High Tibial Osteotomy, a Dash of Physical Therapy, and a Healthy Serving of Barbells. Just What the Doctor Ordered

by Chris Palladino, SSC | May 24, 2023

Meet Dave, a 42-year-old fireman, dad
of fantastic twin girls, and a husband. Dave is a recreational
barbell athlete, training 3-4x a week at a local gym. Dave was born
with a moderate bilateral varus deformity (bow leg) of his knees,
which, over time, had increased stress on the medial compartment of
the knee. Chronic knee pain, stiffness, and clicking were common
problems for Dave for years. In September of 2021, Dave injured his
knee on the job, which led him to receive his first medial
meniscectomy of the right knee. He received the same surgery on his
left knee the following December. Dave found himself on light duty at
work, which offered him little relief. Disappointed at his injuries’
impact on his active lifestyle, he became reluctant to train.

Dave spent the better half of 2021 in
outpatient physical therapy. Physical therapy consisted of your
standard meniscectomy rehab approach, including table exercises,
partial squats in parallel bars, soft tissue massage, ice, and
electronic muscle stimulation. Physical
Therapy got Dave to a baseline of light recreational activity,
but Dave remained sidelined at work and unable to enjoy an active
lifestyle.

Parallel to his physical therapy done
in 2021, he continued his barbell training independently. On his own
accord, Dave found Starting Strength. Through trial and error and
some experience with training, Dave found that barbell training
increased his strength capacity while managing his pain. After
spending time under the bar, he started feeling some relief.

“My knees feel great after squats,
but that relief only lasted for a few days,” said Dave. He
typically ran a Novice Linear Progression (NLP) for a period, but due
to his injuries, he often had to reset weight and reduce range of
motion while staying active.

Quickly realizing that he made more
progress with barbells than with traditional PT, Dave began
researching his barbell training and surgical options for correcting
his knees. Dave met Dr. Andreas Gomoll in mid-2022 from the Hospital
of Special Surgery in New York. Dr. Gomoll recommended Dave as a
candidate for a high tibial osteotomy (HTO) on the right leg. Once
rehabbed and healed, Dr. Gomoll would schedule the procedure for the
left leg. HTO is a surgical procedure that corrects angular
deformities to prevent the development or progression of
osteoarthritis of the medial knee. This procedure does not return the
knee to “normal”; however, it prolongs the life of a
damaged knee, helps relieve pain in the knee, and delays the need for
a total knee replacement. The attending surgeon removes a triangular
wedge of bone from the lateral side of the tibia to redirect the
forces from the medial to the lateral knee.

I met Dave in mid-August of 2022 when
we decided I would rehab his knee after surgery. First, I took over
his programming, cleaned up his form, ran a successful NLP, and
managed his pain level and stiffness until his surgery on September
19. Three days before surgery, Dave completed a 250 lb squat for sets
of three and a 375 lb deadlift for 5. After completing surgery, Dr.
Gomoll placed Dave in a knee immobilizer and recommended that he
would not bear weight for 6-8 weeks. Furthermore, Dr. Gomoll advised
Dave to manage pain, perform ankle pumps, elevate, perform quad sets
and ice for the first two weeks – a standard post-surgical
approach. However, Dr. Gomoll cleared Dave to begin PT three weeks
after his surgery, and weight-bearing as tolerated (WBAT).

On our first rehab session, I could
range his knee to about 110 degrees flexion and -6 degrees knee
extension (normal knee flexion is 135 degrees, normal knee extension
is 0 degrees). While managing swelling and active range of motion
(AROM) over the next two weeks, Dave began his squat progression. His
axillary crutches assisted Dave’s first squat. With the support of
the crutches and the completion of his first few reps, Dave resolved
to keep going. According to the Starting Strength model, we completed
his first week of rehab with a banded bodyweight squat to depth. On
his first day of squats, he performed three sets of bodyweight
squats, each with a progressively smaller band. On his 2nd day of
squats (48 hours) later, he used the same small band and performed
sets across. On his 3rd day, after another 48 hours, he removed the
band and did sets across. I gave Dave a home exercise program, which
he performed religiously.

Consequently, he entered his second
week with 125 degrees of knee flexion and -2 degrees of knee
extension. Simultaneously, he switched from crutches to a cane and
was ready to perform a barbell squat. After a proper warm-up of
banded squats, we used a 10kg bar to perform sets across. During that
week, we managed the squats with tempos, and I supplemented Dave’s PT
with some hip isolation strength, manual stretching, patella
mobilizations, and massage to address swelling. After completing the
second week of rehab, Dave squatted 65 lb for sets across.

By week 3 of rehab (6 weeks post-op),
we ran a full-blown NLP adding 5 lb to the bar each training session,
performing three lifts per day. The right knee’s full range of motion
was achieved, allowing for ADLs (activities of daily living) and,
more importantly, full-depth squats. The surgical site healed, and
Dave ambulated without any assistive device. The pain was
mild/moderate at end range knee extension and when standing for some
time. Dave had difficulty descending stairs as the quad strength
returned. But he stayed motivated.

Fast forward to 14 weeks of LP, Dave
now squats 300 lb and deadlifts 355 lb with little to zero pain!
Dr. Gomoll scheduled Dave’s second HTO surgery on February 13th.

Four weeks after Dave’s second HTO
surgery, his surgical incisions have healed. Though mild and general
swelling remains, we addressed strength and mobility in his hips,
knees, and ankles. Furthermore, we have resumed the Novice Linear
Progression. Dave currently squats 85 lb for sets across and
deadlifts 135 for five, adding 5 lb to each session. The second NLP
and recovery process remains the same, if not better.

“I know what it takes to get
strong again,” Dave stated.

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