Post op rehab question from podiatrist

[Creflo]

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I was wondering if you guys could shed some light on an area of postoperative care that is not very clear to me. So after surgery at the first metatarsal phalangeal joint, its accepted that the joint gets stiff, and therapy is imperative to help prevent this. But my question is how much of this stiffness is related to the local trauma vs. a breakdown in the connection between the brain/CNS and the firing muscle. Specifically, the muscles that are primarily responsible for moving the great toe are located in the leg, far away from the location of the surgical trauma. And during my bunion and hallux limitus surgeries, I don't violate the extensor and flexor tendons. So if the tendons are intact, and the connection between the brain and the firing muscle are intact, why is it so difficult for patients to regain active range of motion, even if they have done a decent job at restoring passive range of motion with therapy? Thanks for any replies!

 

[noyceguy]

I was wondering if you guys could shed some light on an area of postoperative care that is not very clear to me. So after surgery at the first metatarsal phalangeal joint, its accepted that the joint gets stiff, and therapy is imperative to help prevent this. But my question is how much of this stiffness is related to the local trauma vs. a breakdown in the connection between the brain/CNS and the firing muscle. Specifically, the muscles that are primarily responsible for moving the great toe are located in the leg, far away from the location of the surgical trauma. And during my bunion and hallux limitus surgeries, I don't violate the extensor and flexor tendons. So if the tendons are intact, and the connection between the brain and the firing muscle are intact, why is it so difficult for patients to regain active range of motion, even if they have done a decent job at restoring passive range of motion with therapy? Thanks for any replies!

I'll take a stab at it.

So your question is about the production of voluntary movement. Motion at a joint is produced by the production of a conscious thought, an action potential down the nerve, and a contraction of muscle tissue. This is the "hardware;" brain telling muscles telling joints how to move.

But voluntary movement is so much more than just the hardware. There are certain unmeasureable things that go in to how much someone moves. You can call it "software;" motor programming, or motor drive, or just simple willingness to move. A person with a painful joint will be hesitant to move that joint even after the tissues is healed. They may be scared of further injury and refuse to move properly or at all. They may have a sort of motor amnesia which has made them forget how to move one segment at a time. They may think they will never get better. These things all need to be addressed to improve active motion.

Perhaps as a surgeon, you tend to think of problems as being 100% physical - you fix the tissue, the problem is fixed. However, we as PTs are trained to look at subconscious and conscious thoughts and feelings about movement which also need to be fixed to get someone to move better.

So to answer your question, it can be difficult to regain active motion even where there is good passive motion because active motion requires certain intangible qualities such as lack of fear, willingness to move, hope for a good outcome, belief in the rehab process, etc...etc. which passive motion does not require.

 

[bobtheweazel]

I was wondering if you guys could shed some light on an area of postoperative care that is not very clear to me. So after surgery at the first metatarsal phalangeal joint, its accepted that the joint gets stiff, and therapy is imperative to help prevent this. But my question is how much of this stiffness is related to the local trauma vs. a breakdown in the connection between the brain/CNS and the firing muscle. Specifically, the muscles that are primarily responsible for moving the great toe are located in the leg, far away from the location of the surgical trauma. And during my bunion and hallux limitus surgeries, I don't violate the extensor and flexor tendons. So if the tendons are intact, and the connection between the brain and the firing muscle are intact, why is it so difficult for patients to regain active range of motion, even if they have done a decent job at restoring passive range of motion with therapy? Thanks for any replies!

I wonder, if you were to electrically stimulate the nerve which operates the FHL or EHL, such as how Walkaide stimulates the common fibular nerve to achieve ankle dorsiflexion, then how much active ROM would you get out of the MTPJ postoperatively? It would take out the mental aspect and tell you whether or not it truly is a physical problem. If you can maximally stimulate the motor unit that drives the extension or flexion and that elicits your maximum AROM that you're looking for, then the problem is most definitely mental/intangible.

 

[truthseeker]

I'll take a stab at it.

So your question is about the production of voluntary movement. Motion at a joint is produced by the production of a conscious thought, an action potential down the nerve, and a contraction of muscle tissue. This is the "hardware;" brain telling muscles telling joints how to move.

But voluntary movement is so much more than just the hardware. There are certain unmeasureable things that go in to how much someone moves. You can call it "software;" motor programming, or motor drive, or just simple willingness to move. A person with a painful joint will be hesitant to move that joint even after the tissues is healed. They may be scared of further injury and refuse to move properly or at all. They may have a sort of motor amnesia which has made them forget how to move one segment at a time. They may think they will never get better. These things all need to be addressed to improve active motion.

Perhaps as a surgeon, you tend to think of problems as being 100% physical - you fix the tissue, the problem is fixed. However, we as PTs are trained to look at subconscious and conscious thoughts and feelings about movement which also need to be fixed to get someone to move better.

So to answer your question, it can be difficult to regain active motion even where there is good passive motion because active motion requires certain intangible qualities such as lack of fear, willingness to move, hope for a good outcome, belief in the rehab process, etc...etc. which passive motion does not require.

Great answer.

 

[noyceguy]

Great answer.

thanks