Why Acute Injury/Post Op Surgery PT is Key

You know , if you can't tell , the theme that I was I was thinking through the last two weeks was like I'm very busy in the clinic .

Probably honestly the busiest that champions ever been and definitely the on the busiest that I've ever been is like trying to manage a lot of people and then trying to understand how to help people who have a variety of different diagnoses , and it's a lot to keep up with .

I mean , like , unless you're working on like a very specific type of surgical floor or a very specific practice near you that all they do is shoulders you know , lenny and Mike , obviously a lot of knees and elbows , but like they still see a very wide array of cases of things that are going on .

So you kind of got to be nimble on your feet about like what do people need and where are they at along the continuum of rehab , and so , building off of the thing that I think is the most stressful for people is I want to do an episode sharing kind of the systems that I use to approach very acute people surgeries , very acute injuries , um , that have been

cleared of like serious pathology and getting them through more or less the first eight weeks , because that is extremely intimidating when someone is in a ton of pain , um , and really doesn't know the best way to approach that . So that's where my head was at .

And then I did that like every single time that they came in to see where they were progressing and see if we needed to change up anything or just to make sure that they were making progress each session .

Generally and we kind of talked about this with Dan is that try to put a third , maybe a half , of your content education into like , okay , I see a lot of knee ACLs , I see a lot of meniscectomies , I see a lot of total knee replacements , because we have three knee docs that are , like you know , in this local practice .

So the more that you know the anatomy and the more that more that you know the injuries , the path , the mechanics . Oftentimes you don't see these people pre-op , before they come to you , so you're kind of getting a first glance of you know . You got to get to know somebody and make them trust you and develop a rapport and have empathy .

At the same time you have stuff to do in an hour or 45 minute eval . So try your best , as a precursor , to know what does each joint kind of have for major surgeries .

That I'm probably going to see and I think that helps you , as I said in the last episode , helps you be a bit more nimble on your feet in the clinic and kind of answer questions more fluidly , versus like I don't ever treat ankles and now I have an Achilles repair in front of me .

That's , you know , four months or four weeks post-op or something like that . So do yourself a favor and try to be a bit ahead of the curve . Versus like you see all ACLs and you want to learn about concussions , so all you're talking about is concussions Nothing wrong with that , but you have to laser focus

on what's in front of you .

So when , especially with my pre-op kids who are , you know , they haven't gone through this process yet I can say I know where they're going to go , I know what's going to happen when they walk back in the room .

I know what's going to happen when they wake up , Like I know what happened during their surgery , and it puts watching videos or actually going to watch the surgery itself . Just everything looks so much different than you might have like thought in your head , Like it .

Just I think it changes the game a little bit when you can actually see the surgery and like see what they do and see what happens , Cause I mean there were definitely a couple of surprises that I had like like , for example , like I went and watched a TTO surgery . I don't know if you've ever seen one of those , but it was like gruesome .

I was like , oh my God . I thought this was like a little basic surgery where you just like take the little piece of bone and just move it over . Oh no , hammering . Oh yeah , the bone out .

But like I just have like a , a , a bookcase of like different books that I really enjoy , like that I've read all the time but I was able to invest via like shift and company work . But like your clinic should have a surgical hip book . You know what I mean .

There's like surgical textbooks for the hip , uh , athlete , shoulder with with Mike and Lenny , so like if you can't afford them yourselves , but like knee disorders by noise that's like a 2000 page textbook .

And if you have those in the clinic , you know , the night before or the morning of or even in the moment , if something comes on you're not familiar with , you can kind of scoot to the back real quick and be like , oh , let me just look this up real fast and see what that surgery was and like what's going on .

Bob , obviously the protocol will be different from a doctor that you see , but you know those surgical textbooks and the combination of ones , like Mike did with everybody , were super helpful . But the hip one is from the guys at HSS .

I want to say what's his name , I forget , I can't think of my head , but he essentially edited the entire hip repair , surgical repair book . It's two volumes , there's a shoulder one , there's an ankle one . So reading those chapters of what you commonly see are really helpful .

But then also having those in the clinic to kind of refer to and understand like , oh yeah , it makes sense why this person's really having a tough time with clot activation because they had this huge LAT and they had this huge meniscus repair or like whatever it is . So , um , yeah .

So on the second piece of that I would say is you made a really good point , which is that understanding the surgery or visiting surgeries is good for you , but establishing relationships with doctors and being a face and seeing them right , I think the best thing you can do is be a bit nimble and understand the surgery so you can ask good questions .

So you know , don't pester surgeons because they're so busy and they have a lot going on . But once in a while , you know , if I have clarification that I need , I can call a PA or someone that I'm very friendly with and say , hey , like what do you ? I don't have any post-op stuff .

They didn't come in anything like what do you want to do with the brace ? How long for the brace ? How long are they weight bearing ? Do they kind of meniscus repair ?

How many anchors like you can ask those very quickly in a three minute phone conversation and I forget when I posted it , but I've gotten to the point with a lot of surgeons in Boston that I work with that like they're very , very friendly and very nice If you deliver very quick , need to know information and you ask , need to know questions .

We have like cell phones of a lot of the team docs that are in Boston and you know this doctor , dr Ramappa , who's amazing .

He does a lot of the labor , repairs the surgeries on shoulders and stuff or ACLs that we see with like a lot of the high level gymnasts , and so he'll scrub out and call me and leave a 13 second voicemail on what he did and that helps me exponentially more than trying to call his front desk who leads me to the PA , who looks up the notes for the doctor

, who sends them back to the PA , who sends them back to the . You know it's all like this road of nightmares . So if you can get enough exposure with people and refer back and forth , they start to send you people and they're very friendly with you and helping you .

So that's the best thing I've ever done , because I can literally call docs from Boston Children's like , hey , I'm with this person right now . Um , what do you think about this ? This and this ? It's a 17 second phone conversation and then we move on with life and it's great , you know . But I've been to ramapa's office .

I mean , my mom had surgery with him and I've sat with him and I've talked with him and he knows mike and lenny really well . But whatever the doctors in your area are , try your best to be on board with them . You know what I mean ? Is choa directly in a hospital , right ?

But we also have the luxury of having Epic and so I already see like all of those no , it's like they're just like in there , so it's easier than trying to like make sure the patient brings it or like trying to look it up or you know , trying to get a patient to bring all their stuff and obviously their mom can help but like they are often in a lot of

pain and very high and very stressed out about their situation .

Yeah , so I just had two examples here of things like if I see somebody post-op for an ACL , for example , or just a knee surgery in general , meniscus TTO has a little bit of obviously different but like MPFL reconstruction , there's probably going to be a handful of things that you want to know from the beginning .

So before you do all this , you want to try to get an operative note , you want to try to get a diagnosis or some sort of PT eval , you want to try to get a protocol or precautions right . So you need to know those things ahead of time . What are limited you can't

do and I'll . There's an example I have right now is literally a kid who's five days post-op um ACL , bone tendon graft , lat and a meniscus repair . So medium meniscus repair . So he's non-weight bearing for six weeks because their meniscus repair is pretty hefty .

He is not allowed to bend past 90 degrees for six weeks because the meniscus repair is pretty involved . And then , um , they have him in a brace for six weeks crutches , I want to say , for I don't even know how long . It depends on his weight bearing progression . But that's like baseline right and so like you have to know those things going into it .

We'll talk about the hip one separately . But there are different protocols and different restrictions on purpose for certain tissues because you don't want to compromise the tissue .

So a rotator cuff repair , a biceps repair , a hip labor repair , an Achilles tendon thing , there are very set research-based guidelines the surgeons use to have progressions for these people and the exercise selection oftentimes , if they do a great protocol , is based on that stuff too as well .

So you want to have that in your background of kind of do your homework to know what the surgery is and what the protocol is . And if they come to you and they don't know what surgery they had I've literally had this before what surgery to have ? I think about a kid . He's a level 10 gymnast . He tore his ucl and had a tricep repair .

He's doing a ginger , just literally dislocated his elbow and blew his arm up . He came six week post-op and I was like , yeah , man , like what'd you have done ? He's like I don't really know . They like cut the inside and like the back's repaired . I was like that's a big scar . I'm like , did you have a triceps repair ? He's like , yeah , maybe .

I was like what , bro ? I was like you're killing me right now and his mom was there , but his mom had left to go , you know , do something else with his other uh brother . So and I'm like , did he have a UCL repair ? Did he have an augmentation ? Did he have a TJ three ? I have no idea .

So we did the basics of what every elbow needs and didn't go outside what I know the limits were . And then , as I got more information , we kind of progressed things for it .

So on a knee situation , right , the big rocks that you're trying to get through just through this list is like pain , right , pain management , pain affects everything If it quad inhibition comes with that . So there's meds for a reason , right , like dosage of a high , higher grade dosage .

Drugs are there for a reason , in the first few weeks to sleep or kind of get through PT , to move um . Tons of ice right , especially at night before they go to bed , because it's super painful .

They're oftentimes on like a CPM combined with some degree of an ice machine to as well rotating , and that doesn't help with swelling , right , but that does help with pain management and if you don't have as much pain you can move more often and tolerate more exercise . So don't poopoo ice .

I know a lot of people who are like don't use ice ever because it's going to delay healing . But like I'm telling you , if you have a massive rotator cuff repair and you don't want to take a lot of drugs , ice is your best friend to get through that first couple of weeks . And they have a TED stocking sometimes .

And then after a couple of weeks when the stitches come out , you can wear like a knee sleeve or do an ACE wrap or something like that and then just regular motion , right , like I'd rather somebody do 10 to 20 repetitions of hyperextension , inflection every hour for the entire day than one epic stretching session where they push their knee too much and it gets

too cranky . Then they're flared up and they really can't tolerate anymore . So pain's massive .

Educating a patient on their precautions , what they can do , what they can't do , you know you can't weight bear , you can't bend your knee when it's on the ground , you can unlock your brace and sit if you can comfortably get past your limit , but not past 90 because there's a meniscus thing .

So you need to be very clear and tell them about what they can and can't do and oftentimes educate their parents or whoever's like their caregiver that's with them , because the person again is probably on cloud four , you know , with an oxycontin pumping through their system . They're not really with you right now . So trying to uh kind of get through all that .

And then you think about what are the most immediate emergent things that have to happen to not have an issue come up .

And the biggest thing for a knee is full hyperextension to prevent a cyclops lesion , right , so you have to get someone's full knee hyperextension to within a couple of degrees of the other side , because , um , if they get scar tissue in the , in the neural gutter of their ACL , they can't ever get full hyperextension back .

And then you're really in a in a tough situation . And we've done you know some things on the Mike Ronald show about how to do that and long load stretching and stuff like that , but , um , that's like priority .

Number one is like protect the graph , get the swelling down , get the pain down , um , help somebody understand their precautions and get hyperextension back . It's like the immediate first session . If you didn't know their surgery , you didn't know what's going on . Most of those things are okay , depending .

Maybe if they have like an anterior meniscus repair , you wouldn't push hyperextension . That's a nuanced thing , but most people that's pretty good , along with making sure the incisions are clean , covered , stuff like that . So I'll probably go like five at a time and then we'll stop and chat in case you have any questions . But does that make sense ?

Is there anything in there that I think you know I went over too quickly or it doesn't make sense ?

extend your knee all the way it is really hard to like fully contract your quad If you've sat around and tried just like with your knee not all the way straight to try and contract your quad . It's so hard . So I think missing extension is one of the biggest things that I think people are missing out on early on in the rehab process for post-ops .

There's a lot of long-term , like a moon group outcome studies that show that people with hyperextension within a couple of degrees of the other side overall have better outcomes long-term Right .

And there's a whole nother rabbit hole about why , like you know , having not hyperextension leads to like some quad activation and some some uh scarring , but also just problems when they try to go to strength training or run or jump . So the hyperextension is very helpful and on top of that , you know six and five are flipped here .

But patellar mobility is super important early on because regaining your full knee hyperextension requires superior patellar mobility and tilting side to side . So oftentimes they have , you know , a scar above or below if they have a BTB um patellar tendon or a quad tendon graph .

So you just work around that you know it's not the most comfortable thing in the world , but you put gloves on and you teach somebody how to go up and down and teach them on their own , because if they can get more patellar motion they're going to get to end range hyperextension and if they get more inferior gliding over time as the scars here , they're going

to get more comfortable flexion right . So , um , back to your point about um quad strength and getting that back very early on . The hardest thing to do is get a quad to turn back on . Between you know the nerve block and some of the issues like that .

But even trace amounts of swelling 40 CCs of swelling , 40 cc's of swelling in the knee inhibits the quad quite a bit as a protection mechanism . So if you have somebody who has this big ballooned knee , it's very hard to get them to get a quad set and then a leg raise which eventually helps them walk .

So the best tool we have for this is like NMES , like a trigger-based NMES , where you put two pads on their quad and they volitionally try to control a quad set as much as possible , but they turn the stem up so that they can do it on their own . Some units are like time-based , like five on , 10 off or whatever .

But the first day post-op somebody comes to us , we have the quad , you know , uh , the machine on and they're doing their own tolerance and stuff . And I'm doing assisted quad sets , assisted leg raises , passive hyperextension with a towel or a belt .

Um , they're just repping through those because , you know , the faster you can get somebody to turn the quad back on , it's a , it's a positive flywheel , right , if your your knee is less swollen and your quad works a bit better , you can maintain hyperextension a bit easier , which means that eventually , when you start to get off your crutches and brace , you're

going to walk smoothly . So we want to facilitate , you know , swelling and kind of motion because it helps kind of get the fluid out and helps the pain reduce when someone's not afraid of their knee . But , um , pretty big surgery for her ACL and she was just very hypersensitive .

You know she had like some very like couldn't touch her scar , she was very nervous , she was squeamish , it was like hard . She just had like a very mild CRP yes , I think , starting , and we just had to more or less say like every 30 minutes , you know , move your kneecap up and down , get your knees straight , try to flex your quad as hard as you can .

And she's three months now and we're going to have an uphill battle with getting her quad strength back but she gets the plus eight hyperextension . She's out of the woods but she goes from two to eight within one session . She's at two when she comes in because of her quad is not fully strong and fully active .

It's not actively hyperextending her when she does exercises . So he in soft own two more times that day and then just hammer her quads over and over three times a week . So it's hard . But quad soft tissue or hamstring soft tissue to help somebody regain hyperextension is very important .

So yeah , swelling patellar mobility , quad activation with NMES , regular exercise when they're ready for the bike . Maybe not a revolution of the bike , but you can get somebody kind of like halfway on each side to get them to like 90 degrees . Um , yeah , I think those are probably the next ones .

In hyperextension it's more of like I'll , you know , put an ankle weight over there and just sit there for like five minutes , you know , and just like

let it kind of droop down with a heel prop . And I think one of the biggest like pieces of education that you can give to like the family and the patient is to make sure that you're not putting anything under the knee .

You know like five to 10 degrees of knee extension and that's going to put you in a really bad place . And I always tell them I'm like if we start to miss extension , it's going to push our timeline back . So like exactly hammer home extension , cause it's going to push your timeline back more than you think with your strength and motion for sure .

Prop your heel up with a heat pack and a lightweight and just scroll through tiktok , watch a netflix show while it just kind of sits there passively for 10 minutes , right , versus this big epic stretching session where you make the knee a little angry and and hyperextension is sometimes a bit more passive and easy .

But same thing with flexion or sorry for hyperextension . I know like prone hangs are very popular in many circles , but like that oftentimes will cause a hamstring contraction which makes it like you're fighting uphill both ways . Gravity's pulling down , it hurts their hamstrings , firing back and forth .

So we personally don't use those and Lenny has some really great videos on the metrics of that . But prop hyperextension with a knee and a heat is probably our go-to way .

It was like when I started like my job , yeah , like when I started residency here , and then at some point I just kind of like stopped doing it and one of my other co-workers like started doing prong hangs and I was like why did you start doing ? that or like what was your reasoning ? Because I guess I was trying to , I don't know .

There's one kid that we were working really hard on her emotion , that we're trying everything that we possibly could . But I agree with you .

I feel like , no matter the weight , like it's really hard for them to relax in that position if they're tight or if it's painful or uncomfortable , especially if it's uncomfortable over the front of their knee and any of their knees on the table and they take that quad we get mostly quad graft so like they take that piece of quad out right above the patella

which is going to be right where they're going to put their . Like that pressure is going to be pushing on the table right over that piece . It just gets irritated and angry and it doesn't .

That might sometimes help , like the sensitivity of the skin a little bit more . Um , but yeah , I think trying to do regular hamstring type stuff or stretching lightly and then get the hyperextension that way , and then you know , with seated , with flexion too as well , I mean , gravity is your best friend when you're sitting over the edge .

I used to supine people and just crank on them , cause I thought that's what you did until I met Lenny and thought about , if you know , shoot the shit and be casual . And you know another ACL that I had . Um , he had surgery last Thursday and I saw him Monday , so five days post-op . There was a delay in the CPM getting there .

The person didn't know how to set it up with instructions , so I was the first person who wanted to wrap his leg and bend his knee in five days . He was just straight the whole time . Homeboy was not happy . He's a good kid , really nice kid , but we barely got him to 35 degrees right .

It took three bouts to pass a range of motion to barely get him to 90 . He's the one with the LAT and the meniscus repair . So obviously more surgery , more swelling , but we had to .

You know , just talk about Netflix and talk about the Red Sox game and I'm just trying to ignore it and like just really relax and sneak a bit here and he jumps off the table and then Ooh , it's all good , and then we go do exercise , then we come back and do another bout of motion in the hour , then we do another set of this , then we come back and do

another bout of motion in the hour . So try your best to know that it's going to be uncomfortable but like , make light of the situation , sit people on the edge . You don't just sit there and hammer on their knee bent , because it's very hard to relax when someone's towering over you , yanking on your knee and flexing .

You know , a lot of these people are big surgeries , like an LAT , acl , meniscus , and so they're worried about motion stiffness , but they're also worried that person's going to push past maybe a protocol limit so we can set an MPFL reconstruction to 30 , right , and not go past that , versus someone who's going to go to 90 or 60 .

So , yeah , most of them are getting CPMs , yep .

I mean , probably there were oxys involved , obviously , but he was just chilling there and he got . When he came back on Thursday , three days later , he was at sleep 65 , right . So he doubled his motion by just daily CPM , consistently nice and easy , wasn't cranking his leg , you know .

So he alternated between hyperextension , quad sets , basic CPM , just really really easy open chain stuff , and he was much less painful as his yesterday and um , much more comfortable with all of PT . You know , leg raises the next thing we'll tackle , but um , yeah , so , um ,

basic consistent advice is probably good for that . And the last thing that always comes down to is like gate . You know you want to normalize someone's gate as fast as possible . So I will say it's a bit murky when the surgeons aren't really like clear about when you can unlock a brace .

In this case , one of the kids , six weeks non-weight bearing , you know , locked in extension because the meniscus repair .

But the other person , um , who had the LAT as well , um , you know the , the surgeons see them one week post-op and six weeks post-op one week for the surgery , stitches , and then , you know , another six weeks later for just to check up generally .

So in that time though , they're generally want to get off a brace and get off crutches right , they say crutches two to four weeks weight bearing is tolerated for most ACLs and then unlock the brace when you quote , have quad control , like involitional quad control .

So I think that the best way to think about it is , when you're locked in the brace you want to go from two crutches to one crutch , you know , in two hour spurts .

So when you first wake up in the morning , get the knee heated , get it kind of ready , do some exercise , and then do two hours on two crutches or on one crutch , and then go to two crutches for the rest of the day .

The next day add maybe one or two more hours , and then throughout the course of the week , on Sunday to Sunday , you go from two hours on one crutch to eventually getting up like the full day on one crutch and just being around your house , maybe at the end of the day if it's a bit sore , and then you do the exact same thing with one crutch , is that

when you're at home . Try to spend two hours where you're doing no crutches but you have your tabletops around you and your couches , in case you want to , kind of the day with no crutches versus you had like two hours on one crutch or sorry , two hours on no crutches , you added one crutch at school or something like that .

So I find that with like coming out of boots or coming off crutches , it's better to do two hour stepwise progression to not make someone's knee pretty angry .

And then in PT you obviously want to be the first person who tests an unlocked situation and with most ACLs that are weight bearing , you know you're doing mini squats , you're doing weight shifts , you're doing open 90 50s , you're doing closed chain . You know stuff a little bit . So I have three right now the non weight bearing meniscus .

One is obviously locked , but there's another one that's two weeks post op was an ACL meniscus and he's weight bearing is tolerated . They want him to get off his crutches in two or four weeks .

So he's doing mini squats and weight shifts and he's pretty good with hands on the table so that in a week or two when his quad is quote , unquote back and for me that means like you're doing leg raises in each direction . You have a pretty solid 90 50 contraction . You can do a mini squat pretty well .

Um , you're doing weight shifts , maybe some mini step ups like that's showing me that you have basic volitional quad control . We would unlock the brace maybe to 45 , which is what you need for functional ambulation . So zero or hyper extension to 45 so that when walks he has like a little bit of a swing with him .

But you know , god forbid , something happens where he slips or something happens , his knees not going to bend fully to 90 . So that's kind of , you know , probably going to happen for him at four weeks . I think the other girl I want to say it happened at six weeks because she had a pretty , like I said , ami case of mild sensitivity .

So she was off her brace around , I want to say six weeks . After four to six weeks we kept the brace but unlocked it and she slowly weaned off the crutches . So at four weeks she was off crutches .

But that progression from four to six weeks it was like unlock your brace for an hour , walk around your house , go to the bathroom , you know , do your normal stuff , but then lock it at school and make sure you're safe when you're , when you're getting walked by in classes and stuff . So , yeah , that's the next big thing and you know that whole .

You know 12 things , right ? There is more or less the first six weeks of acute ACL or knee repair , right ? Um , yeah , any additions on that Cause ? The labor one is the same thing , but just in a different context .

, just in case like again , like just being able to , like , almost like , catch themselves that they were to step wrong , or something . Being able to do that , I think , is important ?

But labor repairs are very , um are variable based on how many sutures are put in . Do they have any bone involvement ? So did they have like a pincher lesion debrided or a cam lesion debrided , which would be an osteoplasty .

So acetabular osteoplasties with capsular closures are treated a bit more like a cartilage surgery than a labor repair surgery , because you have to pull down and delaminate some of the cartilage to repair it . So they're a lot more cautious with weight bearing versus somebody who just had a labor repair with no osteotomies at all .

They're going to be probably weight bearing is tolerated , but they probably will have a brace . So pain is the exact same thing , right ? Meds , ice , reduce your swelling around the hip . There's you can't see it as much in the hip versus a knee , but there's obviously a lot of swelling going on . So look at the incisions .

They usually have three portal holes to make sure they're clean , they're not rubbing on their skin or their underwear or something like that if they're wearing running shorts . And then regular motion too as well .

Is that you know the the knee precaution situation is that if you have a meniscus repair or something , you don't go past 90 with flexion but you can have full hyper extension with a hip label repair . You oftentimes are limited to 90 degrees of passive motion . Obviously don't cross your legs .

So no ir past a certain 10 degrees but then no er for 40 degrees because you don't want somebody to have , you know , too much stress on the labral tissue .

So passively when you're doing motion you want to do to those tolerances and you want to kind of work in the mildly abducted yard plane , because that's how the scap or the acetabular plane kind of lines up , normally the same way that like a scaption plane in the shoulder we don't really range in close flexion because of the impingement possibly in a rotator cuff .

So we put them slight abducted just to kind of clear more space . So I do all my passive range of motion there .

And then also the version of hyperextension , propped and knee flexion is circumduction and log rolling for somebody who's labor-opera , because circumduction and log rolling aren't closing the femoral neck on the tissue that was repaired , but it's moving the hip joint in circles or moving the synovial fluid around quite a bit right . So you want to have regular motion .

They can't circumduct themselves . But in PT a lot of your work is circumduction , log rolling , basic tolerance to flexion , ir lightly on their back , log rolling , basic tolerance , deflection , er , ir lightly on their back and then within their protocol they'll probably have those restrictions of how long .

It's typically four to six weeks , based on kind of how involved the surgery was . But it's the exact same thing as like a knee has like patellar mobility and this and that you know a quad head or a hip has some quad and adductor soft tissue . That's probably pretty helpful . It has circumduction , it has log rolling and stuff .

And then after a couple of weeks you know they're on there . Um , they have a hip brace that's kind of locked in to prevent them from abducting or abducting inside neutral , but that kind of lasts for you know , up to four weeks and the exact same progression will happen .

If they're just a labor repair , they're going to be , weight bearing is tolerated and it's the exact same crush progression . You know two hours and then go from two to one . Make sure you're not limping . Uh , you don't want to hyper extend your hip too far , um , because it passes zero because of that . So you have to take very short steps .

You can't , like , take a long stride with your leg behind you , because that will pull on some of the anterior tissue . Um , they oftentimes have no active hip flexion as well , um , but the the version of , uh , you know , propped hyper extension for the knee is prone lying in the hip .

So a lot of surgeons want these people on their stomach for five to 10 minutes throughout the day multiple times , just to prevent the risk of any scarring in the anterior tissue where they put the portals through and stuff like that . So lying on your stomach is the same as prop hyperextension to get that motion back .

And then they generally use quad rocking as the main way to get patient controlled flexion back , in the same way that if you're sitting on the table at home you would put your own other good knee behind your bad knee and use that to kind of bend your knee or a CPM .

So the analogous CPM is is quad rocking make sure your knees are apart and make sure your hips are slightly turned out . So we're clearing that space . Um , but literally all the exact same things . Is a checklist for the knee ? It's the exact same approach to a hip , it's just about what surgery , what's the joint differing ?

You know , shoulder has its own set , elbow has its own set , ankle has its own set , wrist has its own set .

You know it'd be a two and a half hour episode to go through them all , but the principles are the same that if you do the work we said about reading and understanding , talking to surgeons , taking courses , you'll get to a point where , between a protocol and your own knowledge , you feel pretty confident with you know , the first , definitely the first couple of

weeks that are terrifying for new grads or people who have not seen a lot of post-ops , but up to the point where when you're off crutches , then it becomes more about like , okay , how do we start a strength program ? You know , how do we start progressing ?

inflammation or irritation at the like interior hip with like your hip flexors , because they can like just they get overworked , especially if I have a lot of kids that are like going to school and they're doing their schools are just so spread out and they're doing walking and I'm like I don't want you in a wheelchair , but like yeah too , and um on the .

There's lots of modifications and when you do start somebody back with active hip flexion , that's probably best done in side lying or in something that's a little bit less intense than anti-gravity . So , yeah , I have a patient . I have two labral repairs right now and one of them is like literally on it .

She's cleared to do a hip flexion fully , but she can't do a full anti-gravity to 90 hip flex because it's just like hasn't done it . She had a huge repair so they didn't let her for six weeks . If you didn't use your arm for six weeks it'd be hard to do a bicep curl .

So just lie on sideline and , do you know , she's perfectly fine to do it in sideline . There's gravity taken away .

I honestly don't do a lot of hip flexion and initially if they're weight bearing , because I know that they're doing a lot of like stress with walking and walking in normal stairs when you get off your crutches is hip flexion .

Sure , yeah , um , cool , so we'll keep this one to 30 minutes and uh , yeah , hopefully that was helpful .

Um , I think I , I knew , I know that I wish I had something along the lines of like a basic systematic approach and , like I said , if you just tackle maybe one month on each joint , you and your homies at the clinic , and kind of get yourself together on a good like , okay , here's the immediate must do things , and then here's the next yellow flag things .

Then here's the next end of the stage goal by six weeks or something like that . But , yeah , hopefully that was helpful . Yeah , all right , we'll see you guys in the next one . Bye , bye .