization and muscle activation, as well as to keep pain and inflammatory signs at an appropriate level. Treatment should be individualized and steadily adjusted as it progresses.

Book appointment for Physiotherapy, Massage oder Group classes: here.

Author:

Anneke Penny

References:

1. Amboss 2021

2.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.

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

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

5.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.

6.Nehrer Stefan et al. (2019) „Knorpel und Arthrose im Sport“, GOTS Expertenmeeting Krems (Donau) Österreich

7.Stop X - rehabilitation & prävention von Knieverletzungen (2022) Stop X - Rehabilitation & Prävention von Knieverletzungen.

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

9.Valle, C. et al. (2019) Prähabilitation und Rehabilitation nach knorpelregenerativen Eingriffen. Arthroskopie 32, 199–204.

10.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.

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