Walking pattern after knee surgery.

After knee surgery, chances are you will be walking with crutches for the first few weeks. It is very likely that you will not yet be able to put some or all of the weight on your knee, which is why you will be walking with crutches. Exercise therapy will be started from week one (low threshold) under the guidance of the therapist. A number of points of attention are central in the first weeks of knee rehabilitation; neuromuscular control, the ability to tighten the upper leg and the stretching pattern (extension) of the knee. 

The ability to properly extend the knee (extension pattern of the knee) is important so that the walking pattern can be resumed as soon as possible in the first weeks. Being able to stretch properly is tied to being able to tighten the thigh muscles (musculus quadriceps femoris, or; the four-headed thigh muscle). To be able to stretch/tighten the operated knee, neuromuscular control for this is important. This means that your brain, can send a stimulus, so that your upper leg will tighten at the moment you want to perform this. 

When these three focal points are going well, the therapist will start initiating gait therapy. Thus, an incorrectly learned gait pattern (bad-habit), will be unlearned as soon as possible. This can be in the case of not stretching the knee properly, when there is still too much bending position, instead of a good stretching pattern.

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Scientific evidence;

Change in "range of motion" after reconstruction of the anterior cruciate ligament (ACLR). (Kaur, Ribeiro, Theis, Webster, & Sole, 2016)

For a good gait pattern, some basic movements are important; bending, stretching and the connection pass. In a study of anterior cruciate ligament reconstruction patients, it was studied to what extent VKB patients still had movement limitations in ROM after rehabilitation. Here, some limitations in movement degrees (ROM) were found. Thus, patients who did have surgery (with anterior cruciate ligament injury) were compared to a healthy population (without anterior cruciate ligament injury) after a period of rehabilitation (healthy condition). Looking at good gait tied to this study, some results emerged. 

The study emphasized gait and stair walking pattern. In the first weeks (early phase) 0-12 weeks came a decreased score of knee adduction (connection pass). Were looking at the long term, a total of 40 studies were included for this study. 27 studies proved strong to moderate evidence that there was no major difference in flexion movements during walking and stair climbing compared to the non-operated target group. Looking at the bending pattern of the knee in VKB patients after rehabilitation, maximum recovery emerged here. In conclusion, the study clearly emphasized that continued practice (compliance) is important for a lasting positive effect. 

Gait development through exercise therapy, the basics. 

Exercise therapy plays an important role in developing good gait. The first few weeks will focus on some basic exercises that directly affect gait. One of these skills, is being able to Pulling the toes toward yourself (dorsiflexion pattern ankle), while the knee is extended. This is important in later stages of walking/going for the heel-strike phase, where the toes should be raised and the knee will be extended. 

The second will focus on tightening the thigh muscles, where the exercise therapist will ask if you have can push the knee into the ground (extension phase) and relax it (relaxation phase). In this way you train the tightening/relaxing of the thigh musculature, coupled with the stretching pattern of the knee. This skill will recur continuously in the gait pattern depending on the activity phase requested.

Another skill that indirectly impacts your walking ability is being able to tighten the gluteal muscles. An exercise for this, is lying in side lifting the thigh and locking back in (abduction/adduction pattern hip). In this way, the buttock muscles are trained.  

The above exercises are basic exercises that will be trained in the first weeks. These exercises form the basis for building muscle strength/mobility again. Which will be continued by strength training with body weight to strength training bound with machines or kilo discs. 

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What phases does the gait pattern consist of (diagnostic)?

The gait cycle (gait analysis) consists of about seven phases. Roughly speaking, we can divide this into two phases; the contact phase and the swing phase. 

Illustration-of-different-phases-of-the-gait-cycle-A-New-gait-terms-B-classic by Matthieu Duvinage

Image: Matthieu Duvinage

The contact phase (or; support phase)

Is the phase when the entire body weight lands on one foot. The contact phase total for 60% consists of the gait cycle and starts when placing the heel on the ground (whole-strike). The contact phase ends at the moment, when the toes of the same foot come off the ground (toe-off). The outside of the foot will unwind during this phase; this occurs in the intermediate (midstance) phase. 

Landing The landing phase (shock absorption phase) begins at the moment, when the foot first makes contact with the ground. This is also called shock absorption; when the body exerts pressure on the front of the leg, the body's center of gravity is actually slowed down. During this phase, the knee bends (flexion pattern) and the foot turns inward (pronation). The total landing phase lasts from the heel-strike to flop-flat. 

The booth phase (mid-stance phase) lasts until the foot leaves the ground (heel-off). The sequence is as follows; (HS= heel strike, FF= foot flat, MS= mid stance, HO= heel-off and TO= toe-off). 

During the state phase During this phase, the foot cannot rotate (pronate). Should this happen, it may indicate instability and overmobility in the ankle region. 

The marketing phase (push-off phase) lasts from heel-off (moment the heel leaves the ground) to toe-off which is also the last phase of the contact phase. During this phase, the foot has a leverage effect, bringing the foot upward (dorsiflexion). Should you have no leverage, this could possibly indicate a neurological symptom (clubfoot) or impaired function of the anterior muscles of the foot lifters. 

The swing phase

The contact phase is followed by the swing phase this constitutes 40% of the gait cycle and is thus shorter than the contact phase. The swing phase, starts the moment the toe comes off the ground, when the support phase ends and is the period between the toe-off and the whole strike of the same foot. The swing phase, ends the moment the foot makes contact with the ground again, where a new running cycle starts again. 

Team Fysio Fitaal focuses a lot on knee procedures both pre and postoperatively. If you would like to know how we work with knee cases, please contact us. info@fysiofitaal.nl. 

 

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Ruben Luijkx

Owner Physio Vital
Physical therapist, MSC. Manuel therapy

With a solid foundation in scientific knowledge, Ruben combines the latest insights with his practical experience to ensure the best results. As owner of Physio Fitaal, Ruben has created a patient-centered environment that works with innovative techniques and a data-driven approach. Whether you are an elite athlete looking to return to the field or someone recovering from knee surgery, Ruben will guide you to a full recovery, with attention to your individual needs and goals.

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