Osteoarthritis Knee Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for patients diagnosed with osteoarthritis (OA) of the knee. The protocol is divided into three phases: Protection (Phase I), Loading (Phase II), and Return to Function (Phase III). Progression through each phase is based on individual patient response, pain levels, and functional improvements, not strictly on time.

Pathophysiology of Knee Osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease characterized by the breakdown of articular cartilage in the knee joint. This cartilage loss leads to pain, stiffness, swelling, and reduced range of motion. Contributing factors include age, genetics, obesity, previous injuries, and repetitive stress. The inflammatory process associated with OA further contributes to cartilage degradation and bone remodeling, leading to osteophyte formation and joint space narrowing.

Phase I: Protection (Acute/Early Phase)

Goals: Reduce pain and inflammation, protect the joint, restore pain-free range of motion, and initiate muscle activation.

• Duration: Approximately 1-4 weeks, or until pain and swelling are controlled.
• Interventions:
  • Pain Management:
    • Ice application (15-20 minutes, several times daily).
    • Activity modification to avoid aggravating activities.
    • Use of assistive devices (cane, walker) to offload the joint.
    • Electrical stimulation (TENS) for pain relief.
  • Range of Motion (ROM):
    • Gentle active-assisted ROM exercises (AAROM) within pain-free limits. Focus on flexion and extension.
    • Patellar mobilization to improve patellar tracking and reduce anterior knee pain.
    • Heel slides, wall slides, towel slides.
    • Stationary cycling (seat height adjusted to minimize knee flexion).
  • Muscle Activation:
    • Isometric quadriceps sets (holding contraction for 5-10 seconds).
    • Hamstring sets.
    • Gluteal sets.
    • Short arc quadriceps (SAQ) with minimal resistance (focus on proper form).
    • Hip abduction and adduction isometrics.
  • Education:
    • Proper posture and body mechanics.
    • Joint protection strategies.
    • Understanding of OA and its management.
    • Weight management strategies if indicated.
• Progression Criteria:
  • Decreased pain at rest and with activity.
  • Reduced joint swelling.
  • Improved ROM within pain-free limits.
  • Ability to perform isometric exercises without pain.

Phase II: Loading (Intermediate Phase)

Goals: Improve strength, endurance, and proprioception; gradually increase functional activities.

• Duration: Approximately 4-8 weeks, or until adequate strength and control are achieved.
• Interventions:
  • Strengthening:
    • Closed kinetic chain (CKC) exercises (e.g., mini-squats, step-ups, leg press, lunges – progressing depth and resistance as tolerated).
    • Open kinetic chain (OKC) exercises (e.g., knee extensions, hamstring curls – focusing on controlled movements and avoiding excessive stress on the patellofemoral joint).
    • Emphasis on quadriceps, hamstrings, gluteals, and calf muscles.
    • Resistance bands, weights, or weight machines can be used to increase resistance.
  • Endurance Training:
    • Low-impact aerobic activities (e.g., walking, cycling, elliptical training).
    • Gradually increase duration and intensity.
  • Proprioception and Balance:
    • Single-leg stance (progressing to unstable surfaces like foam pads or wobble boards).
    • Weight shifting exercises.
    • Balance exercises with eyes open and closed.
  • Flexibility:
    • Gentle stretching of quadriceps, hamstrings, hip flexors, and calf muscles.
    • Hold stretches for 30 seconds, repeat 2-3 times.
• Progression Criteria:
  • Pain-free performance of strengthening exercises.
  • Improved strength and endurance.
  • Improved balance and proprioception.
  • Ability to perform functional activities without significant pain.

Phase III: Return to Function (Advanced Phase)

Goals: Optimize functional performance, return to desired activity level, and prevent recurrence.

• Duration: Variable, depending on individual goals and activity level.
• Interventions:
  • Advanced Strengthening:
    • Progress to more challenging CKC exercises (e.g., deeper squats, plyometrics).
    • Incorporate sport-specific or activity-specific training.
    • Focus on power and agility.
  • High-Level Balance and Proprioception:
    • Agility drills (e.g., cone drills, ladder drills).
    • Sport-specific balance exercises.
  • Functional Training:
    • Simulate activities that the patient wants to return to (e.g., hiking, running, gardening).
    • Gradually increase the intensity and duration of these activities.
  • Maintenance Program:
    • Continue with a home exercise program to maintain strength, flexibility, and endurance.
    • Regularly assess progress and make adjustments to the program as needed.
    • Educate patient on self-management strategies for OA.
• Discharge Criteria:
  • Achievement of functional goals.
  • Pain-free performance of desired activities.
  • Independent management of OA symptoms.
  • Understanding of long-term management strategies.

Common Special Tests for Knee Osteoarthritis

These tests can help assess the specific impairments associated with knee OA.

• McMurray's Test: Assesses for meniscal tears.
• Apley's Compression Test: Assesses for meniscal tears.
• Thessaly Test: Assesses for meniscal tears.
• Varus and Valgus Stress Tests: Assess for ligamentous instability (LCL and MCL, respectively).
• Anterior Drawer Test and Lachman Test: Assess for ACL integrity.
• Posterior Drawer Test: Assesses for PCL integrity.
• Patellar Apprehension Test: Assesses for patellar instability.
• Clarke's Test (Patellar Grind Test): Assesses for patellofemoral pain.
• Ober's Test: Assesses for iliotibial (IT) band tightness.

Note: This protocol is a guideline and should be individualized based on the patient's specific needs and response to treatment. Consult with a qualified healthcare professional for a comprehensive evaluation and treatment plan.