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Should We Delay Range of Motion After a Total Shoulder Replacement?

Total shoulder replacement surgery is being performed more and more each year.  Our current patients were more active in sports in their youth, potentially increasing the chances of developing an arthritic shoulder.  They also want to remain active as they age, potentially increasing the likelihood that they want to have a total shoulder arthroplasty surgery to allow them to remain active.

Over the years, the surgical technique for a total shoulder replacement has improved, though I’m not sure our rehabilitation approach has also improved.  If our patients are younger and want to be more active after total shoulder replacement, then perhaps our rehabilitation programs should adjust based on their goals.

Rehabilitation Following Total Shoulder Replacement

Historically, a conservative approach was appropriate for many patients, as their needs and activity goals were less aggressive than many patients today.  It was acceptable to have a moderate loss of range of motion in exchange for less pain in their shoulder.

Many surgeons continue to recommend a conservative approach to the restoration of range of motion following surgery.

It is true that one of the primary goals of the postoperative rehabilitation following total shoulder replacement is to protect the subscapularis.  The subscapularis muscle is taken down to some extent during the surgical procedure and the integrity of this muscle has been correlated to the overall outcome of the procedure.

Other motions, such as behind the back and shoulder extension behind their body, also place the arthroplasty in a disadvantageous position and can lead to dislocation of the joint.

But even with these precautions, I am still an advocate of early range of motion, especially if you respect these restrictions.

Passive ROM and Active ROM are Not the Same

A recent report was recently published in Journal of Shoulder and Elbow Surgery that may actually be causing some confusion on when to start range of motion.

In the study, the authors compared a group of patients that began range of motion immediately versus a group that delayed 4 weeks.  The authors reported that the immediate range of motion group gained more motion, restored it earlier, and also showed an earlier increase in functional outcome scores.

However, 96% of the patients that delayed range of motion showed healing of the lesser tuberosity osteotomy, while only 82% of the immediate range of motion group showed healing.  Furthermore, functional outcomes scores 3 months and 1 year after surgery were similar between the groups.

This has led to many recommending a delay in range of motion.  But…

When looking deeper at the methods, the authors chose to use the rope and pulley and stick elevation range of motion exercises.  As we all know, these are not passive range of motion exercises, they are active assisted range of motion exercises.

There’s a big difference between passive and active range of motion exercises!

Previous EMG studies have shown the rotator cuff to be between 18-25% active and the deltoid to be between 21-43% active during these exercises.  Not very passive.  Conversely, passive range of motion exercises have been shown to be between 3-10% active.

This is a big difference.  I believe passive range of motion is appropriate, as long as you respect the restrictions on restoring external rotation to protect the subscapularis and avoid behind the body and behind the back motions to protect the replacement.
Immediate Range of Motion Restores Function Faster

Since we all work with these patients after surgery, we know that they are always happier when they restore their motion sooner.  And this increase in range of motion is likely related to the earlier improvement in functional outcome scores.

I think there is a middle ground of immediate, yet cautious, passive range of motion.  Again, I want to reiterate, “passive” range of motion.  Not active.

By focusing on this, I believe our patients will have much better outcomes.

Learn More About How I Evaluate and Treat the Shoulder

I’m pretty excited to announce I have revised my acclaimed online program teaching you exactly how I evaluate and treat the shoulder to now include a lesson on the arthritic shoulder!  If you want to learn more about how I work with the arthritic shoulder, patients following total and reverse shoulder replacements, and everything else related to the shoulder, you’re going to want to take my online course.

 

Muscle Impairments in People with Knee Arthritis

Knee ArthritisA recent paper reviewing the muscle impairments associated with knee arthritis was published in Sports Health that I thought did a great job overviewing the current evidence on the subject.  Alnahdi, Zeni, and Snyder-Mackler discussed several factors associated with muscle impairments and knee arthritis.

I thought I would take this article and combine it with some of my thoughts and recommendations from the “The MOVE Consensus” published several years ago in Rheumatology.

There are a lot of muscle impairments associated with arthritis, proper knowledge of these impairments should allow us to develop more appropriate rehabilitation and fitness programs for individuals with knee arthritis.

 

Quadriceps Strength

Quadriceps weakness and muscle impairment is well documented in the literature.  Previously published papers report strength deficits of the quad ranging from 11-56% when compared to healthy controls.  Even more disparity exists when assessing eccentric strength, with deficits up to 76% in some reported publications.

This loss of strength, especially eccentrically, can have several implications on functional deficits.  Think about how many daily tasks involve concentric and eccentric control of the quad – standing from a chair, getting up off the ground, ascending and descending stairs – all of these activities (and more) become limited and contribute to overall dissatisfaction with arthritis patients.

 

Quadriceps Atrophy and Inhibition

There are two main factors associated with loss of quad strength in patients with knee arthritis – atrophy and muscle inhibition.  The quad has been shown to exhibit a 12% reduction in cross sectional area, representing atrophy, in patients with knee arthritis.  This atrophy obviously contributes to loss of strength, however inhibition of volitional control of the quadriceps has also been found.

Again, the exact mechanism is still unknown but some potential reasons that the altered ability to contract muscle probably relates to alterations in the afferent discharge of knee receptors.  This could be altered due to degenerative changes in joint structures, effusion, pain, inflammation, and laxity.

 

Other Lower Extremity Strength Deficits

The loss of quadriceps strength has been one of the most commonly cited impairments associated with knee arthritis.  Much emphasis has been placed on the quad, however impairment of other muscles have also been identified.  Several papers have been published that demonstrate that patients with knee arthritis also have a:

  • 4-38% reduction in hamstring strength
  • 16% reduction in hip extension strength
  • 26-40% reduction in hip flexion strength
  • 27-40% reduction in external rotation strength
  • 20-43% reduction in internal rotation strength
  • 22-24% reduction in abduction strength
  • 26% reduction in adduction strength

This are pretty big strength deficits that seem to occur in every plane of motion.  I would imagine this again represents a general level of deconditioning associated with the development of knee arthritis.  Muscular weakness and imbalances can have a significant impact on the ability to develop and withstand forces without compensatory movement patterns that increase force applied to the static joint structures.

 

Bilateral Deficits

Interestingly, strength deficits of the quad are not isolated to the involved leg.  The contralateral leg has also been shown to exhibit a 16-26% deficit in quad strength compared to healthy controls.  This deficit isn’t as severe as the involved side but shows that both extremities should be examined carefully.  Volitional control has also been shown to be reduced bilaterally, with greater inhibition on the involved knee.

The reason behind this contralateral deficit is not completely known, however it could again represent general weakness and deconditioning of the patient.

 

The Chicken or the Egg?

If strength and volitional control is so poor in several muscle groups bilaterally in patients with knee arthritis, the classic “which came first, the chicken or the egg” question comes to mind.  Does knee arthritis have such a dramatic impact on muscle impairments of the body or did these impairments precede, and potentially facilitate, the develop of knee arthritis?

There have some studies published that prospectively showed that weaker quadriceps strength was correlated to the development of knee arthritis.  This makes sense to me, as it certainly appears that several of the above factors could be related to general deconditioning of the patient.

Perhaps there is a reason that we see bilateral deficits with the involved knee showing greater impairments.   Maybe knee arthritis begins with a certain level of weakness, imbalances, and overall deconditioning.  Then overtime, this deconditioning is superimposed with inhibition from the natural consequences of knee arthritis, such as effusion, pain, and inflammation.

 

Clinical Implications

After reviewing this well written article, I think we can summarize the following:

  • Quadriceps strength is significantly impaired in subjects with knee arthritis
  • Both activation deficit and atrophy contribute to this weakness
  • Impairments also occur with the hamstrings and hip muscles
  • Strength and activation impairments are seen bilaterally, though the involved side shows greater impairments
  • Strength is a major determining factor for functional activities
  • Strength is predictive of the development of knee arthritis

 

The authors also included a summary of the recommendations from Roddy et al and The MOVE Consensus, which I would summarize as:

  • Both strengthening and aerobic exercise can reduce pain and improve function in patients with knee and hip osteoarthritis, with few contraindications, and are essential in the management of osteoarthritis.
  • Improvements in strength and proprioception gained from exercise may reduce the progression of osteoarthritis, although adherence is the principle predictor of long-term outcome from exercise.

 

In addition to these recommendations, I would suggest that we also include the following principles for the development of rehbailitation and fitness programs for people with arthritis:

  • Exercise and strengthening of the entire lower extremity, with emphasis on quadriceps strength and muscle imbalances, are an essential part of exercise programs for those with arthritis
  • Any deficits and imbalances of the hip should also be addressed
  • Exercise programs should be performed bilaterally, with emphasis on areas of greatest muscle impairment
  • Any exercise program should focus on strengthening, dynamic stabilization, and neuromuscular control of the lower extremities
  • Programs to should be developed to also enhance mobility in people with arthritis
  • Any deficits in muscle impairments should be correlated to altered movement dysfunctions
  • Programs should be developed that reduce specific muscle impairment, mobility concerns, and movement impairments

 

Hopefully we can all make a positive impact on people suffering from knee arthritis.   Understanding and improving some of the muscle impairments, strength deficits, and muscle imbalances associated with knee arthritis is imperative.  Keep these findings and recommendations in mind next time you are working with someone with knee arthritis, don’t just focus on pain control and quad strength, look at the bigger picture!

 

 

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Viscosupplementation for the Treatment of Knee Arthritis

Viscosupplementation is becoming a popular treatment for knee arthritis.  As rehabilitation and fitness specialists, it is important to have a clear understanding of what viscosupplementation is and what it means for our patients and clients that may be dealing with knee osteoarthritis.  There are many options, benefits, and even side effects that we should be aware of.

An Overview of Viscosupplementation for the Treatment of Knee Arthritis

Viscosupplementation is an intra-articular injection of hyaluronic acid into the knee joint by an physician.  Hyaluronic acid (also known as hyaluron and hyaluronate) is a natural substance normally found in the synovial fluid of our joints. Its function is to act as a joint lubricant and shock absorber. It has been found that patients with knee arthritis have less hyaluronic acid in their joint.(1)

The theory behind the injections is that by injecting hyaluronic acid into the knee joint, the knee will have the necessary amount of hyaluronic acid and will also help the body stimulate production of more hyaluronic acid in the joint.  This will improve patient symptoms of pain and allow for better functional mobility.

Here is an image from Genzyme, the makers of Synvisc, describing the benefit of viscosupplementation:

viscosupplementation

Viscosupplementation injections were first approved as a treatment for knee arthritis by the FDA in 1997.  The important point to remember is these injections are a treatment, not a drug or a cure for arthritis.  Hyaluronic acid injections, derived mostly from rooster combs, can provide several months of pain relief, and are given typically in a series of 3-5 injections. However, they do NOT provide any immediate effect on pain.  Success is greater for patients with mild to moderate osteoarthritis. Viscosupplement  injections can be repeated every 6 months if necessary.

 

Viscosupplementation Options

Currently, there are five approved viscosupplements known as the brand names Hyalgan, Synvisc, Orthovisc, Euflexxa, and Supartz.  Each vary slightly:

  • Hyalgan: First FDA approved viscosupplement; manufactured by Sanofi-Aventis; series of 3-5 injections at once per week; up to 6-7 months relief
  • Synvisc: Manufactured by Genzyme; 3 injections a week apart; 6 month relief; now with SynviscOne, a single injection for 6 month relief
  • Orthovisc: Manufactured by DePuy; Only viscosupplement not from an avian source; 4 injections with 6 month relief
  • Euflexxa: Manufactured by Ferring Pharmaceuticals; 3 injections, 6 month relief
  • Supartz: Manufactured by Smith & Nephew; 5 injections; Only viscosupplement approved to state it provides up to 12 months relief; also 3 injection series, providing 6 months relief (2)

 

Side Effects of Viscosupplementation

There are few side effects to these injections. Most often, there can be a local injection site reaction of redness and pain. A “hot knee” or a pseudo sepsis can also occur up to 72 hours after injection. NSAIDS, steroids, and/or arthrocentesis may be used to treat this. On a rare occasion, allergic reactions may occur. In general, this is a very safe treatment for knee arthritis.

 

Benefits of Viscosupplementation

A study done by Bannuru et al (3) published in 2009, compared hyaluronic acid injections to cortisone injections for treatment of painful knee OA. They found that after two weeks, the cortisone group had significantly less pain. At four weeks, both groups pain levels were the same. Finally at eight weeks, the hyaluronic acid group was significantly better than the group receiving cortisone.  This is an important point to remember when patients ask about these injections. Viscosupplements can work well, but will NOT have an immediate result.

There are also studies comparing viscosupplements to saline injections (3) that have shown no difference between groups. Therefore, I tell my patients that there is a chance these injections may or may not help, but they are safe and may prolong the need for surgical intervention.

References

  1. Felson DT. An update on the pathogenesis and epidemiology of osteoarthritis. Radiol Clin North Am 2004; 42:1-9.
  2. www.hyalgan.com; www.synviscone.com; www.orthovisc.com; www.euflexxa.com; www.mykneeandme.com
  3. Bannuru et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: A systematic review and meta-analysis. Arthritis Rheum 2009; Nov 30; 61 (12):1704-1711
  4. Lundsgaard et al. Intra-articular sodium hyaluronate 2 mL versus physiological saline 20 mL versus physiological saline 2 mL for painful knee osteoarthritis: a randomized clinical trial. Scand J Rheumatol. 2008 Mar-Apr;37(2):142-50.

Trevor WinneggeTrevor Winnegge Pt,DPT,MS,OCS,CSCS  has been practicing PT for over 10 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he uses many of these pearls of wisdom regarding viscosupplementation for the treatment of knee arthritis.

 

 

The Use of Glucosamine and Chondroitin Sulfate for Knee Arthritis

A recent review from the January 2009 issue of the Journal of Arthroscopy reviewed the use of glucosamine and chondroitin sulfate for knee osteoarthritis.  Considering the vast amount of people suffering from knee arthritis and the increasing cost of medical care for these patients, the use of any type of supplement to reduce symptoms is welcome.

Research into the efficacy of glucosamine and chondroitin sulfate is certainly not new with studies dating back to 1969.  However, the literature has been filled with many poorly controlled studies, some of which were funded by glucosamine manufacturers!This particular paper reviewed the results of 23 studies that involved double-blind, placebo-controlled, randomized control trials as well as several meta-analyses.

The effectiveness of Glucosamine and Chondroitin Sulfate

The overall results of the review show that there are inconsistent results, but that the results do favor improvement of pain and joint function in patients with arthritis.  The authors also note that one of the most consistent trends between studies involved the length of use of the supplement.  The best results from glucosamine appear to occur after several months of use.  Studies are referenced that show positive results in 3-6 months and even up to 9 months.

In general, if you looked hard enough, you could probably find more articles that say that the use of glucosamine is effective than you could find saying it is not effective.  I realize and agree that there is not overwhelming evidence in support of glucosamine or outlined the exact mechanism of symptom improvement.  However, when we start to run out of options for our patients, I would say there is enough evidence to support it’s use, as long as the supplement is safe.

The Safety of Glucosamine and Chondroitin Sulfate

A potentially more important finding of the current review was that the use of glucosamine and chondroitin sulfate appears to be safe, at least as safe as placebo supplementation.  To me, this is the most important finding for me clinically.  If we are going to recommend the use of a supplement with inconsistent findings, as long as the supplement is safe I have no problem recommending a patient try glucosamine.

Recommended Use of Glucosamine and Chondroitin Sulfate

I have spent a lot of time over the last several years trying to find a consensus statement on the use of glucosamine and chondroitin sulfate.  Unfortunately, this does not appear to exist.  I have taken information from many sources, including the excellent recommendations of noted orthopedist Dr. Frank Noyes of Cincinnati Sports Medicine and information from the Osteoarthritis Research Society International to provide the following information.  I recommend that you read Dr. Noyes’ recommendations, it is a great resource.  Also, realize that you should consult with your own personal physician before taking any supplements and that glucosamine may not be indicated for you personally.  The below information are just basic guidelines for healthcare providers when considering the use of glucosamine:

  • Cosamin DSGlucosamine should be taken with chondroitin sulfate to maximize it’s effectiveness
  • Supplements that include magnesium and vitamin C may help the absorption rate of glucosamine and chondroitin sulfate.
  • To date, the specific brand that has received the highest recommendations appears to be Cosamin DS.
  • Dosage should vary based on body weight:
    • If less than 120 lbs: G 1000mg + CS 800mg
    • Between 120-200 lbs: G 1500mg + CS 1200mg
    • If greater than 200 lbs: G 2000mg + CS 1600mg
  • Supplements should be taken for at least 3 months for noticeable results.  If no response within 6 months, may discontinue.

I have found decent results from the use of glucosamine in my patients, have you?

C VANGSNESSJR, W SPIKER, J ERICKSON (2009). A Review of Evidence-Based Medicine for Glucosamine and Chondroitin Sulfate Use in Knee Osteoarthritis Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25 (1), 86-94 DOI: 10.1016/j.arthro.2008.07.020

Image by scottfeldstein

Autologous Chondrocyte Implantation or Microfracture?

The current issue of AJSM has two great articles regarding articular cartilage repair  procedures that go very well together.  I think this is an amazing aspect of orthopedics as we are making ground on developing ways to restore normal cartilage.  The Cartilage Defectimplications of this are staggering.  If you share an interest in articular cartilage repair, I recommend you read the special issue of JOSPT on articular cartilage and meniscal repair procedures that I guest edited, specifically my guest editorial and my article on postoperative rehabilitation following articular cartilage repair procedures.

 

Autologous Chondrocyte Implantation Compared to Microfracture

The first study is a comparison of outcomes between microfracture and second-generation autologous chondrocyte implantation (ACI).  80 patients with grade III-IV cartilage defects of the femoral condyle or trochlea were enrolled in the study and split evenly between groups.  The second-generation ACI procedure used Hyalograft C. 

microfracture pickingBoth groups showed significantly greater results at the 5 year post-op mark, however, the ACI group showed greater improvements in the International Knee Documentation Committee objective and subjective scores.  Even more interestingly, the return to sports rate between groups was similar at the 2-year mark and remained stable for the ACI group, but decreased for the microfracture group.

 

Results of Autologous Chondrocyte Implantation in Patients with Failed Prior Treatment

The second study prospectively assess the results of 126 patients undergoing ACI after a failure of a previous articular cartilage repair procedure.  This is a very large and prestigious study by the STAR group (Study of the Treatment of Articular Repair), which consists of all the best cartilage repair surgeons in the country.  The past procedures included predominantly debridement (48%) and microfracture (27%), as well as subchondral drilling, abrasion arthroscopy, and osteochondral autograft.

Results of the study were good with 76% of subjects showing successful results for a long duration.  All measurements showed a statistically significant and clinically meaningful improvements after ACI.  However, these results are lower than many of the previously reported outcomes following ACI when used as the first surgical procedure.  Here are photos of before (top) and after (bottom) of ACI for a femoral condyle defect (left) and patella defect (right):

ACI implant on condyle and patella

 

Clinical Implications

Putting the results of these two studies together leads to a very interesting and meaningful result.  While ACI and microfracture may yield similar post-op results at the 2-year follow-up, the ACI procedure continues to show durable results while the microfracture group slowly deteriorates over time.  This is significant when looking at these two studies together.  Although ACI appears to be a valuable surgical procedure for failed articular cartilage repair procedures, results of ACI used as the primary procedure are better than when used secondary after another procedure (such as microfracture) fails.  Based on these results, it may be better to have the ACI in the first place rather than try a microfracture.

These results make sense, as the ACI procedure has been shown to result in Type II collagen tissue similar to native articular cartilage while the microfracture is predominantly Type I collagen.  Think of the ACI procedure as restoring cartilage while the microfracture just creates a “scab” of a fibrin clot that simply covers the defect.  Because this tissue is inferior to Type II collagen, it does not hold up as well to weightbearing and functional loading.  Unfortunately the negative of the ACI procedure is a long rehab course and longer time to return to full activities, but based on these studies the slight delay may be worth it to prevent future complications.

Have you seen these results in your clinic?  Would you agree or disagree?  There are a lot of pros and cons with both procedures.  Hopefully as we continue to improve our knowledge and techniques all repair procedures will show better results.

E. Kon, A. Gobbi, G. Filardo, M. Delcogliano, S. Zaffagnini, M. Marcacci (2008). Arthroscopic Second-Generation Autologous Chondrocyte Implantation Compared With Microfracture for Chondral Lesions of the Knee: Prospective Nonrandomized Study at 5 Years The American Journal of Sports Medicine, 37 (1), 33-41 DOI: 10.1177/0363546508323256

K. Zaslav, B. Cole, R. Brewster, T. DeBerardino, J. Farr, P. Fowler, C. Nissen (2008). A Prospective Study of Autologous Chondrocyte Implantation in Patients With Failed Prior Treatment for Articular Cartilage Defect of the Knee: Results of the Study of the Treatment of Articular Repair (STAR) Clinical Trial The American Journal of Sports Medicine, 37 (1), 42-55 DOI: 10.1177/0363546508322897

 

Glenohumeral Arthritis in the Athlete

Arthritis of the glenohumeral joint is a challenging shoulder injury for athletes.  As our generations change, we will continue to see less and less sedentary patients in the later stages of life.  Their functional goals in rehabilitation will be much greater than in past decades.  Traditionally, care for the older individual with glenohumeral osteoarthritis was based solely on pain relief rather than maximization of functional activities.  Options included activity modification, medications, injections, physical therapy, and possibly joint replacement.  

Patients now want to continue with recreational activities such as tennis, golf, and swimming.  This is especially true when a patient has an early onset of arthritis symptoms.  Recent attention has been made in the orthopedic communities to attempt to maximize function in these patients as much as possible. 

 Photo by Fevi Yu

This month’s journal issue of Operative Techniques in Sports Medicine focuses exclusively on this topic, glenohumeral arthritis in the athlete.  The issue includes descriptive current concepts articles on all aspects of care of the arthritic shoulder, except for physical therapy unfortunately.

The issue begins with a nice article focusing mainly on evaluation and a treatment algorithm.  The article is fairly thorough with reviews of several arthritic conditions (primary osteoarthritis, dislocation arthropathy, osteonecrosis, and rheumatoid arthritis to name a few) and then an algorithmthat sets up the following sequence of articles on arthroscopic management, biological resurfacing, surface replacement, conventional shoulder arthoplasty, and reverse total shoulder arthroplasty.  These are surely exciting times as many new procedures are being developed to maximize function in these patients.  There are some generic postoperative information for rehabilitation but this is clearly not the focus of the issue.  Still, the issue is excellent and a great place to freshen up on the latest management options for the athletic patient with glenohumeral arthritis.

Luckily, there have also been some great articles published recently regarding the rehabilitation of glenohumeral arthritic in athletes

Reg Wilcox over at the Brigham and Womans Hospital in Boston has published two excellent articles on the rehabilitation following total shoulder arthroplasty in JOSPT in 2005 and following reverse total shoulder arthroplasty in JOSPT in 2007.  I had the pleasure of speaking at the MA state APTA meeting last year with Reg and Dr. Higgins, one of his co-authors, and they truely did an excellent job.  These two articles have been especially helpful in my practice.

Todd Ellenbecker, who am sure is recognized by many of the readers, also published a case study in JOSPT earlier in 2008 on humeral resurfacing hemiarthroplasty with a meniscal allograft in a young patient.  This was also a good read and very interesting case.  We certainly are coming a long way with our treatment interventions.  Todd was also kind enough to contribute a chapter on glenohumeral arthritis in my book, The Athlete’s Shoulder (which I received information yesterday that it is finally published and available!).

Does anyone else have any articles on the topic of glenohumeral arthritis in the athlete to recommend?

Should you have arthroscopic knee surgery for arthritis?

“Should I have arthroscopic knee surgery for arthritis or attend physical therapy?” is a common question that you may be faced with in your clinic. A recent AP press release has brought this to the attention of the general population after the publication of new study in the New England Journal of Medicine.  This was a topic of a recent post on myphysicaltherapyspace as well. The study demonstrated that physical therapy and medications were just as effective at treating arthritis than arthroscopic surgery. 

Please comment and share why you think this may be?  Here are some of my thoughts:

  • Arthritis is likely caused for a reason.  Surgery alone will not fix issues with weight, muscle imbalance (strength or flexibility), poor alignment, or poor dynamic biomechanics during sport or functional activities.
  • We are seeing a rise in patients that can be classified as sedentary. Physical activity of any sort, including exercises performed in rehabilitation, can help improve some of the musculoskeletal deficits associated with the onset of osteoarthritis.  Surgery is not a quick fix!  Most surgeons would agree and say that the patient’s work has just begun after surgery and that the key to successful long term outcomes is compliance with physical therapy.