Knee Exercises – Rooms

Exercises

255A Beyers Naudé Dr,
Rustenburg, 0299
Tel: +27 (0)14 592 8322

www.physiotherapy.co.za
P.O.Box 21533
Protea Park
0305

Hospitale/Hospitals
Netcare Ferncrest/Life
Peglerae/Medicare
Tel: +27 (0)14 592 8322

Knee Rehabilitation after surgery

(Anterior Cruciate Ligament reconstruction and Total Knee Replacement)

PROGRESSIVE EXERCISES

2-4 Weeks
EXERCISES SHOULD NEVER BE EXCESSIVLY PAINFULL
REPEAT ALL EXERCISES APPROXAMITALY 10 TIMES

1 - Active Movement

a. Hip flexion
1. Lie down with your knee straight.
2. Tighten your thigh (quadriceps) muscle ie pull up your knee cap.
3. Keep leg straight at the knee and turn the heel in.
4. Lift your leg up towards the ceiling.
5. Hold 5-10 seconds.
b. Abduction
1. Lie down on the healthy side.
2. Make sure your hip and shoulder are in line.
3. Keep your leg straight.
4. Lift the operated leg up towards the ceiling
5. Hold 2-5 seconds.
c. Adduction
1. Lie down on the operated side.
2. Cross the healthy leg up in front of the operated leg.
3. Lift the operated leg upwards toward the ceiling.
4. Hold 2-5 seconds.
d. Knee flexion
1. Lie down on your stomach.
2. Bend your knee upwards toward your buttock SLOWLY.
e. Hip extension
1. Lie down on your stomach.
2. Tighten/squeeze your buttocks.
3. Lift your operated leg straight up towards the ceiling.
4. Make sure you are not using your back muscles.
5. Hold 2-5 seconds.
f. Calves
1. Stand with your knees slightly bend.
2. Push up on your toes.
3. Slowly lower your heels.

2 - Static Exercises

a. Quadriceps
1. Place the operated leg on the bed or a table.
2. Let the healthy leg hand down.
3. Keep your back straight.
4. Keep the knee flat against the bed/table.
5. Hold 20-30 seconds.
6. Repeat only 2 times.
b. Hamstrings and Gluteus
1. Sit with your knees 90° bend.
2. Push your operated side’s foot gently into the ground.
3. Tighten your buttocks.
4. Hold 5-10 seconds.
c. VMO
1. Sit with your operated knee bend 70°.
2. Place your foot flat on the floor.
3. Try to push the foot forward without moving the foot.
4. Feel that the muscle just above and towards the middle of your knee cap tightens.
5. Make sure that your buttock, back thigh or calves don’t tighten.
6. Hold 5-10 seconds.
7. When this can be done easily:
a. Squeeze a towel between the knees.
b. Repeat instructions 1-6.

3 - Knee range

a. Extension: Feet of bed (If your knee cannot straighten completely)
1. Lie on your stomach.
2. Make sure your knee is just off the bed and your thigh is supported.
3. Place a light weight around your ankle to pull your knee straight.
4. Hold this posisiton for 2-3 minutes.
b. Flexion: Heel ups
1. Stand at a table.
2. Make sure your operated leg is straight.
3. Bend the operated knee backwards up to 90°.
4. Slowly straighten the knee.

4 - Theraband exercises

a. Plantar flexion
1. Hold the theraband around your foot.
2. Push your foot down against the theraband.
3. Make sure your knee does not move.
b. Inversion
1. Hold the theraband around your foot.
2. Moving at the ankle pull your foot inwards (toward the other foot) against the theraband.
3. Make sure your leg does not move.
c. Eversion
1. Put the theraband around both your feet.
2. Moving at the ankle push the operated foot outwards against the theraband.
d. Dorsiflexion
1. Tie the theraband infront of you.
2. Pull your foot up towards your body against the theraband.
e. Hip abduction
1. Stand with the theraband tied around both legs.
2. Bend your knees slightly.
3. Shift your weight to the operated leg.
4. Tighten the thigh and buttock muscles on the operated side.
5. Move your healthy leg away from the operated leg (outwards).
6. Place your healthy leg on the ground and spread your weight 50/50.
7. Move your healthy leg back to starting position.
8. Make sure your operated leg stays behind your toes and does not move/give in.

5 - Stepping

a. Healthy leg first.
1. On a low/small step.
2. Keep your back straight.
3. Step up with the healthy leg.
4. Make sure your knee stays behind your toes.
5. Bring your operated leg up.
6. Step back down with your healthy leg first.
b. Operated leg
1. Keep your back straight.
2. Place your operated leg on the step.
3. Keep your healthy sides toes on the floor.
4. Put half your weight on the heel of the foot.
5. Make sure your knee stays behind your toes.
6. Hold 5-10 seconds.
7. Lower the operated leg.
8. When you can do this without any pain climb the step with your operated leg first.

4 – 6 Weeks

1 - VMO in standing:

a. Stand with the operated leg slightly forward.
b. Bend the knee 40°.
c. Keep the knee in line with the toes.
d. Keep your foot flat on the floor.
e. Try to push the foot forward without moving the foot.
f. Feel that the muscle just above and towards the middle of your knee cap tightens.
g. Make sure that your buttock, back thigh or calves don’t tighten.
h. Hold 5-10 seconds.
i. As your balance improves start placing more weight on the operated leg.

2 - Wall squats

a. Stand with your back against the wall.
b. Make sure your toes face forward and your feet are hip width apart.
c. Keep your knees in line with your toes.
d. Tighten your buttocks and hamstring muscles.
e. Keep them tight as you slowly bend your knees and slide down the wall into the squat position.
f. DO NOT BEND MORE THAN 40°.
g. Push up, placing most of your weight on your heels.
h. Do not straighten your knees completely.

3 - Cycle

a. If you have a stationary bike at home you may bike with a LOW RESISTANCE.
b. Set the height of the saddle so that your leg can straighten, but not completely.
c. Step with your heel, not your toes.
d. Keep a steady rhythm.
e. You may progress the time but not the resistance.

6 – 9 Weeks

1 - Cycle

a. On a stationary bike.
b. Medium resistance.
c. Make sure the sadle is not to high.

2 - Walk on a treadmill

a. No incline.
b. Slow speed.

3 - Proprioception and stability

a. Floor balance
1. Stand on your healthy leg for 10-15 seconds.
2. Now stand on your operated leg for 10-15 seconds.
b. Balance board
1. Stand with both legs evenly spaced on the balance board. Keep your eyes open. Keep your balance for 10-15 seconds.
2. Stand with your healthy leg on the balance board. Keep your eyes open. Keep your balance for 10- 15 seconds.
3. Now stand with your operated leg on the balance board. Keep your eyes open. Keep your balance for 7-10 seconds.
4. Repeat steps 1-3 with your eyes closed.
5. Then repeat steps 1-3 and try to throw/catch a ball.
c. Exercise mats or half balls
1. Repeat/progress the same as with a) balance boards.
d. Trampoline
1. Repeat/progress the same as with a) balance boards and b) exercise mats.
e. Rhythmic stabilisation
1. While standing on the balance board or mats.
2. Loop the theraband around your waist.
3. Try to keep your position while your therapist/partner tries to pull you sideways, backwards or forwards by pulling gently on the theraband.

4 - Theraband

a. Do all exercises with both legs.
b. The leg taking the weight must always be slightly bend.
c. Hip flexion
1. Tie the theraband in a loop around the leg of a bed/table.
2. Bend the knee slightly.
3. Stand with the theraband behind you.
4. Move your leg forward.
5. Make sure you move at the hip not at the knee.
d. Hip adduction
1. Tie the theraband in a loop around the leg of a bed/table.
2. Keep the leg straight.
3. Stand with the exercising side closest to the theraband.
4. Move it against the rubber towards and infront of the other leg.
e. Hip abduction
1. Tie the theraband in a loop around the leg of a bed/table.
2. Keep the leg straight.
3. Move the leg outwards against the theraband.
4. Later try walking sideways against the theraband.
f. Knee flexion
1. Tie the theraband around both legs.
2. Stand straight with your leg hanging straight down.
3. Bend your knee backwards against the rubber. (ie heel up).
g. Crawling position
1. If this position is painfull for you, rest your upperbody/chest on the bed in order to take some weight off your knees.
2. Tie the theraband around your thighs.
3. Move your knee outwards as far as possible keeping the knee bend.
h. Hip extension
1. Do this exercise in the following positions.
a. Lying on your side.
b. Standing up straight.
c. Supporting your upperbody/chest on a bed.
2. Tie the theraband around your legs or loop it around the bed.
3. Move your leg backwards against the theraband.
4. Make sure you are moving at the hip not the knee.
i. Foot exercises
1. Same as week 2-4.

5 - Exercise ball

a. Bridging
1. Place both feet on the ball.
2. Bend your knees.
3. Tighten your stomach and buttocks.
4. Lift your hips.
5. Now repeat steps 1-4 with only one leg on the ball.
b. Hamstring pull
1. Place both heels on the ball.
2. Bend your knees, pulling the ball closer to your body.
3. Straighten your knees pushing the ball away.

6 - Lunge – no pain or discomfort!

a. Stand with your feet together.
b. Step backwards with your operated leg.
c. Bend the knees slightly.
d. Return to starting position.
e. Now try stepping forward with your operated leg. Remember to not let your knee fall passed your toes or inwards.
f. Then try stepping sideways.

7 - Squats – no pain or discomfort!

a. Wall squats
1. Stand against a wall.
2. Flatten your back.
3. Slide down the wall bending your knees up to 90°.
4. Remember to keep your knees in line with your toes.
5. Most of your weight should be on your heels, ie behind your knees.
6. When this is comfortable move away from the wall. Start with holding onto a stable surface for balance.
b. Sit to stand
1. Stand up and sit down on a chair.
2. Your weight should be behind your knees, on your heels.
3. Make sure your knee stay in line with your toes and do not pass your toes when standing up.
4. Now try this on a exercise mat or balance board.
5. Later try this while using only one leg.
c. One leg squat with support
1. Stand in facing away from a chair.
2. Place your healthy leg on the chair.
3. Squat/bend your operated leg keeping your weight behind your knee.
4. Make sure your knee stays in line with your toes but does not move forward passed your toes.
5. Keep your body upright.

8 - Stairs – climb stairs to stregthen the knee further.

9 - Stepper – make sure to keep the resistance low-medium.

10 - Stretches

Progress weekly.
a. Hold the position for 30 secs.
b. Repeat 3 times.

9 – 12 weeks

1 - Step down

a. Forwards
1. Stand on a step.
2. Step down from the step moving your leg forward.
3. Make sure to keep your pelvis straight.
4. Do not let the leg fall in towards the other leg.
b. Sideways
1. Stand on a step.
2. Step down from the step moving your leg outwards to the side.
3. Make sure to keep your pelvis straight.

2 - One leg squats

a. If you have no pain over the front of your thigh/knee.
b. Stand on one leg.
c. You may hold onto a stable surface for balance.
d. Squat/bend your knee.
e. Keep your knee in line with your toes.
f. Make sure your knee does not pass your toes.
g. Keep your pelvis straight.

3 - Resisted lunges/walking

a. Tie a theraband around your waist.
b. Tie it to a stable surface or let someone hold it in place.
c. Lunge as instructed week 6-9 pulling against the theraband.

4 - Run lightly on a trampoline

a. Do not straighten your knee when it lands.
b. Slow jog, not a sprint.

5 - Jumping

a. Jump lightly from one leg to the other.
b. Do not land on a straight leg.

6 - Stretches

Lower limb in standing: Progress weekly.
a. Hold the position for 30 secs.
b. Repeat 3 times.

14+ weeks (biokineticist)

1 - Agility

a. Trampoline
b. Steps
c. Direction changes
d. Plyometric exercises

Download Exercises - ACL-RECONSTRUCTION for Rooms.pdf

(Download the complete hospital exercise guidelines document)

Knee Exercises 2 – Hospital

Exercises

255A Beyers Naudé Dr,
Rustenburg, 0299
Tel: +27 (0)14 592 8322

www.physiotherapy.co.za
P.O.Box 21533
Protea Park
0305

Hospitale/Hospitals
Netcare Ferncrest/Life
Peglerae/Medicare
Tel: +27 (0)14 592 8322

Knee Rehabilitation after surgery

(Total Knee Replacement)

GENERAL INFORMATION AND ADVICE:

Number 1

Crutches or other assistive devices should be used as prescribed. (See exercises for instructions on how to walk and for climbing up and down stairs. Be very careful of any turning movements at the knee. You may put full weight on the leg unless told otherwise.

Number 2

If you have received orthopaedic stockings use them as prescribed. They are used to control swelling and to prevent blood clotting.

Number 3

If your calf becomes swollen or painful or your knee becomes hot or red, contact the doctors’ rooms.

Number 4

Try to keep your leg elevated when you are resting to reduce the swelling in your leg. Put your foot up on the sofa so that your ankle is higher than your heart. Do not put a pillow under the knee as it increases the risk for a fixed flexion deformity/extension lag.

Number 5

When sitting bend your knee as far as pain allows. When lying down keep the knee as straight as possible.

Number 6

Be very careful of slipping on wet surfaces, steps etc. No sudden movements with the knee.

Number 7

When dressing, dress the operated leg first up to the knee, dress the healthy leg up to the knee and then pull the pants over your buttocks. Be very careful to not turn the knee in or out.

Number 8

You may sleep on your back or on your sides. Put a pillow between your knees when lying on your side.

Number 9

For swelling and pain ice and heat can be used (See exercises for time specific management). If your knee is very swollen, lift the end of your bed.

Number 10

The dressings must not be taken off until your post-operative appointment at the clinic. The dressing must be kept clean and dry at all times.

Number 11

No driving while your knee is recovering. Only start driving when you can safely drive without any pain and your leg is strong enough to perform all the nessasary actions.

Number 12

Please follow the exercises prescribed. Physiotherapy is very important to insure that the knee is fully rehabilitated and functional. It is very important to remember that walking is the best exercise and that we want as much movement as possible as soon as possible.

Number 13

Consult your physio for a biokineticist referral if you want to start doing gym exercises. The following exercises should preferrably never be done again: a) leg extentions

Number 14

No jogging for at least 3 months. No sport participation for at least 9 months. No breast stroke kicking for 6 months.

EXERCISES:

0-2 Weeks
EXERCISES SHOULD NEVER BE EXCESSIVLY PAINFULL
REPEAT ALL EXERCISES APPROXAMITALY 10 TIMES

1 - Breathing Exercises

a. Sit or lie down comfortably.
b. Breath in through your nose.
c. Breath out through your mouth.
d. Keep your shoulders relaxed.
1. Take a deep breath in and out.
2. Take a deep breath in, hold for 3-5 seconds and breath out.
3. Take a deep breath in, then a bit more in, and breath out.

2 - Circulation exercises to prevent blood clotting:

a. Footpumps
1. Keep your knee still.
2. Move your foot up and down.
b. Patella mobs
1. Sit with your knee straight and relaxed.
2. Hold your knee cap between your hands.
3. Move it up and down.
4. Move it from left to right.

3 - Static Exercises

a. Quadriceps
1. Sit with your knee straight.
2. Push your knee as flat into the bed as possible.
3. Hold 5-10 seconds.
b. Gluteus
1. Lie down on your back with your knee straight.
2. Squeeze your buttocks together.
3. Hold 5-10 seconds.
c. Calves
1. Sit down with your knee straight.
2. Point your toes.
3. Hold 5-10 seconds.
d. Hamstrings
1. Lie down on your back with your knee straight.
2. Push your heel down into the bed.
3. Hold 5-10 seconds.

4 - Active Exercises

a. Straight leg raise
1. Lie down on your back.
2. Keep your knee straight and quads tight.
3. Pick your foot up towards the ceiling, bending at the hip. Make sure not to lift the foot to high (10-15 cm off the bed is enough)
4. Lower your leg slowly.
b. Abduction
1. Lie down on your back.
2. Slide your leg outwards.
3. Slide the leg inwards until it touches the other leg.

5 - Knee extension range

a. Feet on pillow
1. Lie on your back or sit with your knee straight.
2. Put a pillow under your ankle.
3. Let your knee hang towards the bed.
4. Hold this position for 2-3 minutes

6 - Knee flexion range

a. Heelslides
1. Keep your heel on the bed.
2. Move your heel to your buttock as far as possible.
3. Hold for 5-10 seconds.
4. Straighten your knee again.
b. Side of bed
1. Sit over the side of the bed.
2. Make sure your thigh is supported.
3. Bend your knee back as far as possible, you may assist with your healthy leg.
4. Straighten the knee as far as possible, assist with your healthy leg.
5. Once you are able to complete this without difficulty, repeat the exercise without assistance of the healthy leg.

7 - Ice for swelling and pain:

a. Cover the surgery with a clean sheet of plastic or a towel in order the protect the wounds and dressings.
b. Put an ice pack over your swollen or panful areas.
c. Keep it on for 10-15 minutes.
d. You can do this 3 times per day

8 - Mobilisation

a. Please not that it is important to move as much as possible.
b. Please walk for atleast 5 min every hour if pain allows.
c. Please try to climb some stairs atleast 3 times daily if pain allows (even if it is just one step atleast
try.)
d. (see number 9 for instructions for mobilising with crutches)

9 - Crutches

a. Walking
1. Find your balance.
2. Move both crutches forward.
3. Move your operated leg forward. If you are allowed to, put the foot down on the floor, otherwise you can keep it in the air.
4. Bring the healthy leg forward, try to move it further forward than the operated leg.
5. Continue in this order.
b. Climbing up stairs
1. Find your balance.
2. Climb up the stair with your healthy leg.
3. Move your operated leg forward/up.
4. Bring the cruthes up onto the step.
5. Find your balance before continuing upwards.
c. Climbing down stairs
1. Find your balance.
2. Move your crutches down onto the floor.
3. Move your operated leg forward/down.
4. Climb down with your healthy leg.
5. Find your balance before continuing down.
d. Stand up with crutches
1. If possible sit on a chair with arm rests. Put one hand on the chair and one on your crutches.
2. Shift your weight forward – if you have a hip replacement please lean back instead of forward.
3. Putting your weight onto your healthy leg, push up into standing.
4. Find your balance and shift one crutch to your other hand.
e. Sit down with crutches
1. Find your balance.
2. Place both cruthces in one hand.
3. Place one hand on the chair.
4. Slowly lower your body into sitting.

Download Exercises - TKR for Hospitals.pdf

(Download the complete hospital exercise guidelines document)

Important!

All knee surgery patients require physiotherapy after dicharge from the hospital, to prevent post-operative complications and failure of surgery.

You will need 2-3 sessions/ week.
Please phone the practice for an appointment ASAP.

Knee Exercises – Hospital

Exercises

255A Beyers Naudé Dr,
Rustenburg, 0299
Tel: +27 (0)14 592 8322

www.physiotherapy.co.za
P.O.Box 21533
Protea Park
0305

Hospitale/Hospitals
Netcare Ferncrest/Life
Peglerae/Medicare
Tel: +27 (0)14 592 8322

Knee Rehabilitation after surgery

(Anterior Cruciate Ligament reconstruction)

GENERAL INFORMATION AND ADVICE:

Number 1

If you have been fitted with a brace post-operatively, it should be worn as prescribed. Your physio will progressively change the brace settings.

Number 2

Crutches should be used as prescribed. (See exercises for instructions on how to walk and for climbing up and down stairs. Be very careful of any turning movements at the knee.

Number 3

If you have received orthopaedic stockings use them as prescribed. They are used to control swelling and to prevent blood clotting.

Number 4

If your calf becomes swollen or painful or your knee becomes hot or red, contact the doctors’ rooms.

Number 5

Try to keep your leg elevated when you are resting to reduce the swelling in your leg. Put your foot up on the sofa so that your ankle is higher than your heart.

Number 6

When sitting bend your knee as far as possible or as far as the brace allows. When lying down keep the knee as straight as possible.

Number 7

Be very careful of slipping on wet surfaces, steps etc. No sudden movements with the knee. Do not pull the knee all the way straight.

Number 8

When dressing, dress the operated leg first up to the knee, dress the healthy leg up to the knee and then pull the pants over your buttocks. Be very careful to not turn the knee in or out.

Number 9

You may sleep on your back or on your sides. Put a pillow between your knees when lying on your side.

Number 10

For swelling and pain ice and heat can be used (See exercises for time specific management). If your knee is very swollen, lift the end of your bed.

Number 11

The dressings must not be taken off until your post-operative appointment at the clinic. The dressing must be kept clean and dry at all times.

Number 12

No driving while your knee is in the brace. Only start driving when you can safely drive without any pain and your leg is strong enough to perform all the necessary actions.

Number 13

Please follow the exercises prescribed. Physiotherapy is very important to insure that the knee is fully rehabilitated and functional.

Number 14

Consult your physio for a biokineticist referral if you want to start doing gym exercises.

The following exercises should preferably never be done again: a) leg extensions.

Number 15

No jogging for at least 3 months. No sport participation for at least 9 months. No breast stroke kicking for 6 months.

EXERCISES:

0-2 Weeks
EXERCISES SHOULD NEVER BE EXCESSIVLY PAINFULL
REPEAT ALL EXERCISES APPROXAMITALY 10 TIMES

1 - Breathing Exercises

a. Lie down comfortably.
b. Breath in through your nose.
c. Breath out through your mouth.
d. Keep your shoulders relaxed.
          1. Take a deep breath in and out.
          2. Take a deep breath in, hold for 3-5 sec and breath out.
          3. Take a deep breath in, then a bit more in, and breathe out.

2 - Circulation exercises to prevent blood clotting:

a. Footpumps
1. Keep your knee still.
2. Move your foot up and down.
b. Heelslides 1
1. Keeping your heel on the bed.
2. Move your heel to your buttock as far as possible.
3. Straighten your knee again.
c. Patella mobs
1. Sit with your knee straight and relaxed.
2. Hold your knee cap between your hands.
3. Move it up and down.
4. Move it from left to right.

3 - Static Exercises

4 - Active Exercises

a. Straight leg raise
1. Lie down on your back.
2. Keep your knee straight.
3. Pick your foot up towards the ceiling, bending at the hip.
4. Lower your leg slowly.
b. Abduction
1. Lie down on your back.
2. Slide your leg outwards.
3. Slide the leg inwards until it touches the other leg.
c. Hip extension
1. Lie down on your stomach.
2. Keep your knee straight.
3. Lift your foot up towards the ceiling using your buttock.
4. Lower your leg slowly!

5 - Knee extension range

a. Feet of bed
1. Lie on your stomach.
2. Make sure your knee is just off the bed and your thigh is supported.
3. Hold this posisiton for 2-3 minutes.
b. Feet on pillow
1. Lie on your back or sit with your knee straight.
2. Put a pillow under your ankle.
3. Let your knee hang towards the bed.
4. Hold this position for 2-3 minutes.

6 - Knee flexion range

a. Heelslides 2
1. Keep your heel on the bed.
2. Move your heel to your buttock as far as possible.
3. Hold for 5-10 seconds.
4. Straighten your knee again.
b. Side of bed
1. Sit over the side of the bed.
2. Make sure your thigh is supported.
3. Bend your knee back as far as possible.
4. Straighten the knee slightly.
c. Knee ups
1. Stand with good posture.
2. If you have weak balance stand against a wall.
3. Lift your knee as high as possible.
4. Remember to bend your knee and hip.

7 - Ice for swelling and pain:

8 - Crutches

Remember: Good leg goes to heaven (up with the good)
Bad leg goes to hell (down with the bad)

a. Walking
1. Find your balance.
2. Move both crutches forward.
3. Move your operated leg forward. If you are allowed to, put the foot down on the floor, otherwise you can keep it in the air.
4. Bring the healthy leg forward, try to move it further forward than the operated leg.
5. Continue in this order.
b. Climbing up stairs
1. Find your balance.
2. Climb up the stair with your healthy leg.
3. Move your operated leg forward/up.
4. Bring the crutches up onto the step.
5. Find your balance before continuing upwards.
c. Climbing down stairs
1. Find your balance.
2. Move your crutches down onto the floor.
3. Move your operated leg forward/down.
4. Climb down with your healthy leg.
5. Find your balance before continuing down.
d. Stand up with crutches
1. If possible sit on a chair with arm rests. Put one hand on the chair and one on your crutches.
2. Shift your weight forward – if you have a hip replacement please lean back instead of forward.
3. Putting your weight onto your healthy leg, push up into standing.
4. Find your balance and shift one crutch to your other hand.
e. Sit down with crutches
1. Find your balance.
2. Place both crutches in one hand.
3. Place one hand on the chair.
4. Slowly lower your body into sitting.

Download Exercises - ACL-RECONSTRUCTION for Hospitals.pdf

(Download the complete hospital exercise guidelines document)

Important!

All knee surgery patients require physiotherapy after dicharge from the hospital, to prevent post-operative complications and failure of surgery.

You will need 2-3 sessions/ week.
Please phone the practice for an appointment ASAP.