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  • Physiotherapy

    Physiotherapy is an important part of the treatment of knee conditions both before and after surgery. After a knee injury, even if surgery is going to be required, physio will be beneficial for the early recovery. If surgery is arranged, pre-op physio (sometimes called “prehab”) may speed up recovery from the operation.

    It is important to note that the rehabilitation protocols given on this site are simply guidelines and may be varied by individual physiotherapists.

    Following arthroscopic surgery

    Following Arthroscopic Surgery

    Arthroscopic knee surgery is most commonly performed for cartilage tears although a number of other knee conditions can also be treated in this way.

    Rehabilitation is an important part of the healing process regardless of diagnosis and preferably should be done under the supervision of a chartered physiotherapist. Physio is not essential but is recommended as it will speed up the recovery process.

    Aims of Rehabilitation Post operatively


    • 1. decrease pain and swelling
    • 2. restore normal range of movement (ROM)
    • 3. restore normal muscle tone and strength
    • 4. progress to a return to normal daily activities

    Most arthroscopies are carried out as day case surgery. You will usually be able to fully weight bear without the use of crutches.
    It is common to experience some pain, usually quite minor, depending on the exact procedure.

    Swelling causes pressure on the surrounding structures which can impair muscle function and restrict ROM. Early mobilisation of the knee helps to activate the muscles thus helping to increase the circulation to the knee. Exercises performed with the leg raised will also aid in the reduction of swelling whilst you begin to move the joint and strengthen the knee muscles.

    The exercises below should be used as a guideline to aid in your recovery remembering there is no recipe for rehabilitation as every case is different. It is important to follow the advice of your physiotherapist in this early phase and be guided by them.

    1. Knee Flexion using a sling

    Sit with your legs out in front of you, preferably resting your heels on a sliding surface. Put a sling (towel, sheet etc.) around your foot then bend your knee using the sling, as far as it will comfortably go.

    Hold it there for a few seconds before straightening the leg. Repeat 20 times.

    2. Static Quadriceps Contraction (Thigh Squeeze)

    Sit with your legs straight out in front of you and pull you toes upwards. Tense the thigh muscles to try and push the back of your knee against the underlying surface.

    Hold for 10 seconds and repeat 10 times.

    If you find this difficult try it first on the other leg as often a reminder of the feeling prompts a better response when you try it again on the injured leg.

    3. Co-contractions of the quadriceps and hamstrings.

    Sitting with your legs out in front of you place a rolled up towel under your knee.

    Push your knee down onto the towel whilst digging your heel into the surface below. You should feel the muscles at the front and back of the thigh working together.

    Hold that position for 10 seconds and repeat 10 times.

    To progress this, repeat the whole process over two, then three rolls to increase the degree of bend at the knee.

    4. Knee Extensions in sitting

    Sit on a chair and straighten the injured knee pulling your toes up towards you.

    Tense your thigh holding that position for 10 seconds and repeat 10 times.

    5. Straight Leg Raise

    Sit with your legs straight out in front of you and tense the thigh muscle. Turn your foot out slightly and then lift the straight leg up about 3 inches off the bed.

    Hold for a few seconds before lowering – repeating the exercise 10 times.

    As this gets easier to do you should not need to rest the leg down in between repetitions. If you are unable to keep the knee straight during the whole of the exercise it means you are not ready to do this one yet.

    Please note:

    All of these exercises should be done in moderation (little and often) in the first few days after knee cartilage surgery.

    Where possible, elevate the limb when sitting or when applying ice. Ice is used to help minimise swelling in your knee and is often good for pain relief (your physiotherapist will be able to give you all the correct information for this regarding application and timing).

    After this initial stage, your exercise programme will be devised according to your individual needs. The aims are to encourage normal walking and to progress to a more functional strengthening programme. This may include exercises such as ski squats, lunges, knee dips, balance exercises and progression onto mini trampoline, mat work, weights etc..
    Full recovery after simple knee arthroscopy can take from 2 to 6 weeks.


    These rehabilitation guidelines have been prepared with the help of Gill Cannon and Rachel Galley (Physio Action Ltd.) – at David Lloyd Centre, Leeds and Harrogate Gymnastics, Hornbeam Park, Harrogate).

    Following ACL reconstruction

    Following ACL Reconstruction

    Recovery following a routine Anterior Cruciate Ligament (ACL) reconstruction takes place over approximately a nine month period. Active physiotherapy input may be required for the first six months or so. This will depend on your activity levels and other specific requirements.

    The exercise stages may vary if other treatments have been undertaken during the knee surgery. e.g. meniscal (cartilage) repair, microfracture, or reconstruction of other ligaments.

    After your ACL reconstruction, the hard work begins.
    It requires dedication and patience to work towards a good outcome. It is very important that you follow the advice you are given as the exercises are specifically related to the stage of healing.
    Time scales are important. You should remember that even if your knee feels like you could push it harder, the graft may not be ready.
    In essence, you should try to avoid twisting the knee (this probably how it tore in the first place), and putting a forward force on the tibia.
    All quadriceps exercises are designed to reduce the load on the new graft for the first six months and are classified as ‘closed chain’ (or ‘weight-bearing’). This means that they are all performed with the foot placed on a surface throughout the exercise. This compresses the whole of the lower limb and shear forces across the knee are minimised.
    ‘Open chain’ quadriceps exercises are avoided for up to four months and are defined as those done without the foot resting on a surface e.g. leg extensions. They are avoided because they allow the thigh muscle to pull the tibia forward on the femur without the ground forces on the foot. This causes a greater shear stress across the knee and the new graft.
    Some ideas about rehab after ACL reconstruction are contentious, so the following are guidelines only, but commonly accepted by a large number of knee surgeons.

    Aims of physiotherapy

    • 1. To decrease pain and swelling.
    • 2. Regain full range of motion (ROM).
    • 3. To regain a normal gait pattern, ie. Walking without a limp, as soon as possible.
    • 4. Maintain and improve muscle tone and strength.
    • 5. Progressive exercise prescription allowing return to all usual daily activities including work and sports.

    Day 1-14

    Anterior Cruciate Ligament (ACL) reconstruction surgery is usually carried out as a day case or overnight stay. You will usually be allowed to fully weight bear but will need crutches for the first few days to help you walk. It is better to walk well with crutches than walk badly without, and your physiotherapist will advise you as to when you no longer require them. However, they should be discarded as soon as possible.
    Following ACL surgery it is common, not surprisingly, to experience pain in the knee. However it is not usually severe and can be helped with simple tablets.
    Following ‘hamstring-graft’ surgery (most patients) it is normal to feel discomfort, and experience bruising, at the back of the thigh and knee. Swelling causes pressure on the surrounding structures which can impair muscle function and restrict ROM. Exercises will reduce swelling, and having the leg raised will also aid in the reduction of swelling whilst you begin to move the joint and strengthen the knee muscles.

    The exercises below are a small selection and should be used as a guideline to aid in your recovery remembering there is no recipe for rehabilitation as every case is different. It is important to follow the advice of your physiotherapist in this early phase and be guided by them.

    Initial Management- RICE

    Relative Rest – Keep the knee moving as well as having periods of rest
    Ice – To help with swelling, ice regularly for at least 20 mins four times a day. There are cold compression devices available, which may be used during the hospital stay, and may also be acquired for home use.
    Compression – In the early days to minimise swelling
    Elevation – Especially when ice is applied, aids reduction in swelling. Elevate the knee when sitting.

    1. Knee Flexion using a sling

    Sit with your legs out in front of you, preferably resting your heels on a sliding surface. Put a sling (towel, sheet etc.) around your foot then bend your knee using the sling, as far as it will comfortably go.
    Hold it there for a few seconds before straightening the leg. Repeat 20 times.

    2. Static Quadriceps Contraction (Thigh Squeeze)

    Sit with your legs straight out in front of you and pull you toes upwards. Tense the thigh muscles to try and push the back of your knee against the underlying surface.
    Hold for 10 seconds and repeat 10 times.
    If you find this difficult, try it first on the other leg as often a reminder of the feeling prompts a better response when you try it again on the injured leg.

    This is important as regaining full straightening (extension) of the knee is a crucial part of the early period.

    3. Co-contractions of the quadriceps and hamstrings.

    Sitting with your legs out in front of you place a rolled up towel under your knee.
    Push your knee down onto the towel whilst digging your heel into the surface below. You should feel the muscles at the front and back of the thigh working together.
    Hold that position for 10 seconds and repeat 10 times.
    To progress this, repeat the whole process over two, then three rolls to increase the degree of bend at the knee.

    Week 2-6

    • 0-120 degrees flexion
    • Full weight bearing and normal gait pattern
    • Two leg squats, static foot lunge, small knee bends
    • Open chain hamstring exercises
    • Stationary bike

    Weeks 6-12

    • Full range of movement should be achieved
    • Single leg squats, stepping lunges, dips,/li>
    • Proprioceptive (balance) exercises- these are on ongoing key part of ACL rehab
    • Leg press and hamstring curl progression
    • Step ups/downs
    • Cycling, cross-trainer, step, rower
    • Jogging on mini trampoline / mat / straight line jog
    • Exercises for hip, knee, foot of both legs
    • Swimming (Straight leg kick only)

    Weeks 12-5 months

    • Increase to sports-specific training
    • Increase cardio-vascular fitness including pool (normal kicking +/- flippers)
    • Increase agility and speed / change of direction work
    • Increase weights and progress all gym based exercises

    5 Month onwards

    • Start open chain quadriceps exercises under supervision
    • Concentrate on plyometric and sports specific exercises
    • Return to usual training/ skills

    Only return to playing contact or twisting sports once your physiotherapist and surgeon have mutually agreed that you are ready and fit to do so.

    These rehabilitation guidelines have been prepared with the help of Gill Cannon and Rachel Galley (Physio Action Ltd.) – at David Lloyd Centre, Leeds and Harrogate Gymnastics, Hornbeam Park, Harrogate).

    Following knee replacement

    Following Knee Replacement

    Exercise forms an important part of the recovery process following knee replacement. The programme will depend upon the type of operation that you have had.
    There are a few basic principles that can be followed in the early stages for every operation.
    Aims of Post-operative Rehabilitation

    • 1. Decrease pain
    • 2. Reduce swelling
    • 3. Restore normal range of movement
    • 4. Encourage normal muscle function and strength
    • 5. Progress rehabilitation allowing return to normal function- within the aims and expectations of surgery discussed with your surgeon.

    Pain and swelling are important to control as soon as possible as both of these will effect the amount of knee movement. When resting, it is important to raise the leg with the knee supported to reduce swelling. This can be improved by intermittently moving the ankle up and down, squeezing your thigh muscle and tightening your buttock muscles whilst in this position.
    Ice can be used to help reduce swelling in your knee and is often good for pain relief. Ideally, this should be applied in elevation for a period up to 20 minutes and repeated several times per day in the early stages. During your stay in hospital, an ice-compression device/cuff may be used, which can be more efficient.
    Exercises should be done little and often with a good balance of rest in between. Early mobilisation is important to try and achieve a good range of movement and to activate the muscles supporting your new knee.
    The exercises below will help you start this process.

    1. Knee Flexion using a sling

    Sit with your legs out in front of you, preferably resting your heels on a sliding surface. Put a sling (towel, sheet etc.) around your foot then bend your knee using the sling, as far as it will comfortably go.
    Hold it there for a few seconds before straightening the leg. Repeat 20 times.

    2. Static Quadriceps Contraction (Thigh Squeeze)

    Sit with your legs straight out in front of you and pull you toes upwards. Tense the thigh muscles to try and push the back of your knee against the underlying surface.
    Hold for 10 seconds and repeat 10 times.
    This is very important, as it is the basis for regaining a straight knee. It is important to your knee straight early
    If you find this difficult try it first on the other leg as often a reminder of the feeling prompts a better response when you try it again on the injured leg.

    3. Co-contractions of the quadriceps and hamstrings

    Sitting with your legs out in front of you place a rolled up towel under your knee.
    Push your knee down onto the towel whilst digging your heel into the surface below. You should feel the muscles at the front and back of the thigh working together.
    Hold that position for 10 seconds and repeat 10 times.
    To progress this, repeat the whole process over two, then three rolls to increase the degree of bend at the knee.

    4. Knee Extensions in sitting

    Sit on a chair and straighten the injured knee pulling your toes up towards you.
    Tense your thigh holding that position for 10 seconds and repeat 10 times.

    5. Straight Leg Raise

    Sit with your legs straight out in front of you and tense the thigh muscle on the injured leg. Turn your foot out slightly and then lift the straight leg up about 3 inches off the bed.
    Hold for a few seconds before lowering – repeating the exercise 10 times.
    As this gets easier to do you should not need to rest the leg down in between repetitions. If you are unable to keep the knee straight during the whole of the exercise it means you are not ready to do this one yet.
    The exercises will progress on the advice of your physiotherapist according to individual need.

    These rehabilitation guidelines have been prepared with the help of Gill Cannon and Rachel Galley (Physio Action Ltd.) – at David Lloyd Centre, Leeds and Harrogate Gymnastics, Hornbeam Park, Harrogate).

    For patella problems

    For Patella Problems

    Patella problems, Anterior Knee Pain, and patella tendinitis are complex areas which need specific assessment by your surgeon and physiotherapist to formulate the correct rehabilitation programme.
    Below are some general principles, which should be considered as guidelines only.

    Anterior Knee Pain Syndrome (AKPS), and Patella Instability

    In general AKPS means pain at the front of the knee, in the region of the kneecap, without any other obvious cause such as arthritis.
    Physio for AKPS has standardised over the years, but there are still a variety of approaches.

    Strengthening of the quadriceps muscles can help the smooth tracking of the patella. The VMO (vastus medialis obliquus) part of the quads is felt to be particularly important, because it pulls the patella inwards.

    Other muscles which act across the knee include the hamstrings and the calf muscles, and the gluteus muscles via the IT band.

    Recent work has shown that working on the hamstrings, especially the inner hamstrings, is more important than previously thought.

    Assessment of hip and foot alignment may be important, and is part of the physiotherapy assessment.

    Patella Instability ranges from mild maltracking to complete dislocation of the patella towards the outer side of the knee. Many of the rehab exercises are the same as for AKPS. Principles are of muscle strengthening as for AKPS, and training other aspects of joint control, especially proprioception. Your physio will design a specific programme for you.
    With recurrent instability, surgery may be required.

    Patella tendinitis

    Rehabilitation for patella tendinitis aims to reduce pain and and swelling, aiming to return the patient to normal sporting activities. In severe episodes RICE (rest, ice , compression, elevation) helps, along with anti-inflammatories.

    The main principles involves stretching and strengthening.

    Eccentric stretches form the mainstay of physio, as they have been shown to help with healing and reduction in symptoms. An eccentric stretch refers to resisted movements, with lengthening of the muscle fibers while the muscle body itself contracts (shortens). It is thought that this helps develop new healthy collagen in the patella tendon.

    These can be done with both feet flat on the ground. Bend the knees slowly to a squat. Hold it for about 10 seconds. Put more weight through the good leg, and then stand up again. This can be repeated 10 times, 2 or 3 repetitions.
    As symptoms improve, put more through the bad leg. Eventually you can do it with extra weights.
    A decline board (a downwards sloped board) at about 45 degrees, is often use to exaggerate the stretch. The most important part is the downward phase, which is the eccentric component.
    Other strengthening and stretching work (quadriceps, hip flexors) are also important.
    Sports-specific Plyometric exercises may be commenced later. Plyometrics are exercises using fast and powerful movements, to develop strength and speed. Examples are standing jumps, skipping, bounding.

    Patella Arthritis

    General knee strength work is key. Specific VMO strength work can help the patella tracking which may be poor (see above).
    Mobilisations (passive movements of the patella) may be done by the physio to overcome some of the tightness which is often present on the outer aspect of the patella.
    The aims are to maintain or improve function, and to reduce pain.
    Your physio will give you a customised programme.

    See also: