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.