Prehabilitation : Why you must rehab before the operation

Tracy Maunder explains the basics of thorough preparation for joint surgery.

When an injured athlete has got to the point of needing joint surgery, it’s all too easy to ‘write them off’, leaving them to fend for themselves until after the operation, when the sports therapist can pick up the important task of organising their rehab. But this is to miss a significant opportunity to work with the injured client on prehab – preparation leading up to surgery. By designing a prehab programme, a good support professional can prepare their patient mentally and physically for surgery, so that the chances of a successful outcome are maximised.

Mental preparation

After an injury to an athlete’s limb, the injured athlete and their surgeon have agreed that surgery is required. Typical examples are: unstable shoulder resulting from repeated soft-tissue damage to the joint; torn meniscus from a rotatory injury to the knee; or ruptured ligaments of the ankle after an awkward tackle on the rugby pitch.

Patients are often nervous about surgery and will probably have failed or forgotten to ask the surgeon the right questions. Prehab allows the procedure to be explained and the patient to discuss their rehabilitation programme in detail, so that they fully understand what is expected of them. The process of allaying the patient’s fears and answering their questions will allow them to go to surgery with a positive mental attitude.

This mental preparation enables the patient to be both confident and realistic about setting and achieving postoperative goals. Without it, they are much more likely to become frustrated and demotivated when recovery seems to be taking a long time, because they never had a realistic understanding of the time-frame in the first place.

For example, after ACL reconstructive surgery of the knee, patients are not usually allowed to run until 12 weeks post-op, or to resume serious training for four to five months. Yet they may have picked up very different timescales from a combination of hearsay and media reports of very unusual cases, which could have set up vastly different expectations about the speed of their recovery.

Moreover, many orthopaedic surgeons have their own specific protocols for post-op programmes, so the prehab period is a valuable opportunity for the patient to learn about this, and even to practise the exercises.

Physical preparation

The basic principles of physical preparation apply to all joint surgery. However, the nature of prehab for acute injuries (those needing surgery within the first few weeks, such as an ACL rupture) will be somewhat different from that needed for chronic injuries (those needing cold surgery such as an osteoarthritic knee awaiting joint replacement). The main focus below is on the former group.

Acute injuries

After a traumatic injury a joint will experience several possible inflammatory reactions to varying degrees. Pain and swelling occur at the site of injury, followed by reflex inhibition of the surrounding musculature, which in turn leads to joint stiffness and muscle weakness. Rehab must therefore commence from the time of injury, not from the time of surgery, in order particularly to help minimise the muscular weakening.

A skier twists their knee awkwardly when their skis fail to come off. The diagnosis of an ACL rupture is made. Because the success of surgery is significantly enhanced if the joint is calm prior to the operation, the surgeon has given the patient three to four weeks to prepare the knee so that it is non- inflamed and has good strength, full flexion and hyperextension.

If a surgeon operates on a swollen, stiff and weak knee, intra-articular fibrosis is more likely to occur postoperatively, causing joint stiffness and possibly affecting the long-term outcome of the surgery. This would have implications for private medical insurers, who are keen to minimise the number of post-op physio treatments.

Prehab: key aims

* Reduce pain and swelling rapidly

All inflamed joints will benefit from RICE: rest, ice, compression and elevation. RICE initially causes vasoconstriction in the area to reduce the blood flow and stop the bleeding of the injured tissue. Cooling by ice also reduces the perception of pain. Ice can be applied as an ice pack, wrapped in a towel for compression, for 10-15 minutes every 2 hours. The patient must rest with the limb elevated, so that gravity helps the swelling to reduce. For a leg injury the foot is supported higher than the hip; an injured arm is elevated on pillows so that the hand is higher than the shoulder.

If our skier’s ruptured ACL happens to be combined with a medial collateral ligament injury then their knee joint will need to be supported in a brace to help protect against further injury. The skier will also be partially weight bearing on crutches to reduce pressure through the joint.

Ice and compression can be given in the form of a cryo-cuff, a pouch filled with iced water which compresses the joint. The advantage of this method of cooling is that the cuff can stay on the skin for longer (eg 30 minutes) and applications can be easily repeated throughout the day.

* Restore range of movement

As the pain and swelling start to reduce, gentle mobilising and stretching exercises will encourage a return to as near normal range of movement as is possible. It is important for the client’s trainer to be involved at this point, as they can supervise and encourage the client to maximise their potential for improvement prior to surgery.

Upper limb injuries respond well to active/assisted exercises, eg gripping fingers together and using the stronger arm to take the weaker arm into further flexion, or using a rope and pulley system to similar effect. For lower limb injuries, hydrotherapy or gentle exercises in water are very effective. The buoyancy of the water can be used to assist or resist movement.

For the athlete with the ruptured ACL, gentle flexion/extension exercises are used for knee joint mobility. It is important to restore full hyperextension (equal to the uninjured knee) prior to surgery, because swelling in the knee joint can only be fully compressed by a maximal isometric contraction of the quadriceps muscle when it is in the locked or hyperextended position.

If an athlete has a bucket-handle tear of the meniscus that is blocking the knee joint by 20-30 degrees from full extension, early arthroscopy is necessary. The quadriceps muscle will weaken rapidly if extension is not restored within a few days.

Full hyperextension can be achieved by using passive hamstring stretches such as knee hangs with only the heel supported on a pillow, or prone knee hangs (the patient lies on their stomach and allows only the thigh to be supported while the lower leg hangs over the end of the bed).

To improve knee flexion, the patient can sit on a desk with legs dangling and knees bent at 90 degrees. They then use the good leg to push the injured one gently back into further flexion. Alternatively, the patient can sit with their legs straight in front, bend the injured leg at the knee and use their hands to grip the ankle, easing the leg into greater flexion.

* Gain muscular control of the injured limb

The pain and swelling arising from acute inflammation produce reflex inhibition (reflex weakening) of the muscles surrounding the injured area. Neuromuscular control needs to be restored prior to surgery in order to facilitate muscle recovery post-operatively. The stronger the muscles are, the faster they will recover afterwards.

Prehab strengthening exercises for all limb injuries would include isometric contractions, progressing to isotonic exercises against light resistance. The athlete may even be able to do light resistance training using gym machines, but they must understand that prehab exercises have to be closely monitored and that the joint must not be aggravated. If they end up provoking further pain and swelling, it may even delay surgery.

For knee prehab, isometric cocontractions of the quadriceps, hamstring and calf muscles will help reduce atrophy and can be performed sitting, lying and standing. Once the patient can maintain full hyperextension with a maximal isometric quadriceps contraction, begin straight leg raises.

Patients must gain active muscular control of hyperextension so that the knee does not ‘flick’ into that position during weight bearing. Where an ACL rupture has left an unstable knee, closed kinetic chain exercises are best, as muscular co-contraction occurs around the joint and reduces the anterior shear force on the tibia. Closed chain exercises also improve proprioception around the joint. These include static cycling, cross trainer, half squats, lunges and leg press.

* Encourage proprioceptive awareness and normal movement patterns

Any sporting action, whether it’s kicking a ball or throwing a javelin, depends on the co-ordination and fine-tuning of the neuromuscular control of all the soft tissues contracting around the joint. Joint injuries involving soft tissues that contain proprioceptors (such as capsular tears of the shoulder or ACL ruptures of the knee) will have reduced awareness of joint movement. For athletes the importance of restoring neuromuscular function, including balance reactions and proprioception, cannot be over-emphasised.

A gymnast who has to balance her body weight through her arm on the beam must be able to feel where the joint is. Proprioceptive exercises need to be started prior to surgery to stimulate the neuromuscular mechanisms and make them more responsive after surgery.

Examples of upper limb proprioceptive exercises are press-ups over a Swiss ball, or pushing a soft ball on to the wall with one arm, then rolling it in different directions.

Anyone with a painful and swollen knee will normally limp. And as the symptoms improve, they often continue to limp because the motor cortex of the brain has accepted the changed motor pattern as normal. The correct gait pattern can be re-learnt prior to surgery to reprogramme alignment, weight transmission and proprioceptive input. This helps to facilitate a normal postop gait pattern.

For ACL-deficient knees, gentle balance exercises can be introduced, such as balancing on one leg with eyes open and then closed. A brace may have to be worn during exercise if the knee is very unstable. Balance boards and balancing on trampettes are also options. Most proprioceptive training comes postoperatively, once the knee has been stabilised with the new tendon graft.

Chronic joint injuries

If an athlete has suffered with a chronic joint injury over a long period and the joint has become increasingly stiff and painful, the body will almost certainly have developed compensatory movement patterns to try to offload the affected joint. Prehab is the place to try and reduce these movements and work on correct movement and recruitment patterns.

Weak, unstable shoulders will often compensate by over-using the trapezius muscle so that the position of the scapula becomes elevated and protracted. The humero-scapular area is not stabilised and this may lead to impingement problems of the rotator cuff or to neck and shoulder pain.

A typical example of lower limb compensation would be a former footballer in his fifties who had a total medial meniscectomy (removal of the inside meniscus) in his twenties and has developed medial compartment osteoarthritis. The decision has been made to perform a hemi-arthroplasty (half joint replacement) on the medial side of the knee joint.

The footballer, not surprisingly, limps. This causes the hamstring and calf muscles to tighten and places extra pressure on the patello-femoral joint, causing it to become painful. A degree of chronic swelling will be present which can contribute to weakened musculature on the affected side. Limping can also place pressure on the lumbar spine or sacro-iliac joints and cause low back or hip pain.

This patient would need to start a prehab programme at least one month prior to surgery so that the limb can be mobilised and strengthened. His prehab programme would include:

• Deep soft-tissue massage and stretching of the hamstring and calf muscles (release of posterior tightness will allow increased extension, helping to prevent flexion contractures post-operatively);
• Mobility exercises (eg flexion/extension) and gentle stretching into the end of range of movement;
• Manual mobilising techniques and possibly McConnell taping to loosen the patella and improve alignment in the trochlear groove of the femur;
• Quadriceps, hamstring, calf and hip abductor strengthening exercises within a pain-free range of movement (isometric and isotonic concentric and eccentric muscular contractions);
• Gait re-education and proprioceptive balance work (the motor pattern of a limp feels normal to the patient and he will have to re-learn the correct pattern of walking).

By the time the moment of surgery has arrived the patient will be feeling more confident about the strength and function of the knee and will be motivated to work harder at the post-op programme to achieve best possible results.

Tracy Maunder is a chartered physiotherapist and principal of Portland Physio, London WC1

www.portlandphysio.co.uk