Therapy after an injury
Q. I’m a 69-year-old woman. While visiting my son in Arizona a few months ago, I accidentally missed the last step coming down the stairs and fell — while getting ready to leave for the airport, no less!
I fractured the tibial plateau of my left knee, as well as the lower portion of my left ankle on both sides. My injuries required surgery and pinning of my ankle. The doctor instructed me not to put any weight on my leg for at least another month.
However, she hasn’t mentioned formal physical therapy yet. Considering I still need to fly home to Pennsylvania, when should I start therapy? And, what should I expect when I do?
Anne, Richboro, PA
A. Wow, you definitely have some major healing and physical therapy to do! An injury like yours — one that afflicts both joints simultaneously — is uncommon and presents a couple of unique challenges.
It’s very important, if not imperative, that you begin a formal physical therapy regimen for your ankle as soon as possible, regardless of your travel plans. Because your injuries are a few months old now, it’s about the right time to start really moving and stretching your ankle. (I’m sure it has grown very tight after the surgery and subsequent healing.)
It won’t be easy, but your non-weight-bearing physical therapy should focus on the flexibility of your ankle — especially in the areas of dorsiflexion and eversion. These terms basically refer to the stretching of your foot and ankle up and toward your face, as well as out to the side. Although hardware the doctor imbedded in your ankle might limit these stretches a little, it’s important to get as much typical motion back as possible. Doing so will help you return to a more normal walking pattern when the doctor gives her go-ahead.
Additionally, considering you underwent surgery, your physical therapist should focus on your ankle’s ability to perceive different sensory information to ensure better protection from future injuries.
Regarding your tibial plateau fracture — and depending on the position and location of that fracture — many orthopods prescribe at least three months of non-weight-bearing. Because the knee has a very limited blood supply especially to its inside middle portion where your tibial plateau is located, more healing time is required before you can start to really stress it. And, when you are finally able to stress and load your knee by putting weight on it, it will be a progression.
Keep in mind that the hardware inside your ankle might need to come out in the future if it’s impeding your range-of-motion progress and/or becomes essential for your comfort.
Q. I just turned forty, and I’ve been an avid runner(on and off) for most of my adult life.
I’m experiencing tightness in my left knee, which is nothing new. The last time I felt it, I consulted an orthopedic surgeon, who did some imaging. While he didn’t see anything wrong with my meniscus at the time, he didn’t rule it out either.
Eventually, my knee got better on its own. But, when I recently returned to running again, I felt the same tightness afterward — and now there’s some swelling on the outside, too.
Do I need to go back to the surgeon?
Nancy, Oxford, Maine
A. Having worked with many avid runners in my career, I won’t (futilely) attempt to tell you to ease off. I do, however, want you to understand why you and your brethren typically have so many knee issues.
Human beings aren’t constructed to run for long periods of time. Every time you take a normal walking step, you place between two and three times your body weight on that knee. Every time you run and land on that same knee, the joint impact increases to as much as nine times your body weight. Surely, then, the cortical bone, end plates, and cartilage that make up your joints will break down faster than normal if you keep up your activity.
The local swelling you’re experiencing might be meniscus involvement, but other symptoms are typically present with such an injury — specifically, a feeling of that knee “locking” or “giving way.”
Swelling often indicates a more superficial problem, such as patello-femoral syndrome, which leads to pain, edema, and chondromalacia (softening of the patella, or knee cap). If your knee cap isn’t correctly tracking in its groove, it can cause swelling. And, when the appropriate muscles aren’t working to help keep your tracking “on track,” the knee cap will migrate laterally, or to the outside — hence the swelling you’re seeing and the accompanying feeling of tightness.
A licensed physical therapist can examine your knee for patello-femeral syndrome and assess your quadriceps angle — the angle of pull from the quadriceps to the patella. In males, the normal range is between twelve and fifteen degrees; in females, between fifteen and eighteen degrees.
Because it’s unlikely you’ll give up running altogether, be aware of a more joint-friendly running technique: the Pose Method. It advocates shorter strides and increased stride frequency, which allow your knees a more flexed angle when they make contact with the ground, which reduces the weight load applied.
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"Therapy after an injury"
authored by:
Scott Kushner, PT, MS, Cert. MDT, is the author of Back to Basics: A No-Duh Guide to Prevent Back Injury – and Maybe Even Surgery. He received his formal education at Thomas Jefferson University, College of Graduate Studies, in Philadelphia. Kushner ...
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