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Gait pattern after knee surgery

After knee surgery, chances are you will be walking with crutches for the first few weeks. You may probably not or partially load your knee and therefore you walk with crutches. Exercise therapy will already be started from week one (low threshold) under the guidance of the therapist. A number of points of interest are central in the first weeks of knee rehabilitation; neuromuscular control, the ability to tighten the upper leg and the extension of the knee. 

The ability to properly extend the knee (extension pattern of the knee) is important in order to resume the walking pattern as soon as possible in the first few weeks. Proper stretching is tied to the ability to tighten the thigh muscles (quadriceps femoris muscle). To be able to stretch/tighten the operated knee, neuromuscular control is important for this. This means that your brain, can send a stimulus through, which will cause your thigh to tighten at the moment you want to do this. 

When these three points of attention are going well, the therapist will start walking therapy. A wrongly learned walking pattern (bad-habit), will be unlearned as soon as possible. This can be the case when the knee is not extended properly, when there is still too much bending in stead of a good extension pattern.

Bjorge Janssen - @bstrongbybjorge

Scientific Evidence;

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

For a good walking pattern a number of 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 the ROM after a rehabilitation trajectory. Here several limitations in movement degrees (ROM) were found. For example, patients who had undergone 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 a good walking pattern tied to this study some results emerged. 

In the study, emphasis was placed on the gait pattern and stair climbing pattern. In the first weeks (early phase) 0-12 weeks came a reduced 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 nonoperated target group. Looking at the bending pattern of the knee in UKB patients after rehabilitation, maximum recovery was shown. In conclusion, the study clearly emphasized that continued exercise (compliance) is important for a lasting positive effect. 

Gait development through exercise therapy, THE BASE. 

Exercise therapy plays an important role in developing a good walking pattern. In the first weeks, the focus will be on a number of basic exercises which directly influence the gait pattern. 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/running for the heel-strike phase, in which the toes should be raised and the knee will be extended. 

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

Another skill that indirectly impacts your running ability is being able to tighten the gluteal muscles. An exercise for this, is lying in sideways lift the upper leg and close again (abduction/adduction pattern hip). In this way, the gluteusculature is 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. This will be followed by strength training with bodyweight and strength training with equipment or kilo discs. 

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

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. 

The contact phase (or; support phase)

Is the phase in which the entire body weight lands on one foot. The contact phase consists altogether for 60% of the gait cycle and starts when placing the heel on the ground (heel-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 phase (midstance phase). 

Landing The landing phase (shock absorption phase) starts 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 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 The function of the foot is to form a supporting surface, in this way the foot ensures that the entire body weight can be transferred over the foot (a sort of bridge idea). 

The marketing phase (push-off phase) lasts from heel-off to toe-off which is the last phase of the contact phase. During this phase, the foot has a leverage effect, which brings the foot upwards (dorsiflexion). If you do not have a leverage effect, it may indicate a neurological symptom (footdrop) or reduced function of the anterior muscles of the footlifters. 

The swinging phase

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

Team Fysio Fitaal focuses a lot on knee trajectories both pre and postoperatively. If you are curious how knee trajectories work at Team Fysio Fitaal, please contact us. [email protected]

 

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