Querry in treatment of post-op Tibia #

[dinku86]

I have a patient who had a lower 1/3rd tibia #. He was operated on 24th september 2008 with screw fixation....After 1and half month patient had fat emboli...He had to put on the cast for 4 months...then he started regular physiotherapy at other centre...
I am treating him since 3 months...The knee flexion range is 125 degrees but the stiffness comes in my way...til now as the patient was co-operative, the range use to improve gradually but since few days I am not able to move his leg after 130-134 degrees.....when i make him do exercise, it do get flexed to that range but next day due to stiffness it comes back....now i am not getting proper measures for this....
the patient wishes to sit in full squat position.....
CAN U HELP ME OUT

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[pudding_bowl]

If the stiffness is due to the immobilisation... There isn't much more to do other than stretch it harder and you can try to mobilise the knee joint with a seatbelt to help encourage flexion.
Have you got him practicing his squat position?

[msk101]

Hi There,

It would depend on why the stiffness is there.. is it due to soft tissue contracture due to immobilisation or disuse, or is it swelling/oedematous, or other structural impediments. Have you queried whether surgery would consider a manipulation under anaesthetic if you're really stuck as it has been a long time since cast was removed. If it's just due to short tissues and stiffness that way i would be very aggressive with prolonged stretching and kneeling back onto heels as far as possible to sit for as long as possible (ie. 15 minutes at a time) to cause actual tissue fibre lengthening (rather than a short term stretch response which occurs with short duration stretching and mobilisation). also check that the rotational component of tibia on femur is occurring correctly to enable full flexion and full extension of the knee.

Hope that helps.
msk101

[dinku86]

thanx a lot for ur postings...
What I can draw out is that making him sit in full squat position for 15 min. would be a better option...He can sit in full squat for no more than 5 min. since 20 days..
My Senior physiotherapist told me to use dynamic knee flexion splint and he told that now if u stretch this patient more .... the collagen formation will also increase and there is every chance for stiffness which will be invited by me only....The next option he told was surgery...
SO WHAT U PEOPLE SUGGEST....

[pudding_bowl]

Discuss it with your patient what they would prefer first. Find out what surgery they are referring to - if it's a manipulation under anaesthetic or if it's something else. This way you can give your patient the options.
The conservative option of increasing the stretching is probably more desireable - remember we can increase tolerance to stretch but to cause growth of more sarcomeres and actual muscle lenthening then the stretching needs to amount to many hours a day to place the demand on the body required to initiate new growth of muscle.