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ACL Rehab--Phase I 0-2 weeks after surgery
1st POST OP WEEK—YOU WILL BE DISCHARGED WITH KNEE SUPPORTED IN A BRACE
IT IS EXTREMELY IMPORTANT THAT YOU WORK ON EXTENSION IMMEDIATELY.
* Control pain and swelling
* Care for the knee and dressing
* Early range of motion exercises
* Achieve and maintain full passive extension
* Prevent shutdown of the quadriceps muscles
* Gait training
Control Pain and Swelling
1) Control Swelling. Following discharge from the hospital you should go home elevate your
leg and keep the knee iced using the Ice packs. You may get up to use
the bathroom and eat, but otherwise you should rest with your leg elevated.
2) Do not sit for long periods of time with your foot in a dependent position (lower than the
rest of your body), as this will cause increased swelling in your knee and leg. When
sitting for any significant period of time, elevate your leg and foot.
3) Control Pain. You will be sent home with a prescription medication.
You should take this for severe pain, as directed on the prescription.
4) As your pain and swelling decrease you can start to move around more and spend more
time up on your crutches.
Caring for your knee
1) The first night and day after the surgery you can expect the bandages to get bloody. This is normal! We want the blood to drain out of the knee on to the dressings rather than build-up in your knee and cause swelling and pain.
2) We recommend that you limit weight bearing to prevent swelling. Use Crutches till you are able to bear weight on the leg without any discomfort.
3) You can start using a stationary bike. Cycling is an excellent conditioning and building
exercise for the quadriceps. Start with the seat fairly high and use a short diameter
pedal if available so that the knee doesn’t bend too much. At this early stage, you
should just “spin” without any resistance. Use your good leg to turn the pedal.
4) You may shower, but you must keep your incisions dry for the first 7-10 days. This can
be achieved by placing a waterproof dressing or plastic bag over your leg.
5) The sutures, if used will be removed between 10-12 days
IT IS IMPORTANT TO KEEP THE INCISIONS DRY FOR THE FIRST 7-10 DAYS.
7) You may remove the knee brace while doing exercises or if you are in a safe, protected environment. However, the knee immobilizer should be worn while sleeping for the first 4 weeks, and at all times while you walk for the first 6 weeks.
Early Range of Motion and Extension
1) Passive extension of the knee by using a rolled towel. Note the towel must be high
enough to raise the calf and thigh off the table.
• Remove the knee immobilizer from your knee every 2 - 3 hours while awake
• Position the heel on a pillow or rolled blanket with the knee unsupported
• Passively let the knee sag into full extension for 10 - 15 minutes. Relax your
muscles, and gravity will cause the knee to sag into full extension.
This exercise can also be done by sitting in a chair and supporting the heel on the edge
of a stool, table or another chair and letting the unsupported knee sag into full
2) Active-assisted extension is performed by using the opposite leg and your quadriceps
muscles to straighten the knee from the 90 degree position to 0 degrees.
Hyperextension should be avoided during this exercise.
3) Passive flexion (bending) of the knee to 90 degrees.
• Sit on the edge of a bed or table and letting gravity gently bend the knee.
• The opposite leg is used to support and control the amount of bending.
• This exercise should he performed 4 to 6 times a day for 10 minutes. It is
important to achieve at least 90 degrees of passive flexion by 5 - 7 days after
1) You should start quadriceps isometric contractions with the knee in the fully extended
position as soon as possible.
• Do 3 sets of 10 repetitions 3 times a day.
• Each contraction should be held for a count of 6 sec.
This exercise helps to prevent shut down of the quadriceps muscle and decreases
swelling by squeezing fluid out of the knee joint.
2) Begin straight leg raises (SLR) with the knee immobilizer on 8 sets of 10 repetitions 3
times a day. Start by doing these exercises while lying down.
• This exercise is performed by first performing a quadriceps contraction with the
leg in full extension. The quadriceps contraction "locks" the knee and prevents
excessive stress from being applied to the healing ACL graft.
• The leg is then kept straight and lifted to about 45-60 degrees and held for a
count of six.
• The leg is then slowly lowered back on the bed. Relax the muscles.
REMEMBER TO RELAX THE MUSCLES EACH TIME THE LEG TOUCHES DOWN
This exercise can be performed out of the brace when the leg can be held straight without
sagging (quad lag). Once you have gained strength, straight leg exercises can be performed
1) For patients who have had ACL reconstruction using the hamstring tendons it is
important to avoid excessive stretching of the hamstring muscles during the first 6
weeks after surgery.
• The hamstring muscles need about 6 weeks to heal, and excessive hamstring
stretching during this period can result in a "pulled" hamstring muscle and
• Unintentional hamstring stretching commonly occurs when attempting to lean
forward and put on your socks and shoes, or when leaning forward to pick an
object off the floor.
• To avoid re-injuring the hamstring muscles, bend your knee during the activities
below, thus relaxing the hamstring muscles.
2) The hamstring muscles are exercised by pulling your heel back producing a hamstring
• This exercise should be performed only if your own patellar tendon graft was
used to reconstruction the ACL.
• If a hamstring tendon graft from your knee was used to reconstruct the ACL, this
exercise should be avoided for the first 4 - 6 weeks, as previously mentioned.
Postoperative Days 8 – 14
Use the guidelines within this section for days 8-14 after your surgery
Goals: Physical therapy
Maintain full extension
Returning to work
1) Schedule an OPD follow-up.
2) As the steri-strips get wet, they will peel off. Do not pull at them for the first 2 weeks.
3) After 3 weeks, you may apply vitamin E oil or another emollient to the incisions, as this
will improve their appearance.
Physical Therapy and Full Extension
1) Outpatient physical therapy will be modified during the first postoperative office visit.
2) Continue doing the quadriceps isometrics, SLR, active flexion, and active-assisted
REMEMBER THAT IT IS EXTREMELY IMPORTANT TO CONTINUE TO REMOVE YOUR LEG
FROM THE KNEE IMMOBILIZER 4 TO 6 TIMES A DAY FOR 10 - 15 MINUTES AT A TIME TO
MAINTAIN FULL EXTENSION.
Returning to Work
1) As far as returning to work, if you have a desk type job you can return to work when
your pain medication requirements decrease, and you can safely walk with your
crutches. Typically this is between 5 - 10 days after surgery.
2) Patients who have jobs where light duty is not permitted; policemen, firemen,
construction workers, laborers, will be out of work for a minimum of 6 - 12 weeks.
ACL Rehab Phase II 3-12 weeks post surgery
Postoperative Week 3-4
Use the guidelines in this section AFTER the second week of your surgery
Goals: * Maintain full extension
* Achieve 100 – 120 degrees of flexion
* Develop enough muscular control to wean off knee
* Control swelling in the knee
MAINTAINING FULL EXTENSION AND DEVELOPING MUSCULAR CONTROL ARE IMPORTANT
Maintain Full Extension
1) Continue with full passive extension (straightening), gravity assisted and active flexion,
active-assisted extension, quadriceps isometrics, and straight leg raises.
2) Work toward 90-100 degrees of flexion (bending)
Develop Muscular Control
1) Start Partial Squats.
• Place feet at shoulder width in a slightly externally rotated position.
• Use a table for stability, and gently lower the buttocks backward and downward.
• Hold for 6 seconds and repeat.
• Do 3 sets of 10 repetitions each day.
2) Start Toe Raises.
• Using a table for stabilization, gently raise the heel off the floor and balance on
the ball of the feet.
• Hold for 6 seconds and ease slowly back down.
• Do 3 sets of 10 repetitions each day.
3) Continue to use the knee brace for walking even if you have good muscle control of the
leg. This will protect your graft.
4) Wean from crutches when you can put full weight on the leg and walk with a normal
heal-toe gait and no limp.
5) You can continue using a stationary bike. Cycling is an excellent conditioning and
building exercise for the quadriceps.
• The seat position is set so when the pedal is at the bottom, the ball of the foot is
in contact with the pedal and there is a slight bend at the knee.
• No or low resistance used. Maintain good posture throughout the exercise.
• As your ability to pedal the bike with the operative leg improves, you may start
to increase the resistance (around 5-6 weeks).
• Your objective is to slowly increase the time spent on the bike starting first at 5
minutes and eventually working up to 20 minutes a session.
• The resistance of the bike should be increased such that by the time you
complete your work-out your muscles should “Feel Tired”
THE BIKE IS ONE OF THE SAFEST MACHINES YOU CAN USE TO REHABILITATE YOUR KNEE, AND
THERE IS NO LIMITATION ON HOW MUCH YOU USE IT.
When can you drive a car?
• First, you must not be taking any prescription pain medications.
• During driving the knee brace can be unlocked.
• Patients who have had surgery on the left knee and have standard transmissions,
should not drive until they have good muscular control of the leg. This usually
takes 4 weeks.
• Patients who had surgery on the right knee should not drive until they have good
muscular control of the leg. This usually takes 4-6 weeks.
Postoperative Weeks 5-6
Goals: * Full range of motion
* Strength through exercise
1) Expected range of motion is from full extension to 100 – 120 degrees of flexion. Add
wall slides (see Figure 3) and hand assisted heel drags to increase your range of motion.
2) Continue quadriceps isometrics and straight leg raises (see Figure 9).
3) Continue partial squats and toe raises (see Figure 10 and Figure 11).
4) If you belong to a health club or gym you may start to work on the following machines:
• Stationary bike. Seat position regular height to high to avoid too much bending
or straightening of the knee. Increase resistance as tolerated. Try to work up to
15-20 minutes a day.
• Inclined leg-press machine for the quadriceps muscles. 70 - 0 degree range.
• Seated leg curls machine for the hamstring muscles. Note this exercise should
be delayed until the postoperative week 8-10 if your ACL was reconstructed with
a hamstring tendon graft.
• Upper body exercise machines.
• Swimming: pool walking, water bicycle, water jogging.
No diving, or whip kicks.
Postoperative Weeks 6 – 12
By week 6, your range of motion should be full extension to at least 135 degrees of flexion.
Goals: * 135 degree of flexion
* Continued strength
* NO Running on treadmill yet!!
1) Continue quad sets, straight leg raises, partial squats, toe raises, stationary bike,
elliptical machine, leg presses, and leg curls.
2) Hamstring reconstruction patients can start leg curls in a sitting position. If you develop
hamstring pain then decrease the amount of weight that you are lifting, otherwise you
can increase the weight as tolerated.
IT IS IMPORTANT TO AVOID USE OF A LEG CURL MACHINE THAT REQUIRES YOU TO LIE ON
YOUR STOMACH. THIS MACHINE PUTS TOO MUCH STRAIN ON THE HEALING HAMSTRING
MUSCLES, AND CAN RESULT IN YOU "PULLING" THE HAMSTRING MUSCLE.
3) Continue tilt board and balance board for balance training.
4) Continue swimming program.
5) Start treadmill Walks (flat only).
6) You may begin outdoor bike riding on flat roads.
NO MOUNTAIN BIKING OR HILL CLIMBING!
Postoperative Weeks 12 – 24
Goals: * Continued strength
* Introduce jogging – Do not try and sprint
* Introduce agility drills
1) Continue all of week 6 -12 strengthening exercises.
2) Start straight, forward and straight, backward jogging and light running program.
3) Start functional running program after jogging program is completed.
4) Optional fitting for ACL functional brace.
5) Start agility drills, zig-zags and cross over drills.
24 Weeks Postoperative onwards (6 -8 months)
This is the earliest you should plan on returning to full sports.
Goals: * Start Practicing, warm ups and Plan for gradual returning to sports
To return to sports you should have:
• Quadriceps strength at least 80% of the normal leg
• Hamstring strength at least 80% of the normal leg
• Full motion
• No swelling
• Good stability
• Ability to complete a running program