flexion is required for a normal swing phase during gait, and 105 degrees is needed to rise

comfortably from sitting. Final postoperative knee flexion ROM depends on the type of implant

used, the preoperative ROM, 157 and the mobility of the patient ’ s soft tissues. Aggressive

rehabilitation and adequate pain control are also paramount to prevent postoperative contractures

and optimize flexion ROM. It has been suggested that a lack of physical therapy can contribute

to decreased functional ROM after TKA. 158

To achieve optimal results, ROM activities for the patient with a TKA should be initiated soon

after surgery. Patients often have a flexion contracture immediately after surgery because of

irritation of the joint and hemarthrosis. This will resolve with time and appropriate rehabilitation.

ROM activities can include passive knee flexion and extension, as well as active heel slides and

supine wall slides. Forward and backward pedaling on a stationary bicycle can also increase flexion

ROM. With the saddle of the bicycle high, a patient with limited flexion can often “ rock ” back and

forth and ultimately complete a backward revolution. This is an excellent way for a patient to

improve ROM in a safe and self-controlled manner.

Full extension ROM is also essential for a normal gait pattern and for effi cient function of the

lower extremity. A limitation of as little as 5 degrees of extension may require a quadriceps force of

30% of a person ’ s body weight to stabilize the knee, with more force being needed as the amount

of knee flexion limitation increases. 159 Therefore a patient who cannot achieve full extension during

gait will expend more energy walking. They may also have limited knee stability as a result of

compromised strength of the quadriceps muscles after TKA. Full extensioncan be achieved in a

variety of ways ( Fig. 10-11 ).

FIG. 10-11 Activities to increase knee extension

First, the patient should not sleep with a pillow under the knee, although this will be a position of

comfort. To achieve full extension, the patient may lie prone with the knee on the edge of the bed,

allowing gravity to extend the knee. Another option is to lie supine and place a pillow under the

heel, allowing the knee to extend. To further intensify this stretch the patient may use a slow-

sustained pressure manually or from a small weight, such as a phone book or weighted bag, to

achieve full extension. Backward walking may also help the patient who has diffi culty achieving full

extension. This may be done in a pool or on land.

Prevention and early recognition of ROM limitations are essential to prevent arthrofi brosis, a

potential complication of any knee surgery. Arthrofi brosis is a process that occurs when diffuse scar

tissue or fi brous adhesions form within or around a joint. This scarring can restrict flexion,

extension, or patellar mobility. Manual patellar mobilization, as well as mobilization of the soft

tissues of the quadriceps and patellar tendon, is critical to restoring normal extensor mobility and

ultimately a functional knee. The patella should be mobilized in all planes, mediolateral and

superoinferior, and the tendons should be manually mobilized medially and laterally ( Fig. 10-12 ).

FIG. 10-12 Patellar mobilization

Gentle patellar and scar mobilization initiated after the incision site is stable may also help prevent

contractures and promote functional ROM. Patellar mobilization is very important because the

suprapatellar pouch is often where adhesions that limit ROM develop. These mobilizations should

also be taught to patients so that they can be performed at home. Decreased superior mobility of

the patella interferes with the ability of the quadriceps muscles to straighten the knee and may also

result in an extensor lag. An extensor lag occurs when the range of active extension is less than the

passive extension of the joint. In the case of the knee, this may also be known as a quadriceps lag

because it is caused by the quadriceps muscles not being able to straighten the knee fully even

though the patient may have full passive extension. Full inferior glide of the patella is essential to

maximize flexion ROM.

If rehabilitation techniques are not effective in achieving functional ROM, it may be necessary

to add bracing, such as dynamic splinting ( Fig. 10-13 ), or have surgical intervention through

arthroscopic release or manipulation under anesthesia to maximize ROM. Early motion is the key for

the successful rehabilitation of the postoperative knee. 160

FIG 10-13 Dynamic splinting of the knee for increased ROM. Low load prolonged

stretching device that can be used to improve knee flexion or extension ROM. Courtesy

Dynasplint Systems, Inc.

Pool therapy is an excellent adjunct for gait training, ROM, strengthening, and ultimately

recreation in patients after TKA. One study in Germany with 25 patients reported that hydrotherapy

was superior to the “ standard rehabilitation program ” in the rehabilitation of patients with TKA. 161

Another activity that often helps patients achieve full knee extension ROM is standing closed-chain

knee extensions using a resistance band (or towel) placed at the distal thigh and held by the

therapist for feedback. This activity will also improve extension by increasing active extension force

and gently stretching the posterior capsule.

Electrical Stimulation. Neuromuscular electrical stimulation (NMES) is an alternative and

potentially more effective means than exercise alone of decreasing persistent quadriceps weakness

in the appropriate patient. It adds to active exercise alone by recruiting a greater proportion of type

II fi bers. These fi bers have a higher incidence of atrophy in patients with a history of severe OA. 162

It has been shown that NMES used alone or in combination with volitional exercise is helpful in

regaining functional quadriceps strength in this patient population.163 In a case study of an elderly

patient with difuse atrophy after TKA, NMES was used to supplement volitional exercise of the

quariceps femoris dan resulted in an increase of force production from 50% (involved/uninvolved) at

3-weeks postsurgery to 86% at 8-weeks postsurgery. 164 NMES has also been shown to increase

walking speed in a prospective randomized controlled study of 30 TKA patients treated for 4 hours a

day for a period of 6 weeks.165 NMES has also been reported to improve the functional capacity of

the quariceps and to attenuate difuse atrophy associated with TKA.166

Exercise. Rehabilitation after TKA must restore the function of muscles that cross the knee

joint, as well as those muscles that infl uence the proximal and distal motion segments. During the

initial stages of rehabilitation, regaining motor control of the quadriceps muscles should be

emphasized. In patients with an acute knee effusion as a result of acute or surgical trauma, reflex

inhibition of the quadriceps is common. 167-169 Strengthening exercise after TKA should start with

quadriceps isometrics and straight leg raises. Open-chain lower extremity strengthening activities

can be progressed as tolerated to promote voluntary quadriceps control. Repetitive openchain

exercises, especially in the range of 40 degrees to full extension, may increase soft tissue irritation

that can occur in the early postoperative period. 140 Electrical stimulation, biofeedback, and tactile

stimulation can be used for quadriceps facilitation. In addition, hip adduction and abduction

strengthening exercises, as well as hamstring curls, may be added to strengthen all muscle groups

around the knee joint. As strength improves and pain decreases, closed-chain strengthening should

be added to improve function. Most patients with chronic knee joint arthritis have altered

quadriceps function, especially for performing closed kinetic-chain activities such as stair stepping. 170-172 Closed-chain exercises may include minisquats, front and lateral step-ups, stool pulls, and

lunges as tolerated ( Fig. 10-14 ).

FIG. 10-14 Sample of closed kinetic chain exercises for the lower extremity, A, Mini-

squt; B, step-up; C, stool pull/push; D, lunges

These activities improve quadriceps, hamstring, and overall lower extremity strength. 173,174 The

patient should avoid activities that increase load on the joint because this may damage the replaced

surfaces. Such activities include squats and leg presses performed at more than 90 degrees of

flexion. Some rehabilitation professionals feel that TKA patients should be treated similarly to

patients with patellofemoral pain syndrome, since many of these patients have very limited

quadriceps strength and dysfunction of their extensor mechanism. Gym equipment may also be

used for a variety of closed-chain strengthening activities. Stationary cycling, pool therapy, and a

walking program may be added to achieve optimal function and allow patients to ultimately return

to participation in selected recreational sports activities. However, activities that involve high impact

should be avoided because these increase wear on the components and can hasten the need for

revision.

Sensorimotor functions, such as proprioception, joint position sense, and balance, are all

important for function of the lower extremities. Proprioception is the conscious and unconscious

perception of limb position in space, including the awareness of joint position and movement. 175

Balance is the ability to maintain a posture or postural control during movement. 176 Elderly people

and patients with arthritis and with TKAs have been shown to have a poorer joint position sense

than young people without OA, and reestablishing joint position sense and balance are important for

optimizing patient outcomes. 177-180 Some studies have shown that proprioception and balance

improve after a total knee replacement, although not consistently for all types of implants and not to

levels equal to age-matched subjects without joint disease. 181-185 Some studies have postulated that

improvement in joint position sense and balance after TKA is due to reestablishment of soft tissue

tension and joint space, reduction of pain and chronic infl ammation, and the resumption of ADLs. 185

Since balance and proprioception can impact the frequency of falls and subsequent injury,

rehabilitation programs for TKA should include activities that will improvethese functions (see

Chapter 13 ).

SHOULDER ARTHROPLASTIES

Shoulder arthroplasty is not as common as THA or TKA, and most general orthopedic surgeons have

limited experience with it. However, the number of TSAs has increased substantially over the past

decade from approximately 10,000 in 1990 to 20,000 in 2000. 6 TSAs involve replacement of both the

glenoid and the humeral head, whereas hemiarthroplasties involve the replacement of only the

humeral component. Because of the need for careful soft tissue balancing and implant insertion, this

procedure is considered by many to be mainly for pain relief, although Jensen et al found that many

patients were able to return to prior recreational activities such as golf. 186

Pathology. Both constrained and nonconstrained TSA prostheses are currently used. A

constrained TSA has a ball and socket design that reduces humeral motion. A nonconstrained TSA

more closely resembles the normal anatomical motion of the shoulder joint, allowing for more

humeral motion, and is the type of prosthesis most commonly used. A semiconstrained prosthesis

with a hood on the superior aspect of the glenoid that helps with stability is sometimes used for

patients with irreparable rotator cuff tears. The humeral component of total shoulder replacements

can be either press-fi t or cemented, whereas the glenoid portion is always cemented. Symptomatic

loosening of the glenoid component is usually associated with pain, whereas loosening of the

humeral component is often asymptomatic. The implant may loosen if an eccentric load is placed on

the glenoid by the humeral component, especially if the humeral head migrates superiorly as a result

of poor deltoid or rotator cuff function from weakness or a tear. Postoperatively, 1% to 13% of

patients with TSAs develop rotator cuff tears. 187

Another less common form of shoulder arthroplasty is the Copeland surface replacement of

the humeral head, which replaces only the damaged joint surface and restores the anatomy with

minimal bone resection. This procedure is indicated for patients with rheumatoid arthritis (RA) and

OA if the bone is strong and the joint is not severely damaged. 188

Shoulder arthroplasty involves an incision from a point superomedial to the coracoid process

down toward the anterior insertion of the deltoid on the upper arm. If the surgery is undertaken

because of a humeral fracture, the soft tissue attachments of the tuberosities are preserved and

reattached to the humeral shaft and stem before the wound is closed so that the rotator cuff can

function. If the surgery is undertaken because of arthritis, the subscapularis muscle and the joint

capsule are taken down. The humeral head is then removed and the glenoid is inspected. If it is

signifi cantly worn, it is replaced. The humeral canal is then reamed, and the humeral component is

inserted, with or without cement, depending on the shoulder’s condition and the surgeon’s

preference. The final components are then placed and the subscapularis is repaired. The

deltopectoral interval and the skin are then closed ( Fig. 10-15 ).

FIG. 10-15 Total shoulder arthroplasty procedure

Prognosis. Over the past 2 decades, TSA and hemiarthroplasty of the shoulder have been

successfully used to treat a wide variety of shoulder conditions. Most total shoulder replacements

are performed on patients with OA, RA, avascular necrosis, or posttraumatic fractures.189 A

retrospective study indicates that patients of surgeons with a higher annual caseload of shoulder

arthroplasties have fewer complications and shorter hospital lengths of stay than patients of

surgeons who perform fewer of these procedures. 190 It has also been shown that centers where

more of these procedures are performed have better outcomes and lower complication rates. 191

The outcome depends on factors common to all total joint replacements, as well as those

specifi c to the shoulder, most importantly, the status of the rotator cuff muscles. In patients with

minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon,

a multicenter study has shown that the outcome of shoulder arthroplasty done for OA is similar to

that for patients without rotator cuff tears. However, if the infraspinatus or less importantly, the

subscapularis is involved, the outcome is poorer. 192 Although patients often have limited ROM,

strength, and function before surgery, TSA can primarily be expected to relieve pain rather than

improve other symptoms. Meta-analyses have found that more than 90% of patients with shoulder

OA, RA 191 or osteonecrosis194,195 and over 70% of patients with shoulder fractures do have complete

or near-complete relief of pain after TSA. 196,197

Functional results after TSA vary, depending largely on the underlying cause. Patients with OA

or osteonecrosis tend to get the best ROM, reaching 75% to 80% of normal and being able to

achieve an average forward flexion ROM of greater than 140 degrees and external rotation ROM of

45 degrees, as well as reaching their hand behind their back to approximately 2 to 3 levels above

their presurgical ROM. Flexion after hemiarthroplasty performed in patients with humeral

fractures198 can range from 90 to 120 degrees. Outcome is best with a well-reduced fracture, a

motivated patient, and an appropriate rehabilitation program with a maximum recovery of function

usually occurring within 6 to 12 months of the surgery. 199-201 Patients with RA or dislocation

arthropathy have poorer functional outcomes than other patients, regaining on average 50% to 60%

of normal motion because they often have poor soft tissue and bone quality. Patients with

arthropathy that is a result of a rotator cuff tear also fare poorly, generally achieving only 33% to

50% of normal motion. 202 Some patients who have a TSA for recurrent instability have pain and

arthrosis after surgery, at times because of continued multidirectional instability, overtightening of

the soft tissues, or progressive cartilage wear.203,204

Strength after TSA is generally suffi cient to allow ADLs, as well as light recreational fi tness

activities such as golf, light fi tness training, gardening, and swimming. Goldberg et al documented a

self-reported increase in the performance of functional tasks in the patients who underwent TSA for

the treatment of OA.205 Patients rated their ability to perform a total of 12 tasks, including lifting,

tucking in their shirt, underhand toss, and sleeping on the affected side, at spesific intervals before

and up to 5 years after surgery. Before surgery, patients reported that they could perform 3.8 of the

tasks, 1 year after surgery they could perform 9.5 of the tasks, and 5 years after surgery they could

perform 10 of the tasks.

The surgeon and rehabilitation professional need to communicate and characterize the

anticipated functional improvement after TSA in a way the patient can understand. Shoulder-specific

functional gains in relation to preoperative shoulder function are the most effective way to present

this information. TSA for the treatment of primary OA signifi cantly increases shoulder function from

4 out of 12 to 9 out of 12 tasks. 206 Patients with better preoperative function tend to have better

postoperative function, although patients with the poorest preoperative function may have the

greatest improvement overall. On average, patients reported that they gained two-thirds of the

functions that had been absent preoperatively. Thus TSA can provide substantial improvement in

shoulder function.

TSA also signifi cantly improves quality of life for patients with OA. Self-assessed health status

improved significantly after TSA and to a similar degree as for hip arthroplasty and CABG surgery,

although for none of these procedures did health status reach the level of healthy subjects without

indications for these procedures.207 A retrospective study of 138 patients who underwent

hemiarthroplasty as a result of a fracture found that the variables most predictive of a decrease in

functional outcome included advanced age, presence of a preoperative persistent neurological

deficits, the use of alcohol or tobacco, and the need for an early reoperation.208

In patients undergoing Copeland surface replacement for the treatment of RA, a case series of

75 shoulders between 1986 and 1998 noted improvements of 50 degrees in flexion, to 100 degrees

of total flexion motion, with 96% of patients reporting improved satisfaction compared to their

preoperative status. 209

The major complications of TSA are loosening of the glenoid component, instability, and late

rotator cuff tears, although sepsis and nerve injury have also been reported. TSA failure is primarily

the result of loosening of the glenoid component, which has a risk of 1% per year. 210,211 A

metaanalysis of 838 cases of TSA found a reported incidence of postoperative dislocation of 1.2%

over a follow-up period of 20-54 months.199 The incidence of instability was higher after

hemiarthroplasty alone, with a reported rate of 6.7% in a meta-analysis of 4 series with a total of 152

cases.197 Activities that involve repetitive impact, vibration, heavy lifting, pulling, pushing, or jerking

maneuvers may jeopardize implant stability; thus realistic expectations must be set to foster

compliance for long-term implant survival.212 Results for TSA survivorship are generally good with

93% survivorship at 10 years and 87% at 15 years, according to a retrospective analysis of patients

between 1975-1981.213

Interventions. The rehabilitation clinician must consider a number of unique anatomical and

biomechanical features of the shoulder when designing a rehabilitation program for patients after

TSA. First, the shoulder is not a weight-bearing joint but still achieves joint compressive loads equal

to the weight of the arm when it is abducted. Lifting a weight, tossing a ball, or swinging a racquet or

golf club signifi cantly increase this load. Second, the glenohumeral joint is quite unstable because

there is little contact between the bones and because it is subjected to shear forces in many

directions. Stability in a TSA is achieved through the prosthetic components and appropriate tension

in the soft tissues. Patients with OA and those with generalized joint laxity may have persistent

glenoid retroversion despite attempts at surgical correction and can therefore be prone to posterior

instability especially with shoulder elevation and horizontal adduction. 214 The risks of anterior

instability may be increased by anteversion of the glenoid or by anterior capsule insufficiency. 215

Patients with RA are more likely to have multidirectional instability as a result of rotator cuff or

capsuloligamentous instabilities. An optimal functional outcome requires restoration of an optimal

scapulohumeral rhythm and upper quarter length-tension relationships, as well as functional

strength.

Rehabilitation begins with PROM on the day of or the day after the surgery. Early mobilization

promotes appropriate collagen formation, decreases pain, and minimizes the adverse effects of

immobility. 216-217 The amount of external rotation and forward flexion PROM achieved by the

surgeon at the time of wound closure should guide rehabilitation. 218 Ideally, the shoulder should

externally rotate 40 degrees without excessive tension on the subscapularis. 219 The extent and

amount of activity alloweddepends on the extent of soft tissue damage and the quality of the repair.

During surgery, the subscapularis muscle is cut and then repaired. Therefore passive external

rotation and active internal rotation are limited for the first 4 to 6 weeks after surgery. Elements of

the surgery that may limit or alter the rehabilitation process include rotator cuff repairs and

subscapularis z-plasty lengthening.

Patient-conducted fl exibility programs performed several times a day after TSA to improve

shoulder ROM and fl exibility have been reported. 220 A home-based program that started with

PROM and progressed through AAROM at week 5 and eventually to elastic-band strengthening at

week 10 has also been described. 221 This program was coordinated and instructed by a PT but was

completed by the patient at home. Some patients with RA, traumatic arthritis, and osteonecrosis did

not maintain flexion ROM postoperatively, which may be due to weakened, thinned rotator cuff

muscles or an excessive infl ammatory response. Muscle weakness has been implicated as a risk

factor for not regaining flexion ROM after humeral fracture and TSA. 222 Self-motivated patients with

OA and no other shoulder pathology who undergo TSA may benefi t from an independent home-

based program coordinated and supervised by a rehabilitation professional, but patients with

additional shoulder pathology may need a clinicbased program.

Neer described limited goal rehabilitation (LGR) for patients with deficient rotator cuff or

deltoid strength or patients with significant bony deficiencym such as severe osteoporosis, who

could not tolerate a typical rehabilitation program. Patients with rotator cuff arthroplasty, those

with long-standing RA, or those with certain revision arthroplasty may also fall into this category.

The goal of LGR is only pain relief and joint stability but not necessarily functional ROM or strength.

Current programs for TSA rehabilitation are based on experience, without research into their

effectiveness or superiority. Typically there is a progression from PROM to AROM, followed by

progressive strengthening and stretching. The patient is usually in a sling for 2 weeks for an

uncomplicated TSA with a longer period of protection of 4 to 6 weeks if the surgery involved a

rotator cuff repair or fracture. It is important to instruct the patient to take his or her arm out of the

sling frequently to perform ROM exercise for the joints distal to the shoulder for a few minutes to

avoid problems with stiffness in these areas. PROM, and possibly AAROM, are initiated on

postoperative day 1. These activities include pendulum exercises in the standing position, as well as

supine PROM flexion and PROM/AAROM into external rotation to a limit of usually 40 degrees.

Pendulum or Codman ’ s exercises facilitate relaxation and initiate early glenohumeral joint motion

and scapulohumeral mobility. 223,224 This exercise is also useful as a “ warm-up ” activity and often

helps modulate pain and spasm of the shoulder girdle musculature. It is important to teach the

patient the correct way to do this activity because vigorous motion done actively can avulse the

anterior capsule and subscapularis repair, or in the case of fractures, tuberosity displacement, which

can have devastating complications. This exercise may be too painful for patients with generalized

soft tissue laxity because of the distractive force of the hanging upper limb, which is equal to

approximately 14% of total body weight. 225

Interventions

• PROM and AROM exercises in supine, prone, and seated to facilitate increased flexion and

extension. Exercises to include activities on a stationary bicycle, as well as clinician- and

patient-directed ROM.

• Soft tissue mobilization of the scar and peripatellar area, and patellar mobilizations, to

improve ROM and soft tissue extensibility.

• Open and closed kinetic-chain strengthening activities to improve strength and ultimately

function. If quadriceps strength is not responding to active strengthening techniques, NMES

will be utilized.

• Balance and proprioception will be improved through single leg balance activities.

• Aerobic capacity and endurance will be improved through cycling and treadmill walking.

• Ice and electrical stimulation or a cryotherapy/pneumatic compression device will be used at

the end of the treatment session to control pain and swelling.

Please see CD that accompanies this book for a case study discribing the examination,

evaluation and interventions for a patient after a shoulder hemiarthroplasty.

CHAPTER SUMMARY

Joint arthroplasty is most commonly used to treat pain and loss of function caused by arthritis. It is

one of the most widely performed orthopedic surgical procedures in the United States and will

doubtless increase in frequency with the increasing longevity of the population. Understanding and

implementing appropriate rehabilitation interventions after joint arthroplasty is essential. Studies of

patient outcomes, although not extensive, have demonstrated that patients who undergo joint

arthroplasty have limitations in ROM, strength, proprioception, and ultimately function that are

decreased by appropriate rehabilitation. Through thoughtful evaluation and appropiate patient-

specific, goal-oriented, evidence-based interventions, the quality of life of patients who have

undergone joint arthroplasty can be improved by physical rehabilitation.