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flexion contracture 6 weeks post TKR

 
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flexion contracture 6 weeks post TKR - October 18, 2006 9:56:00 PM   
ragempt

 

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From: linden, michigan
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15 degree passive extensor lag in a 52 yo healthy Physician Assistant. Passive flexion is 97 degrees. He is 6 weeks post TKR and threw a clot that seems to be under control. I saw him on Monday and he saw his surgeon on Tuesday. I told the patient on Monday that it is crucial that we begin aggressive manual therapy to return his extension as soon as possible. When the patient came in on Wednesday he told me that the surgeon said naaaaa, extension will come naturally, tell your therapist (me) that he should concentrate on flexion

I was baffled and a little embarrassed. I told him there both important but the lack in extension will leave you with a limp. How should I handle this and why would the surgeon ignore my concern. How should I handle this?
Thanks,
Rodger
Go Blue
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 9:09:00 AM   
PHSPT

 

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Im with you man,
Unfortunately the surgeon, may have his gown cap a bit too tight around his head! :)
The orthopedist dismissal of such a crucial component of rehabilitation, makes him/her seem arrogant and overconfident.
In order to maintain good channels of communication it is important that all health professionals are in the same sheet of music, or at the least make more tactful comments...other than NAAAA...
My take is be cool about it! dont take it personally. Explain the patient that every orthopod has their particular protocol, having said that emphasize on the orthopod's concern but equally concentrate on extension, explain arthrokinematics, (he'll listen, hes a PA!), do whatever you need to to get this pnt back on their feet.... After all Im sure the script did not read: TKR work on flexion only!. IF you encounter more resistance, Ill contact the MD and discuss rationale, perhaps have some literature ready to back your claims.

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 10:35:00 AM   
jma

 

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You should discuss this with the surgeon immediately. Its already been 6 weeks and waiting longer to address the lack of extension may not be a good idea. Document your conversation if there is still resistance to it.

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 10:41:00 AM   
ragempt

 

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thanks, guys. the script specificaly said "mostly flexion" and the patient(PA) said the MD said naaaaa to agressive extension

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 10:41:00 AM   
ragempt

 

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thanks, guys. the script specifically said "mostly flexion" and the patient(PA) said the MD said naaaaa to aggressive extension

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 11:13:00 AM   
ehanso

 

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How is his patellar and scar mobility? If he has limited patellar mobility, this will inhibit extension. Limited tibial rotation can also inhibit extension. If these are doing well, then take a look at his popliteus and hamstings. If these are tight and tender, a counter strain release will help with extension.

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 11:31:00 AM   
Shill

 

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I would comment that I respectfully disagree, and continue to work on both, documenting it, and the rationale behind it the entire time. I dont think the manual therapy needs to be ultra aggressive at this point, just progressive, aggressive ROM with prolonged stretching.

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Steve Hill PT

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 19, 2006 12:56:00 PM   
ragempt

 

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junction, your right there may be reasoning behind it but naaa is a poor explanation considering the patient is a PA. fallpt. everything is tight. yes prolonged is the way i do it

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 24, 2006 11:20:00 PM   
PhysioThis

 

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Ragempt,
Be careful with whatever extension mobs/ROM you do with this patient. The Doc is hiding something - perhaps a flexed femoral component or something. His (her?) comments are ridiculous, and ultimately s/he will lay the blame for either a poor outcome or failure on either you or the patient.

_____________________________

Ed, PT, MTB-XC

(in reply to ragempt)
Post #: 9
Re: flexion contracture 6 weeks post TKR - October 25, 2006 7:08:00 AM   
PTupdate.com


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There is a product out there called the Knee Crank...easy to make with piece of plywood, and a few old dress belts. Enables the user to apply a low load, but long term static stretch to the knee to gain extension. Therefore, no aggressive extension is being done, the guy uses it at home, so the PT isn't doing the extension as this MD (weirdly) suggested, and everybody makes out.

Duffy
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to ragempt)
Post #: 10
Re: flexion contracture 6 weeks post TKR - October 25, 2006 10:49:00 AM   
jlharris


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Funny, just had a orthopod request I order a Knee Crank brace for his pt (BTW, he called it a 3x10=0 brace). I had never heard of it before.

Knee ROM is the great paradox in PT practice. I spoke once with a group of surgeons asking them about there main c/o with PT care for their TKA pt's. Guess what they said? Over agressive ROM/stretching/mobs. "It'll come they said". So, what happens? Doc from the same physicians group is upset because (at 6 weeks out) pt hasn't reached ROM limits he achieved on the table. Forget the guy has a femoral block, was under anesthesia, and had a gaping incesion down his knee at the time, lol.

Sometimes you can't win for losing. Oh, I had expressed my concern with the pt's lack of extension at an early f/u but the MD felt it was unimportant at the time. Go figure.

Just do your best with you skills to get the pt functional and back to what they'd like to do.

_____________________________

Jason L. Harris, PT, DPT
My PT Blog

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - October 27, 2006 3:22:00 AM   
rv36116

 

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4 words with what ever stretch you give them...

-pressure on / pressure off-

any sustained stretch is going to flare this guy up to high heck being 6 weeks post.

(in reply to ragempt)
Post #: 12
Re: flexion contracture 6 weeks post TKR - November 1, 2006 6:54:00 PM   
ragempt

 

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hey guys thanks. his extension has gone from 15.5 lack to 12.5 lack. oppisite knee lack 4 degrees so it is not horribly bad. passive fleion has gone from 94 to 108 in two weeks. progress is there. he returns to work in a month and he feels his knee is moving better. physiothis, interesting perspctive. you may be on to something. so far there is progress so i will wait and see

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - November 2, 2006 12:28:00 AM   
PhysioThis

 

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Ragempt
If you're using a standard goniometer, you may not have the progress into extension that you think. Remember, there is a 5 degree measurement error with those things. He sounds pretty locked up (in terms of extension). What's the end feel like there? What does the patient experience with overpressure into extension?

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Ed, PT, MTB-XC

(in reply to ragempt)
Post #: 14
Re: flexion contracture 6 weeks post TKR - November 2, 2006 5:17:00 PM   
ragempt

 

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physiothis, normal end range extension pain. his pain is all over. the only reason im not to concerned is because when he did his prone leg hangs on day on there was a 12 inch difference from one heel to the next heel now there is about a 4 inch difference. he also says stuff like i dont think i need my cane anymore. he is also increasing all his exercises. he can scale an 8 inch step. 1.5 weeks ago he was challenged by a 4inch. i put more faith in function than a goni measurement

(in reply to ragempt)
Post #: 15
Re: flexion contracture 6 weeks post TKR - November 2, 2006 10:29:00 PM   
PhysioThis

 

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Ragempt,
Certainly sounds like he's improving. "His pain is all over" - interpret this as a relatively good thing right now - esp. with extension overpressure b/c it's a sign that you're stretching his tight soft tissue as opposed to having inert componentry abutting and blocking motion.

_____________________________

Ed, PT, MTB-XC

(in reply to ragempt)
Post #: 16
Re: flexion contracture 6 weeks post TKR - November 2, 2006 11:28:00 PM   
rv36116

 

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are you using constant or intermittent stretching?

(in reply to ragempt)
Post #: 17
Re: flexion contracture 6 weeks post TKR - November 3, 2006 7:07:00 PM   
ragempt

 

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never looked at it that way physio., thanks

Rob, i do both. constant with and ankle weight 7# for 10 minutes and intermitent with my hands both prone and supine. i also have him walk backwards and include many functional exercises. Mostly Gary Gray stuff, who in my opinion is the god of physical therapy.

(in reply to ragempt)
Post #: 18
Re: flexion contracture 6 weeks post TKR - November 4, 2006 7:43:00 PM   
jlharris


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Gary Gray is the god of physical therapy? I thought I was! Man, it's tough to learn these things like this....awkward

_____________________________

Jason L. Harris, PT, DPT
My PT Blog

(in reply to ragempt)
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Re: flexion contracture 6 weeks post TKR - November 5, 2006 10:20:00 AM   
ragempt

 

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yes its a little awkward. i also think its mind blowing that there are PTs out there who have never taken classes from Gary Gray or McKenzie or Mulligan. I went to a conference and spoke with PTs that have never heard of Gary Gray. I was like what the f___ do yopu live in a cave? Then they talk about how they rehab their ACLs. and their doing stuff like leg press and machine extension and flexion exercises. One guy said he still uses cybex machines. I almost went in the bathroom and puked.

(in reply to ragempt)
Post #: 20
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