The following is a video Jeff and Kendra recorded to discuss the course of action one could take if they are waiting on an elective surgery for the hip or knee. It’s a frustrating wait! If you’d prefer to read, rather than watch, a full transcription of the video is available to read below.
Hello, my name is Jeff Petersen. I’m a physical therapist at Petersen Physical Therapy. We’re going to present some information today on pre-habilitation. If you like the information, and it’s helpful please feel free to subscribe to our YouTube channel, like our Facebook page and offer comments. If worst comes to worst, pick up the phone and give me a call if you have any questions. We’re here to help. I want to talk to you about prehabilitation today because over the last year, with COVID-19, several large hospital groups have suspended elective surgeries. They call them elective surgeries but if you’re waiting to have a knee replacement or a hip replacement or a shoulder surgery it doesn’t feel “elective.” You’re in a position where you can’t move around you have pain maybe having difficulty sleeping so if you fall into that category of having your elective surgery suspended or postponed, then there are some strategies you can do to manage your pain and even improve your function up to the surgery.
Research has shown that you can even improve the outcome of the surgery ultimately. So, there’s about – I’m guessing – 790 knee replacements in a year 790,000 knee replacements each year in the United States and there’s about 450,000 hip replacements and about 460,000 shoulder rotator cuff repairs. That’s a lot of surgeries and there are things you can do to prepare yourself and to maintain some measure of quality of life prior to a surgery. You can be making home ice packs and heat packs, you can be doing massage to the muscles around the area. Some of those strategies we will cover in a different video.
Today I want to talk about some of the exercises that you can do and the importance of it but let’s first talk about the main reason why you’re having surgery other than you can’t do the things you want to do and the quality of your life has been impacted. Most of us are driven to the doctor and the therapist because of pain, so I just want to review the pain science. Keep in mind that pain is defined as “an unpleasant emotional experience associated with actual or potential tissue damage.” The reason it’s important to remember that is there are a lot of things you can do to prepare yourself physically and emotionally. The other thing that’s important about that definition is oftentimes the primary tissue that’s going to be involved in the surgery may not be the source of the pain. For example, in a degenerative hip often times it’s the soft tissue surrounding the hip that is the primary source of pain. Now, once you get bone on bone, that becomes a different pain in a different tissue.
One of the things you can do is exercise. When we talk about exercise, we’re not talking (exercise is a broad category). One thing you can do is if you can improve your fitness level. One way to improve your fitness level is if you have a lower extremity involvement to do exercises that involve your upper extremities. If you have upper extremity involvement like shoulder, do exercises that involve your lower extremities. The other thing you can do is you can exercise a joint. If you have a hip problem, exercise the hip or adjacent joints – the knee, the low back, etc.
What’s important is to look at are the qualities of exercise that you’re looking for. The three qualities that we look at in physical therapy is the intensity of an exercise program (that is how hard you’re working), the frequency of an exercise program (how often you do it), and then the duration (how long you’re doing it). As you get into exercise science, there are other issues to deal with, but just as a statement of generality it is important just to look at those three when you’re going to start an exercise program. Before we talk about exercise, I want to talk about just a couple of the strategies. If you have a knee, for example, that is unstable because you have some degenerative arthritis, you can be applying heat ice massage to your quadriceps. The other thing you can do is some some taping. We use a lot of kinesio tape and you’ve seen the athletes wear and use that in the Olympics. You can also use bracing. There is a brace – there’s an unloading brace. Imagine that you have a knee and this is your right knee and this is the medial side of your knee. If you apply stress on the inside of the outside of the knee it can open up that joint so that that the area that’s degenerated is not gliding on itself or compressed. There are some strategies in terms of bracing. Exercise is one of the more helpful things.
I mentioned the parameters of exercise – the intensity, frequency, and duration. What we do is we extrapolate how much work can that joint of those muscles tolerate. The Holton Curve was designed by Oddvar Holten from Norway. I actually took a couple classes from him but studied him extensively in my manual therapy training. He established that the maximum amount of intensity is the amount of resistance that a muscle group or a joint can overcome one time. That’s a lot. That’s one time and you’re fatigued. What we do is we extrapolate from that. You’ve got certain percentages here and here. When you’re doing prehab, what we do is we work down here in the lower percentages – the sixty percent of that one repetition – working on mobility and circulation and vascularization.
We’re going to show you some of those that you can do that will actually increase the circulation to tissue and increase the flexibility without stressing the joint. It’s really important to understand that not all exercise is the same. For example, if you have a degenerative knee, you can be working your quads gently. Work in gentle range of motion, work your hamstrings. What’s also important is you can also work the adjacent joint like your hip and your low back. How many of you have knee pain and after a few weeks of walking around and limping you start to have hip and back pain? You can maybe not deal with the degeneration of the knee but you can improve the quality of your life by localizing this pain to the area that is primarily involved while you wait to have a surgery.
As a physical therapist, when we’re prescribing it or dosing an exercise routine, it’s as much art as it is science. The science that we use is based upon the Holten Curve so that we can adjust the intensity of the training. We’re also looking at isometrics that you can do, we’re looking at flexibility exercises you can do, we’re looking at working the adjacent joints from the one that may be involved, and then we’re also going to look at cardiovascular training as a way to increase your overall fitness. What I’d like to do now is we’ll go in the other room and we’ll demonstrate some of these exercises that you can do if you have a degenerative knee and you’re waiting for a knee replacement.
Knee and Hip Anatomy
We’re going to talk about some exercises for the knee, but I want to show you just a crude illustration of the knee. You’ve got the femur. You can see that the femur is also part of the hip, and you’ve got these little condyles of these knuckles. Those knuckles the patella glides in those those condyles and it glides by the quadricep muscles pulling on the top of the kneecap. When the quadricep muscles pull on the top of the kneecap, there’s a tendon that runs from the bottom of the kneecap to the tibia. That’s how your knee extends. So, if you have a problem with your knee it can impact the hip and also up into the spine.
We’re going to just show you some gentle exercises that you can do if you have a degenerative knee and you’re waiting for a knee replacement. These will also work well if you have a degenerative hip and you’re waiting for a hip replacement. Really they really do work for both conditions. Keep in mind that you do want to make sure pain is your guide. Not all pain is the same but if any of these exercises the pain increases as you continue to move or cause you residual pain when you’re done, then you need to stop and talk to your physical therapist. What we’re talking about are low level intensity exercises as a way to increase your circulation and mobility. So that shouldn’t be the case, but everybody’s a little bit different so use some caution and always feel free to talk to your doctor or physical therapist. Kendra here has again graciously agreed to serve as our model for these exercises. We’re going to presume she has a degenerative knee or a degenerative hip. These are some of the exercises that you can do at home as a way in preparation or while you’re waiting to have a surgery.
Exercise 1: Quad Sets
The first one is is called the quad set. Your quadricep muscles are here. What we’re doing is setting them now. Keep in mind that the kneecap I showed you in that picture of the skeleton glides and sometimes that can hurt when you do a quad set. What I want you to do is take a small towel roll – it can be a bath towel – and just put it under your knee so that you’re not hyper extending your knee because that usually can encourage some of that pain. What you’re going to gently do is, Kendra I want you to push that knee into that towel roll while you contract these muscles right here and she’s getting a nice tight contraction here and her foot has even moved a little bit now if that hurts what you can do is increase the intensity of the contraction within a comfortable range. This is an exercise that you should be able to do at least 30 to 50 repetitions with decreasing levels of discomfort. If you find you have increasing levels of discomfort then you want to stop and talk to your physical therapist but this is a good one to wake up those quadricep muscles.
Exercise 2: Ankle Pumps
The next one we want to do is more for circulation and flexibility of the calf and it’s called an ankle pump. What she’s going to do is she’s going to pull that ankle up here, stretch it, and then she’s going to point and she’s going to pull and she’s going to point. Wow she’s working her ankle which is the other end of the tibia. It helps form the ankle and what you’ll notice is she should be able to do about 20 to 30 of these. When you start doing these you might find some discomfort in your calf and you might even get some cramping. If that’s true, then you want to work up to being able to do about 20 of these two to three times a day. Give yourself a break throughout the day. If you persistently have have cramping, sometimes that’s a magnesium issue, sometimes it’s just a flexibility issue. Then you want to not be so rigorous in holding and you just want to move it gently. If you can stretch the calf, point the toe, stretch the calf, point the toe. You want to start you should be able to do 20 to 50 of these without a problem. If you have problems then lower the number of repetitions until you can do those successfully and safely.
Exercise 3: Glute Sets
We’ve got the ankle, we got the knee, and now we’re going to move up to the hip. Another isometric exercise she can do is a glute set. She’s going to squeeze her buttocks muscles together as tight as she can and you can see her pelvis raise a little bit. She’s going to relax for isometric exercise. The rule of thumb is about two seconds of hold is about a repetition in terms of if you are moving. You hold for two seconds and relax. She would do 10 of those that would be equivalent to 20. Again, these are exercises that you should be able to do 20 to 50 without much difficulty. If you have difficulty, that’s okay. Then you if you can only get through 10 or 15 of them and then take a break and you do 10 or 15 later on in the day. Same thing later on the day. Try to do them three or four times a day. That’s when you would increase the frequency, because the duration of the exercise is not tolerated. That’s how you manipulate those parameters. She’s working on her glute sets.
Exercise 4: Heel Slides
The next one, and do you mind if I take your shoe off here for the next exercise, pull it off just pull it off, right there no laces. The next one is called the heel slide. What she’s working on is she’s going to give herself a little bit of assistance and she’s working on mobility. She’s going to slide her heel up towards her bottom, give herself a little bit of assistance, and then she’s going to kick into the strap. You see how much knee bend she has? Often times if you have a degenerative knee it’s going to hurt. If you go to that amount of knee bend and if it does then you don’t want to go that far. If it’s a hip patient usually 60 degrees of hip flexion is not a problem. Again this is one you can do 20 to 50 repetitions. Another strategy is to time yourself for two or three minutes. That’s going to be about 30 to 40 repetitions. That’s a heel slide, working on mobility.
Exercise 5: Hamstring Stretch
Now, let’s say she’s been doing these for a few weeks and she’s feeling really good. One of the things you can work on is stretching your hamstrings. We’ve shown this one in in other posts for various reasons but she can bend her knee and really work on stretching the hamstrings. If the knee hurts when it’s in extension, she can flex her knee just a little bit and flex her hip just a little bit more to feel the tension on the hamstrings right there. With stretches, we usually suggest you hold for at least a count of 30 and you want to do three to five of those. If you have a shoulder problem this sometimes is a little difficult but this is a good exercise to maintain and increase the flexibility of the hamstrings.
Exercise 6: Glute Bridge
Then a more aggressive exercise in terms of the level of intensity is a bridge. This one will be done with a certain amount of caution. You want to put your shoe on for this one? Need some grip, there you go. For example, one of the things that we measure in our patients when they come in is their hips their ability to hold the single leg bridge and how long they can hold it. In this case if she has a degenerative hip or a degenerative knee, the knee may determine the amount of knee flexion that you’re allowed to maintain comfortably. in this case, we’re going to pretend it’s a hip problem and what she’s going to do is going to do a pelvic tilt. She flattens her back into the table and then she’s going to push through her heels, driving her pelvis straight up to the ceiling. She’s going to squeeze her buttocks. She should, you should feel this exercise in your buttocks and in your hamstrings. If you feel it in your back, you’re probably not holding that pelvic tilt. If you feel it in your hip and not in the muscle, sometimes – you can see she’s now stretching these quads a little bit – you might feel a little bit of stretch in that the front of the hip. That’s not necessarily a bad thing. Now, to do this exercise because the intensity is higher – so we talked about intensity, frequency, and duration – so the frequency is going to be a little, the duration’s going to be less. Instead of doing 50 repetitions, because this would be a hard one to do for 50 repetitions, she’s going to do about 10 of these take a break. Another 10, take a break, another 10. Now, if her hips are weak enough this may become a strengthening exercise. If this exercise hurts then you want to hold off on that and I’ll show you an alternative.
Exercise 7: Clams
An alternative is let’s have you lie on your side. An alternative exercise is what we call the clams. This would be a clams without resistance. So now she’s working one hip at a time. She’s just bringing her hip up and out. There’s a little bit of rotation, a little bit of abduction, and she’s working similar muscle groups. There’s not quite the same intensity. She would do three sets of 10 to 12 to 15. Again, depending upon the condition of her hip, this may be considered a strengthening exercise because the hip is weak. So start with an exercise like this. You start for about 10 repetitions and then you can build up to 15. When you can do three sets of 15 then, you add another few repetitions.
Exercise 8: Opposite Hip Stretch
Another exercise for flexibility of the hip would be simply bringing the opposite hip towards the chest. You can see when she does that initially her knee comes up. Now she’s getting a stretch in the front of her hip here. For stretches you hold for 30 seconds. You try to do three to five of those couple times a day. As she gets more flexibility she can then drape her leg over the edge of the bed or over the edge of the table, being careful that if this hurts then you’re going to at least keep it on the bed.
Exercise 8: Bent Knee Windshield Wipers
Another exercise for flexibility is flexibility of the low back, where she’s in that bridge position and she’s simply going to gently rotate her knees from side to side within a comfortable range as far as she can go without producing any pain. This is a mobility exercise but also works on the flexibility. What I suggest is you can do 20 to 50 of these because it’s mobility within a comfortable range and then at the end when you get to the end range you do a 30 second hold just gently feeling the stretch along the IT band into the hip and gently into the back.
Exercise 9: Opposite Arm-Leg Stretch
The final mobility exercise or flexibility exercise that is really good for the hip and knee (you need to be a little bit careful if you have a shoulder problem) is the opposite arm-leg stretch. In this case this leg comes here, the toes come up, she drives her heel all the way to that far wall, and on the right side you’re going to reach up and reach all the way up and try to reach reach reach reach as far as she can. She’s literally elongating her spine, elongating her hip. Sometimes this hurts a little bit in the front of the hip, but you want to stretch it out gently holding for 30 seconds three to five of those. Then she does the opposite side this is called the opposite arm-leg stretch.