11.5 Post-Surgical Conditions, Implanted Devices & Ostomies
Key Takeaways
After a total hip replacement through a posterior approach, the hip is kept out of flexion beyond 90°, adduction past midline, and internal rotation; anterior-approach precautions focus on avoiding combined extension and external rotation.
Direct scar mobilization begins only after the incision has fully closed with no scabs, drainage, or signs of infection, and within the surgeon's protocol.
Clients with an ostomy are positioned so the pouch is not compressed, the pouch seal is checked before treatment, and no pressure is applied over or immediately around the stoma.
Pressure, vibration, and percussion are avoided over a pacemaker or defibrillator generator, and arm elevation on the device side is limited as instructed for several weeks after implantation.
After lymph node removal, the affected quadrant is treated as at risk of lymphedema: no deep pressure, heat, or constriction (see 5.2).
Post-Surgical Conditions, Implanted Devices & Ostomies
1. Why Post-Surgical Care Is a CKT Topic
The PCs-PIs appendix lists post-surgical conditions as a category of commonly occurring conditions: conditions involving orthopedic interventions, artificial openings, and implants. RMTs frequently treat clients after surgery to manage pain, edema, scar tissue, compensatory muscle tension, and mobility. Safe practice depends on knowing the procedure, the surgeon's restrictions, the stage of healing, and the devices the client now carries. When in doubt, the therapist asks the client for their post-operative instructions or contacts the surgical team with the client's consent.
2. General Post-Operative Screening
- Procedure and date: What was done, which approach, and what restrictions apply (weight-bearing, range limits, lifting limits)?
- Wound status: Sutures or staples (usually removed around 10–14 days), closure, drainage, and signs of infection—spreading redness, heat, swelling, pus, or fever—which require medical referral.
- Thrombosis risk: Surgery, immobility, and orthopedic procedures (especially hip and knee replacement) raise DVT risk for weeks; screen every visit (1.2 and 5.2).
- Medications: Anticoagulants after joint replacement, opioids that blunt pain feedback, and antibiotics.
- Lymph node removal: Axillary or inguinal dissection or radiation creates a lifelong lymphedema risk in that quadrant.
Scar Tissue Management
Healing moves through inflammation, proliferation, and remodelling (5.1). Before closure, treatment stays away from the incision while proximal areas receive gentle lymphatic and relaxation techniques. Direct scar mobilization (skin rolling, gentle multidirectional shearing, and later cross-fibre friction) begins only once the incision is fully closed, with no scabs, drainage, or infection, and within the surgeon's protocol—commonly about 6 weeks or later for deeper techniques. Mature scars continue remodelling for a year or more. Hypertrophic scars stay within the original wound; keloids grow beyond it.
3. Orthopedic Interventions
| Procedure | Key precautions for massage and exercise |
|---|---|
| Open reduction and internal fixation (ORIF) | Respect the fracture-healing stage and weight-bearing status; no deep pressure or mobilization over the fracture site until medically cleared; hardware may be palpable and tender |
| Total hip arthroplasty (THA), posterior approach | Avoid hip flexion beyond 90°, adduction past midline, and internal rotation (dislocation risk). Side-lying requires a pillow between the knees; avoid deep hip flexion when getting onto the table |
| THA, anterior approach | Avoid combined hip extension with external rotation; follow the surgeon's specific list, because precautions vary |
| Total knee arthroplasty (TKA) | Swelling management, scar care once closed, and progressive range of motion within the surgical protocol; watch for DVT |
| Spinal fusion | No mobilization of fused segments; early restrictions on bending, lifting, and twisting; adjacent segments may become overloaded |
| Rotator cuff repair | Sling and passive-only motion early, as the surgeon dictates; no resisted rotator cuff work until cleared |
| ACL reconstruction | Follow the rehabilitation protocol to protect the graft; manage swelling and quadriceps inhibition |
| Amputation | Residual-limb edema and skin care, desensitization of the stump, scar mobility, and education about phantom limb sensation and pain; check the prosthesis socket area for pressure points |
4. Artificial Openings (Ostomies and Tubes)
- Colostomy and ileostomy: The bowel is brought through the abdominal wall as a stoma, with output collected in a pouch. Urostomy diverts urine.
- Positioning: Supine or side-lying with the pouch free; prone positioning is used only if the client is comfortable and the pouch is not compressed (bolsters can create space). Ask the client to empty the pouch beforehand and check the seal.
- Treatment: No pressure on the stoma or the skin immediately around it, and no abdominal massage near the stoma unless guided by the client's ostomy nurse. Watch for a parastomal hernia (bulge around the stoma).
- Other openings: Tracheostomy (keep the airway clear and uncovered; avoid positions that kink the tube) and gastrostomy feeding tubes (avoid pressure and traction on the tube).
5. Implanted Devices
| Device | Precautions |
|---|---|
| Pacemaker or implantable cardioverter-defibrillator (ICD) | Avoid pressure, vibration, and percussion over the generator (usually below the clavicle); after implantation, arm elevation on that side is typically limited for about 4–6 weeks to protect the leads; a client whose ICD fires should stop and contact their cardiology team (911 if repeated shocks, chest pain, or fainting) |
| Central venous ports and PICC lines | Avoid pressure over the port and traction on lines (see 11.3) |
| Insulin pumps and continuous glucose monitors | Avoid the infusion site and sensor; check glucose concerns (5.4) |
| Intrathecal (e.g., baclofen) pumps and spinal cord stimulators | Avoid pressure over the abdominal pump or battery; avoid aggressive spinal mobilization around leads |
| Ventriculoperitoneal (VP) shunt | Avoid deep pressure along the tubing behind the ear, down the neck, and over the chest |
| Breast implants | Avoid deep pressure over the implant, especially after recent surgery; position prone with appropriate support |
| Joint replacements and fixation hardware | Respect the precautions above; avoid aggressive mobilization of the prosthetic joint |
| Cochlear implants | Avoid pressure on the external processor and the area over the internal receiver |
6. Clinical Vignette
A 69-year-old client is 7 weeks past a posterior-approach total hip replacement on the left. Her incision is closed and pale, she walks with a cane, and she is still following hip precautions. The therapist positions her right side-lying with a firm pillow between the knees so the left hip stays out of adduction and internal rotation, and avoids flexing the left hip beyond 90° during transfers. Treatment includes gentle scar mobilization around the healed incision, myofascial work to the gluteal and lateral thigh muscles, and swelling management. The therapist screens her calf at the start of each session because DVT risk persists after joint replacement, and documents that the precautions were followed.
A client is 6 weeks past a posterior-approach total hip arthroplasty. Which positioning respects her hip precautions?
Seated on a low stool so the operated hip is flexed well beyond 90° while the back is treated
Side-lying on the non-operated side with the top knee resting on the table in front of the body to stretch the gluteals
Supine with the operated leg crossed over the other leg at the ankle to relax the hip abductors and gluteal muscles
Side-lying on the non-operated side with a firm pillow between the knees to keep the hip out of adduction
A client with an ileostomy books a full-body massage. Which practice is appropriate?
Apply circular abdominal massage directly over the stoma to stimulate bowel output
Insist on prone positioning for the whole session so the stoma is protected against the table
Position so the pouch is not compressed, check the seal, and avoid pressure on and around the stoma
Remove the pouch during treatment so the abdomen can be fully lubricated and massaged
Three weeks after a pacemaker implantation below the left clavicle, a client requests deep work to the left pectoral region and full overhead stretching of the left arm. What is the safest response?
Apply vigorous percussion over the device to loosen the pectoralis major
Avoid pressure, vibration, and percussion over the generator and limit left arm elevation as instructed
Refuse all massage, because a pacemaker is an absolute contraindication to manual therapy anywhere on the body
Perform full overhead stretching because the leads are fixed securely within the first week
When can direct mobilization of a surgical scar usually begin?
Once the incision is fully closed with no scabs, drainage, or signs of infection, within the surgeon's protocol
As soon as the staples are removed, even if a small area is still draining
On the day after surgery, provided the dressing is left in place during treatment
Only after one full year has passed, because scar tissue cannot change at all before it is fully mature
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