Physiotherapy Rehabilitation Plan

Post-Operative Elbow Stiffness | Elderly Female Patient

Baseline ROM: 0–60° Flexion | Duration: 2 Months | Session Length: 1 Hour

Patient Profile & Baseline Assessment

Clinical Note: In elderly women, post-operative elbow stiffness is compounded by reduced soft tissue elasticity, potential osteoporosis, and slower healing. The program prioritizes joint mobilization, pain-free progressive stretching, and functional independence.

Phase Overview

SESSION STRUCTURE (1 Hour Template)

PHASE 1 — Weeks 1–2: Acute Phase

🟡 Warm-Up (10 minutes)

Heat increases tissue extensibility and reduces pain before exercise. Avoid heat if acute inflammation is present — use cold instead.

🟠 ROM & Stretching Exercises (20 minutes)

• Patient uses opposite hand to assist the affected arm into flexion
• Move to pain-free end range (do not force past 60° in Week 1)
• Hold 10 seconds at end range
• 3 sets × 10 reps

• Patient actively extends elbow from a flexed position
• Emphasis on full extension to 0° (prevent extension lag)
• 3 sets × 10 reps

• Elbow bent to 90° (supported on table)
• Rotate palm up (supination) and palm down (pronation) gently
• 3 sets × 10 reps each direction

• Prevents distal joint stiffness and maintains forearm muscle length
• 2 sets × 10 reps

• Seated; forearm rests on thigh; allow gravity to gently flex elbow
• 30-second hold × 3 repetitions

🔵 Strengthening (15 minutes)

Minimal resistance in Phase 1 — focus is motor re-activation only.

• Elbow at 45°, push against wall or opposite hand (no movement)
• Hold 6 seconds, 10 reps × 2 sets

• Elbow at 45°, push hand against resistance
• Hold 6 seconds, 10 reps × 2 sets

• Gentle squeezing of therapy putty
• 10 reps × 2 sets (prevents hand and forearm atrophy)

🟣 Manual Therapy (10 minutes)

• Humero-ulnar joint: oscillatory anterior glides
• Small amplitude, pain-free, neurophysiological pain inhibition effect
• 3 sets × 60 seconds

• Myofascial release of the posterior capsule
• Gentle sustained pressure with thumbs
• 3 minutes

❄️ Cool-Down (5 minutes)

• AAROM elbow flexion: 3×10, twice daily
• Pendulum stretch: 3×30 sec, twice daily
• Isometric flexion/extension: 2×10 daily

PHASE 2 — Weeks 3–4: Mobility Phase

🟡 Warm-Up (10 minutes)

🟠 ROM & Stretching Exercises (20 minutes)

• Sit at table, forearm resting, place folded towel roll under distal humerus
• Use body weight or light cuff weight (0.5 kg) to gently flex elbow
• Hold 10–15 minutes (total across session, broken into sets)
• Cornerstone technique for capsular stiffness — most effective intervention for post-operative elbow contracture

• Using opposite hand, apply sustained overpressure at end range flexion
• Hold 30 seconds × 5 repetitions

• Patient side-lying, shoulder at 90° abduction; elbow flexion in horizontal plane
• Reduces gravity load, allows greater ROM
• 3 sets × 15 reps

• Pronation to supination, full available range
• 3 sets × 15 reps

• Theraband light resistance
• 2 sets × 15 reps

🔵 Strengthening (15 minutes)

• Elbow flexion through available range only
• 3 sets × 12 reps

• Prone position with arm supported; extend elbow against gravity
• 3 sets × 10 reps

• Light resistance (0.5 kg or band)
• 2 sets × 12 reps each

• Seated, pull shoulder blades together
• 3 sets × 15 reps

🟣 Manual Therapy (10 minutes)

• Anterior glide of ulna on humerus in near end-range flexion
• 3 sets × 60 seconds
• Aim to incrementally push ROM boundary

• Therapist stabilizes humerus, applies sustained overpressure into flexion
• 3 × 30-second holds

• If neurodynamic tightness detected on assessment
• 3 sets × 10 repetitions (slider technique)

❄️ Cool-Down (5 minutes)

• Ice 5 minutes
• Progress HEP: add LLPS with 0.5 kg weight for 10 min at home, twice daily

PHASE 3 — Weeks 5–6: Strengthening & Progressive ROM

🟡 Warm-Up (10 minutes)

• Moist heat: 5 min
• Active upper limb warm-up: shoulder circles, wrist rotations, finger extension
• Theraband shoulder warm-up: 2×15 internal/external rotation

🟠 ROM & Stretching Exercises (20 minutes)

• Increase to 0.75–1 kg cuff weight
• Sustained stretch, 10–15 minutes total session time

• Patient uses a cane/stick to self-overpressure elbow into flexion
• 5 × 30-second holds

• Lie prone with arm hanging off table edge; elbow flexes under gravity
• 3 × 30-second holds

• Hold a light hammer, rotate forearm — lever effect increases stretch
• 3 sets × 15 reps

🔵 Strengthening (15 minutes)

• Full available range; slow eccentric phase (3 seconds down)
• 3 sets × 12 reps

• Overhead triceps extension with light theraband
• 3 sets × 12 reps

• Neutral forearm grip, 1 kg dumbbell
• 3 sets × 10 reps

• Using theraband anchored at hand level
• 3 sets × 12 reps each direction

• Medium resistance putty
• 3 sets × 15 reps

🟣 Manual Therapy (10 minutes)

• Humero-ulnar anterior glide at end-range flexion
• Increasing amplitude, targeting capsular restriction
• 3 sets × 60–90 seconds

• Soft tissue work on anterior compartment to address anterior capsule tightness
• 4 minutes

• Sustained ischaemic pressure on brachialis trigger points
• 60–90 seconds per point

❄️ Cool-Down (5 minutes)

• Ice 5 min
• HEP updated: bicep curls 1 kg at home, LLPS daily, self-overpressure stretches

PHASE 4 — Weeks 7–8: Functional Restoration

🟡 Warm-Up (10 minutes)

• Heat: 5 min
• Active elbow flexion/extension through full available range: 2×15
• Shoulder/wrist warm-up circuit: 3 min

🟠 ROM & Stretching Exercises (20 minutes)

• 1–1.5 kg cuff weight
• Focus on terminal degrees of flexion (110–130° range)
• 10–15 min sustained load

• Unloaded, full available range, 3×20 reps

• Reaching to face (simulated eating/drinking) with loaded cup (200 ml water)
• Reaching to opposite shoulder (hair combing simulation)
• 5 functional repetitions each × 3 sets

• Combined movement for ADL (dressing, hair care)
• Only if ROM permits; supported with opposite hand
• 3 × 20-second holds

🔵 Strengthening (15 minutes)

• Full ROM, controlled eccentric
• 4 sets × 12 reps

• Medium resistance band
• 3 sets × 15 reps

• Alternating grip bicep curls
• 3 sets × 12 reps

• Carry light bag (0.5–1 kg) while walking 5 metres, 5 repetitions

• Arms at shoulder height against wall
• 3 sets × 10 reps

🟣 Manual Therapy (10 minutes)

• High-amplitude end-range joint mobilization for final ROM gains
• 3 sets × 90 seconds

• Over brachialis and posterior capsule
• 3–4 minutes

• In last 2 sessions: measure ROM, grip strength, and perform DASH score (Disabilities of Arm, Shoulder and Hand)

❄️ Cool-Down (5 minutes)

• Ice or contrast therapy (if available)
• Final HEP: maintenance exercise program for home

HOME EXERCISE PROGRAM SUMMARY (All Phases)

ROM Progression Targets

Special Considerations for Elderly Female Patients

Static Elbow Splinting (Adjunct to Physiotherapy)

Low-load prolonged stretching via static progressive splinting is among the most evidence-supported methods for post-operative elbow contracture (Doornberg et al.; Duke Orthopedic rehabilitation guidelines).

Discharge Criteria (End of Week 8)

• Elbow flexion ≥ 120°
• Full active extension to 0° (or near-full)
• NPRS pain score ≤ 2/10 at rest and during activity
• Independent in all basic ADLs (eating, dressing, grooming)
• DASH score improved by ≥ 20 points from baseline
• Patient confident and independent with home exercise program

Disclaimer: This plan is a clinical guideline and should be individualized based on the patient's surgical notes, implant/fixation type, pain levels, bone quality, and treating surgeon's post-operative instructions. Always consult the operating surgeon before commencing mobilization if no post-op protocol has been issued.

Physiotherapy Rehabilitation Protocol

Severe Right Knee Instability + Mild Osteoarthritis | Elderly Female

Duration: 2 Months | Session Length: 1 Hour

Patient Profile & Clinical Baseline

Clinical Rationale: Knee instability in elderly women results from a combination of ligamentous laxity, muscle weakness (especially quadriceps and hip abductors), and proprioceptive decline. Superimposed mild OA causes pain and further inhibits quadriceps activation (arthrogenic muscle inhibition). The program must simultaneously address instability, pain, muscle strength, balance, and safe functional mobility — progressing carefully to avoid OA flare-ups. As supported by Non-Surgical Management of Hip & Knee Osteoarthritis guidelines, both neuromuscular and quadriceps strengthening exercise programs show significant and comparable improvements in pain and physical function in knee OA patients.

Phase Overview

SESSION STRUCTURE (1 Hour Template)

PHASE 1 — Weeks 1–2: Pain Control & Neuromuscular Activation

🟡 Warm-Up (10 minutes)

Heat reduces stiffness and pain before exercise. If significant joint effusion or warmth is present, substitute with ice pack or TENS for first 2–3 sessions.

🟠 Therapeutic Exercises (20 minutes)

• Seated or supine, roll under knee for comfort
• Tighten quadriceps, press back of knee into surface, hold 6 seconds
• 3 sets × 15 reps | Rest: 30 sec between sets
• Critical first exercise — directly addresses arthrogenic inhibition

• Supine, opposite knee bent; lift straight leg to 45°, hold 3 seconds, lower slowly
• 3 sets × 12 reps

• Supine, roll under knee; extend leg from 45° to 0°, hold 3 sec at top
• 3 sets × 12 reps

• Supine; slide heel toward buttock, flexing knee through comfortable range
• Maintains ROM and prevents stiffness from OA
• 3 sets × 15 reps

• Seated in chair; extend knee from 90° to full extension
• 3 sets × 12 reps

• Stabilize pelvis; raise top leg to ~30°, lower slowly
• Strengthens hip stabilizers critical for valgus/varus control at knee
• 3 sets × 12 reps

🔵 Neuromuscular & Balance Training (15 minutes)

• Standing, hold support rail; shift body weight side-to-side and forward-back
• Controlled, slow, 10 repetitions each direction
• 2 sets

• Hold rail; brief unilateral left limb loading to begin proprioceptive training
• Right knee protected at this stage
• 5 seconds hold × 5 repetitions

• Feet in line (right foot forward), hold support
• 10-second holds × 5 repetitions
• Challenges static balance safely

🟣 Manual Therapy / Electrotherapy (10 minutes)

• Electrodes over medial and lateral knee
• Frequency: 80–100 Hz (conventional TENS for pain relief)
• 10 minutes
• Evidence supports TENS for OA pain reduction and facilitation of quadriceps activation

• Gentle superior, inferior, medial, and lateral glides of patella
• 2 minutes, 3 directions
• Maintains patellar tracking and reduces anterior knee pain

• Posterior calf and distal thigh
• Reduces oedema and promotes circulation
• 3 minutes

❄️ Cool-Down (5 minutes)

• Ice pack to right knee: 5 minutes (critical for OA management post-exercise)
• Brief review of Home Exercise Program

• Quad sets: 3×15, twice daily
• Straight leg raise: 3×12, once daily
• Heel slides: 3×15, once daily
• Ice application after exercise: 10 minutes

PHASE 2 — Weeks 3–4: Stability & Early Strengthening

🟡 Warm-Up (10 minutes)

• Moist heat: 5 min
• Seated marching (hip flexion/extension): 2 min
• Seated ankle circles + knee extensions: 3 min

🟠 Therapeutic Exercises (20 minutes)

• Hold rail or chair back; shallow squat, stay within pain-free range
• Keep knee aligned over 2nd toe (avoid valgus collapse)
• 3 sets × 15 reps

• From chair of standard height; slow controlled rise and lowering (3-second eccentric)
• Use armrests as needed for safety
• 3 sets × 10 reps
• Functional exercise directly applicable to daily life; best closed-chain quad activator for this population

• Holding rail; right leg abduction to ~30°, slow return
• 3 sets × 15 reps

• Back against wall, feet 30 cm from wall; slide down to 45° only
• 3 sets × 10 reps | 5-second hold at bottom

• Rise onto toes, slow lower (3 sec eccentric)
• Strengthens soleus/gastrocnemius for knee dynamic stabilization
• 3 sets × 15 reps

• Lying prone; lift straight right leg, squeeze glute, hold 3 sec
• 3 sets × 12 reps

🔵 Neuromuscular & Balance Training (15 minutes)

• Hold rail lightly; stand on right leg, hold 10 seconds
• Progress: fingertip touch only by end of Week 4
• 5 sets × 10 seconds

• Along parallel bars or against wall
• 5 metres × 4 repetitions
• Challenges dynamic balance and gait coordination

• Standing; tap right foot onto a small step (5 cm) forward and to the side
• 3 sets × 10 taps each direction

• Standing on left leg (supported); reach right foot to 12, 3, 6, 9 o'clock positions without bearing weight
• Trains dynamic postural control
• 2 sets × complete clock

🟣 Manual Therapy / Electrotherapy (10 minutes)

• Electrode placement over VMO
• Frequency: 50 Hz, pulse width 300 µs
• 10 minutes during quad sets or SLR
• Avramidis et al. demonstrated VMO electrical stimulation significantly improves rehabilitation outcomes (Physical Therapist Management of Total Knee Arthroplasty, p. 26)

• Posterior glide of tibia on femur in supine
• Maintains joint mobility and reduces stiffness
• 3 sets × 60 seconds

• Myofascial release laterally and medially
• 3 minutes

❄️ Cool-Down (5 minutes)

• Ice: 5 min
• Updated HEP: add sit-to-stand practice (5 reps, 3×/day), single-leg stand right (hold rail, 3×10 sec)

PHASE 3 — Weeks 5–6: Progressive Strengthening & Dynamic Stability

🟡 Warm-Up (10 minutes)

• Stationary cycling (if available): 8 min, low resistance, comfortable ROM
• OR: seated marching + heel slides + ankle pumps: 10 min
• Cycling is the preferred warm-up for OA — low impact, joint-friendly, and promotes synovial fluid circulation

🟠 Therapeutic Exercises (20 minutes)

• Unsupported or with fingertip touch on rail
• Slow eccentric (4 seconds down), 2-second hold at bottom
• 3 sets × 12 reps

• Theraband around thighs (just above knees); side-step 10 steps each direction
• Targets hip abductors and gluteus medius — critical for frontal plane knee stability
• 3 sets × 10 steps each direction

• Step up with right foot leading; slow controlled step-down
• 3 sets × 10 reps each leg

• Theraband anchored behind knee; from slight flexion to full extension against resistance
• Directly trains VMO and dynamic knee stability in standing
• 3 sets × 15 reps

• Progress from bilateral; hold rail, rise on right foot alone
• 3 sets × 10 reps

• Hold rail; step right foot back into lunge position, return
• Load distributed safely; less knee stress than forward lunge
• 3 sets × 8 reps each leg

🔵 Neuromuscular & Balance Training (15 minutes)

• Unsupported for 20–30 seconds
• Eyes open → progress to eyes closed by Week 6
• 5 sets × 20–30 seconds

• Stand on foam pad (unstable surface); bilateral → right unilateral
• 20-second holds × 5 repetitions
• Challenges proprioceptive system significantly

• Stand on right leg; reach left foot to clock positions
• 2 sets × full clock

• Walk a marked 6-metre course with small obstacles (2 cm cones)
• Emphasize heel-strike, knee extension at mid-stance, appropriate step length
• 5 repetitions of the course

🟣 Manual Therapy / Electrotherapy (10 minutes)

• Anterior and posterior tibial glide for full ROM maintenance
• 3 sets × 90 seconds

• Apply patellofemoral taping (McConnell technique) or kinesio tape for medial support
• Wear during session and ADLs
• Reduces pain and improves proprioceptive feedback

• If medial OA tenderness present
• 1 MHz, 1.0 W/cm², 5 minutes pulsed
• Reduces inflammation at medial joint line

❄️ Cool-Down (5 minutes)

• Ice: 5 min
• Updated HEP: add lateral band walks (theraband), TKE with band, foam pad standing

PHASE 4 — Weeks 7–8: Functional Independence & Fall Prevention

🟡 Warm-Up (10 minutes)

• Stationary cycling: 8–10 min, moderate resistance
• OR: brisk seated warm-up circuit (marching, knee extensions, ankle circles)

🟠 Therapeutic Exercises (20 minutes)

• Bodyweight or with 1–2 kg vest if tolerated
• 4 sets × 12 reps

• Right and left lead alternating
• Add light hand weights (0.5–1 kg) if able
• 3 sets × 12 reps each leg

• Step up sideways onto step (right limb leads)
• Targets VMO, hip abductors and lateral stabilizers
• 3 sets × 10 reps

• From standard chair, arms crossed on chest
• 3 sets × 12 reps
• Target: complete independently without arm assistance — functional discharge benchmark

• Hip abduction, hip extension, hip flexion in standing
• 2 sets × 15 reps each movement

• Step up and down a 2–3 step flight
• Lead with stronger (left) leg going up; lead with right going down initially
• Therapist guards closely
• 5 ascents/descents per set × 3 sets

🔵 Neuromuscular & Balance Training (15 minutes)

• 30-second holds × 5 repetitions
• Near wall for safety

• No rail; if unsafe, fingertip wall touch
• 5 repetitions

• Therapist applies gentle, unexpected pushes to shoulders/hips while patient stands
• Trains reactive stability responses
• 5 perturbations × 2 sets each direction

• Standardized functional test: rise from chair, walk 3 m, turn, return, sit
• Practice 5 repetitions per session; track improvement week by week
• TUG > 13.5 seconds indicates high fall risk in elderly — aim for below this threshold

• Walk through 10-metre course with turns, directional changes, stepping over objects
• Simulates real-world community walking
• 3 repetitions

🟣 Manual Therapy / Electrotherapy (10 minutes)

• Maintain and consolidate ROM gains
• 3 sets × 90 seconds

• Medial knee support taping maintained throughout Phase 4

• WOMAC (Western Ontario McMaster Osteoarthritis Index) or KOOS (Knee Injury and Osteoarthritis Outcome Score)
• Timed Up and Go (TUG)
• Single-leg stance time (right limb)
• Manual muscle test: quadriceps grade

❄️ Cool-Down (5 minutes)

• Ice: 5 min
• Final HEP issued (maintenance program for home)

HOME EXERCISE PROGRAM — Phase Summary

Outcome Progression Targets

Assistive Device Guidance

Special Considerations for Elderly Female Patients

Adjunct Therapies (Recommended as Available)

Discharge Criteria (End of Week 8)

• Quadriceps strength ≥ 4/5 on manual muscle testing
• Single-leg stance time (right limb) ≥ 25–30 seconds
• TUG test < 13.5 seconds (below high fall-risk threshold)
• Independent sit-to-stand without upper limb assistance
• Stair ascent/descent with rail, independently
• WOMAC/KOOS pain and function scores improved ≥ 20% from baseline
• Patient confident and independent with home maintenance program
• Fall risk formally reassessed and documented

Disclaimer: This protocol is a clinical guideline to be individualized based on the patient's full assessment, comorbidities (cardiovascular status, osteoporosis grade, BMI), medication profile, and pain tolerance. A physician review of the instability etiology (ligamentous, muscular, neurological) is recommended prior to commencing loading exercises. Modify progression based on weekly pain and function response.