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Therapy: General Frequently Asked Questions
How can I manage my OCD non-operatively (or without surgery)?
Non-operative management of knee joint OCD will be directed by your physician and rehabilitation team. Your potential to manage without surgery will be determined by your physician and will depend on your age as well as the size and location of the OCD in your knee. If non-operative management is pursued, you may be asked to restrict your activities and avoiding sports for several weeks to give the the OCD a chance to heal. During this time, your knee may be placed in a cast, brace or immobilizer to restrict knee motion and protect the knee joint. Crutches may also be prescribed to limit weight bearing for a period of time. Your doctor may suggest that you see a physical therapist who can assist you in reducing pain and swelling in the knee, using ice, compression, elevation and electrical stimulation. Your physical therapist will instruct you in an exercise program to improve your motion and strength. Your physical therapist will also start a balance and gait training program with you when it is safe for you to increase your weight bearing. You may also be instructed in exercises in the pool.
Once this initial phase of care has passed, you should have very little knee pain and swelling and be ready to progress off of your crutches. If you continue to have limitations in strength, mobility or functional activities, physical therapy may still be recommended to help you address these issues. When any residual limitations resolve and your health care team feels comfortable with the progression of the healing within the OCD, you will likely be progressed back to functional activities slowly. If the lesion fails to heal, additional treatment may be needed to help this process.
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When can I go back to my sports activities?
Return to sports will depend on how the OCD is healing and how you are progressing. Once you are cleared to walk without crutches your physical therapist will progress your exercises and activities to improve your balance, coordination, and strength over the next several weeks to months. Conditioning and endurance training activities such as swimming and cycling may be included at this time. All exercises and activities will be progressed gradually to minimize a painful response and initially limit the amount of impact that occurs at the knee joint. At this point your program will be progressed depending on what your specific activities will demand of you. You may be allowed to initiate jogging and light plyometric exercises with gradual progression to a running program. All these activities will be gradually increased in intensity, frequency and duration as tolerated, as long as the OCD lesion continues to show signs of healing. When you can demonstrate normal mechanics with your sports specific activities and all other limitations have been addressed, your physical therapist can run a series of functional tests to determine your readiness to return to unrestricted sports participation.
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What will my recovery be like after surgery?
Surgical management of an OCD lesion of the knee will vary depending on your age as well as the size and location of the lesion. Your recovery and treatment after surgery may vary depending the type of surgery required to manage your OCD lesion. Your physician will direct your care by communicating with you, your family and your physical therapist. Typically, after surgery, you will begin a protective phase of recovery. During this time (4-6 weeks) your activities will be very restricted. You will need to use crutches to limit weight bearing. Some physicians prescribe the use of a continuous passive motion machine to assist you with range of motion. You may need to wear a knee immobilizer or brace to protect the knee. Your physical therapist will work with you to control pain, swelling and improve range of motion and strength. You will be instructed in a home exercise program which may include safe range of motion exercises, straight leg raises and gentle isometrics (quads and hamstrings). Emphasis will be placed on gaining quadriceps (upper thigh) muscle control, protecting the OCD lesion, controlling pain, eliminating swelling, and improving range of motion.
The next phase of recovery is considered the restorative phase. This may take up to 6-12 weeks. During this time you will be allowed to gradually increase the amount of weight you put on your leg. Your physical therapist will progress your exercises and activities. Your exercises may progress to include gentle quadriceps and hamstring strengthening in open chain (non-weight bearing) and closed chain (weight bearing) positions. You may be able to cycle and swim for endurance training. Balance and functional training exercises will also be incorporated as long as you can perform these exercises safely and correctly. Treatment goals during this phase are to restore normal range of motion and strength, eliminate pain, restore a normal walking pattern, and progress a safe home exercise program that will allow the lesion optimal healing.
The final phase of recovery may take 3-6 months. During this time you may gradually return to normal activities when your physician determines the lesion has healed and your health care team determines you are ready. Your physical therapist will monitor and progress your activities. These activities will help increase your strength and endurance. Specific focus will be placed on gradually adding sports specific training exercises (running, jumping, and cutting). This is also a time when your physical therapist may work with you to improve your coordination and movement patterns so that you can return to activities safely and efficiently. Your physical therapist will run a series of functional tests to determine your readiness to return to full activities and your physician will need to clear you for full activity.
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Therapy of the Ankle
The main protocol for therapy of Ankle lesions is currently under review. However, for the following doctors, here are some general guidelines:
Dr. Roger Lyon: Patients will be non-weight bearing in a brace for 6 weeks and out of sports for 3 months for either non-operative or operative (post drilling) management.
Dr. Jennifer Weiss: Patients will use a fracture walker and remain non-weight bearing for 6 weeks. At the same time, patients will work on range of motion and strengthening exercises.
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Therapy of the Knee
Non-operative Management
If non-operative management of this condition is appropriate, physical therapy treatment will begin in phases:
Initial Phase: This phase may last 4-6 weeks. There may be a period of time when the knee is placed in a cast, brace or immobilizer to restrict knee motion and protect the knee joint. The application of ice, compression, and electrical stimulation may be used by the physical therapist to decrease knee pain and swelling. Crutches and partial weight bearing may also be prescribed during this phase. Your physical therapist may use weight shifting and gait training activities to progress you from non-weight bearing to partial weight bearing. Range of motion (ROM) exercises (passive, active-assistive, and active ROM) will be progressed as tolerated. Joint mobilization and lower extremity stretching, hip, knee, ankle and core strengthening will be progressed to improve muscle strength. Neuromuscular electrical stimulation may also be used to improve quadriceps muscle strength. Balance exercises will be incorporated along with your weight bearing progression. Sports activities will be restricted, as will any activities that cause pain symptoms in the knee joint.
Goals during this phase are to minimize knee pain and swelling, maintain weight bearing status without adverse effects, demonstrate normal gait pattern, restore ROM to 0-120 degrees, perform a straight leg raise without an extension lag, and increase lower extremity muscle strength to allow good quad control when shifting weight onto the involved leg.
Intermediate Phase: This phase will begin at 4-6 weeks and may last 6-12 weeks. During this phase, the cast, brace or immobilizer will be removed, and weight bearing will be progressed from partial to full when full knee active ROM is achieved, walking pattern is normal and there is no increase in pain or swelling with the increase of weight. Your physical therapist will progress exercises and activities to restore a normal walking pattern, full ROM and normal strength. Exercises will include activities to restore normal balance and proprioception (knee joint sensation) in the involved lower extremity. The exercises will be progressed from open kinetic chain (off weight bearing) to closed kinetic chain exercises for the entire leg, beginning with both legs on the ground and progressing to single leg activities. Core strengthening exercises will also be progressed. Your physical therapist will focus on your training technique to minimize your body compensations. These exercises will be progressed in a gradually. If pain is provoked the exercises and activities will need to be modified. During this phase endurance training, such as swimming and cycling is also important.
Goals during this phase are to minimize pain and swelling in the knee, walk painfree, with normal mechanics, demonstrate normal range of motion and functional strength in the involved lower extremity. You should also be able to demonstrate normal mechanics during open and closed kinetic chain activities and maintain balance standing on the involved leg, on an unstable surface for the equal amount of time that is achieved by the uninvolved side.
Advanced Phase: This phase may take up to 3 months. Your physical therapist will utilize lower extremity flexibility activities to help you maintain full ROM. Functional strengthening will also be progressed in terms of what your specific activities will demand. You may be allowed to initiate jogging and progress to return to running program. Motor control activities will include a progression of plyometric activities with focus on your movement technique which are sports specific and will be increased in intensity, frequency and duration as tolerated.
Goals during this phase are to eliminate pain and swelling in the knee joint, restore the ability to jog with a normal mechanics, demonstrate quadriceps muscle strength that is 85% of the uninvolved side, and demonstrate normal mechanics with plyometric and sports specific activities. Achievement of these goals indicates that you are ready for re-entry into higher level activities. This does not suggest that you are ready for full, unrestrictive activity participation. Your physical therapist will run a series of functional tests to determine readiness.
Post-Operative Management
Physical therapy will begin after surgery and will progress in the three phases similar to the non-operative management, with a few deviations.
Protective Phase: During this time (4-6 weeks) the physical therapist will work with the patient to control pain, swelling and improve range of motion, with emphasis on full passive knee extension and gradual return of knee flexion. The exercise program prescribed will include safe range of motion exercises, straight leg raises and gentle isometrics (quads and hamstrings), with the emphasis on quadriceps control. The physician may prescribe the use of a continuous passive motion machine for 6-8 hours a day. All other activities will be restricted. A knee immobilizer or brace may be prescribed. The patient will be limited to partial weight-bearing as well. All this will be determined by the physician based on where the lesion is located and the nature of the repair.
Goals during this phase are to protect the lesion repair, control pain, eliminate swelling, and improve range of motion.
Restorative Phase: During this phase (6-12 weeks), the patient will be allowed to gradually return to full weight bearing. The physical therapist will progress exercises to include gentle quadriceps and hamstring strengthening in open chain (non-weight bearing) and closed chain (weight bearing) position. The patient may be able to cycle and swim for endurance training. Balance and functional training will also be incorporated, as will assessment from the physical therapist on the patient’s ability to perform exercises safely and correctly.
Goals during this phase include restoring normal range of motion and strength, eliminate pain, and establish a home program that is safe and will allow the lesion optimal healing.
Return to Activities and Sports: This phase my take up to 3 – 6 months. The patient may gradually return to normal activities when the physician determines the lesion has healed (based on imaging studies).The physical therapist will direct the patient to increase strength and endurance exercises and gradually adding sports/activity specific training exercises (running, jumping, cutting). This is also a time when the therapist may work with patient to improve his/her coordination and movement patterns, so that unnecessary joint stress is avoided in the future.
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Therapy of the Elbow
General notes:
No activity should cause sharp pain or a significant increase in pain afterwards. “As tolerated” means that all prior phases and steps have been achieved and that the activity does not cause pain.
Ice should be applied to the elbow for 20 minutes following each exercise, therapy, or training session.
Return to sport based on provider team (physician, physician assistant, athletic trainer, and therapist) input and appropriate testing.
All times and exercises are to serve as guidelines. Progression through the protocol should be based upon criteria as opposed to dates listed and will vary depending on each individual patient. Progress should be agreed upon by the patient and his/her team of providers.
Phase 1 - Post-op Week 1
Brace: None. Utilize sling, for comfort.
Therapeutic Exercises: Finger, hand, and wrist, motion encouraged. Take arm out of sling and gently straighten elbow at least 3 times per day.
Ice- 15-20 min 3-5 times a day.
Phase 2 - Post-op Weeks 1 to 6
Brace: Discontinue sling as tolerated.
Weight bearing: Continue with non weight bearing status during this phase.
ROM (range of motion): Active (your muscles cause movement) and active assisted (surgical arm gets help moving) to regain elbow ROM. Regain full extension, flexion, pronation, supination as tolerated. Gentle upper body ergometer (UBE) may be initiated.
Therapeutic Exercises:
Strengthening: Arm strengthening in non-weight bearing manner. Isometrics only, as tolerated.
Core Strengthening: May be initiated as tolerated
Conditioning: Stationary bike, elliptical, stepper, glider, etc. may be initiated as tolerated.
Progression to Phase 3:
- At least post-op week 6
- Full/pain free ROM
- Discontinued use of sling
- No swelling
Phase 3 - Post-op Weeks 6 to 12:
ROM: Full ROM
Weight bearing: Progress to full
Therapeutic Exercises:
Strengthening: Arm resistance exercises allowed, as tolerated in all planes. Weight bearing should begin only with approval of provider team.
Core Strengthening: Progress as tolerated
Conditioning: Progress as tolerated
Progression to Phase 4:
- Full pain free strength throughout involved upper extremity
- Able to fully weight bear on upper extremity without pain
Phase 4 – Post-op Weeks 12 and beyond:
Therapeutic Exercises:
Strengthening: Upper body plyometric activities in addition to ongoing arm strengthening
Core Strengthening: Progress as tolerated.
Conditioning: Progress as tolerated.
Throwing rehabilitation: Interval throwing may be initiated
Progression to Phase 5:
- Successful completion of interval throwing program
Phase 5 - Return to play
Final clearance for full, unrestricted return to play will be determined by the medical provider team (physician, physician assistant, physical therapist).
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