Orthopedic post-surgical protocols & Physical Therapy

If you have the misfortune of needing to have an elective orthopedic surgery, you will likely be referred to Physical Therapy following the surgery. You will likely follow a post –surgical rehabilitation protocol. Orthopedic surgeons and Physical Therapist have developed standard protocols for each surgical diagnosis or surgical procedure. The protocol will outline the step by step process of recovery and rehabilitation process. The protocols are often developed around the standard phases of tissue healing. I describe the phases of tissue healing as the first stage is “rest and protect”, the second phase as “on the fence”, and the final phase as “push and build”. The determination of which phase is primarily based on the number of days from surgery. In addition to the number of days post-surgery clinical measures (strength, range of motion, pain levels) are used to determine which, phase the patient has achieved. For each phase the most appropriate level of activity and exercise is spelled out. More importantly for each phase what activity or exercise should be avoided is spelled out.

The protocol defines the expected time frame for recovery from the surgery. The expectations stated in the protocol should be adjusted for each individual. Each individual brings their own unique parameters to the surgery. The age, previous medical history, pre-existing fitness level, medication history can influence the rate of healing and rehabilitation.

It is common for patients to compete against the expectations of the protocol. Patients want to progress through the phases at a faster time. This is a mistake. The progression through the protocol is determined by “Mother nature”.   Mother Nature does not like to be interfered with. High levels of motivation and high pain thresholds do not speed the healing process. In my experience high level s of motivation and high pain thresholds are more likely to disrupt the healing process. Progressing too fast through the protocol is like picking the scab delaying the tissue healing.

Some surgeons post their post-surgical protocols on the internet. To find a post-surgical protocol go to the orthopedic you’re surgeon’s web site. In Richmond Va. it is likely one of the following internet sites: VCU/MCV: Tuckahoe Orthopedics; Advanced Orthopedics; OrthoVirginia West End Orthopedic Clinic. Go to the hyperlink for your surgeon, than look for a hyper-link for a particular joint that you expect to have or have had surgery. Here is an example of post-surgical protocols: shoulder protocol example; knee protocol example. If the surgeon does not post the post-surgical protocol on the internet ask his office staff for a copy.

Recognize the pre-operation surgical diagnosis may not be the same as the post-operation surgical diagnosis. Often when the surgeon is performing the surgery and “gets in there” he finds unexpected issues that need to be addressed. There are generic protocols, but many surgeons have specific modification because of unique things that they do during the surgery.

Unfortunately, most protocols are written with many abbreviations, and with jargon you may be no be familiar with. Ask you physical therapist to write a glossary of the abbreviations and confusing terms.

Many protocols list everything that is permissible during a particular phase of the protocol. Listing all the things that are permissible to eat on a low fat diet does not mean you should eat everything on the list. Obviously you can eat more calories than you need much like you can exercise more than you should. Ask your Physical Therapist which of the exercises on the protocol deserve higher priority.

Ask you physical therapist for something extra. Ask for more than the standard protocol.

If the orthopedic surgery was needed because of a traumatic injury and you were previously orthopedically healthy, ask what I do after finishing the protocol to manage potential compensations related to the structural changes resulting from the surgical repair? Orthopedic surgeons and Physical Therapist are very good at what they do, but they cannot repair the injury to “as good as God originally made it”. Despite the outstanding surgery and outstanding rehabilitation program the injury and surgery is a repair and salvage procedure. Quite frequently there is an increased risk of experiencing a compensatory repetitive use injury as a result of joint injury and surgical repair. Ask the Physical Therapist what strategies can be undertaken to prevent future injuries? For example surgeries often stabilize the painful joint so the joint motion is limited and less painful. If a joint has relatively limited motion the adjacent joints will automatically compensate by moving more than normal. Strategies need to be developed to address this issue and your Physical Therapist can help with this.

If the elective orthopedic surgery was needed to address a degenerative process/injury that occurred as a result of mal-alignment and/or faulty movement patterns ask the Physical Therapist what I can do to correct the previous mal-alignment or faulty movement patterns that contributed to the wear and tear and degeneration of the tissue. For example total knee joint replacement surgery that occurs because of degeneration of the knee joint. The degenerative knee joint likely occurred because of faculty alignment of the foot/ankle and/or hip. It also could be related to faulty movement patterns originating from the hip joint. How can you learn to move in a more ideal movement pattern at the adjacent joints, how can you decrease rate of impact loading on the extremity to spare the adjacent joint or surgical repaired joint?

Following a post-surgical rehabilitation protocol is quite simple. Knowing how to adjust the progression through the protocol to meet your individual needs is a bit more challenging. There are many more things we can do to screw up the healing process than we can do to speed up the healing process.   Find a Physical Therapist who can coach you through the post-surgical protocol, but also who can help you reach beyond the protocol.


Damien Howell Physical Therapy – 804-647-9499 – Fax: 866-879-8591 At-Home, At Office, At Fitness Facility – I come to you, I do home visits Damien@damienhowellpt.com