Introduction
When a child, adolescent or adult with a neurological condition needs orthopaedic surgery, it is easy to think of the operation as the decisive moment of treatment: there is a deformity, a contracture or a biomechanical problem that makes function harder, and surgery tries to correct it.
And that moment is undoubtedly extremely important. Surgery can change structure, but it cannot automatically teach the body to use that new biomechanical situation.
After the operation, rehabilitation begins: regaining mobility, strength, confidence and function. In many cases the person will have to learn to stand up, walk or carry out everyday activities with a body that now moves differently.
That is why, as well as asking ourselves “what do we want to correct with the operation?”, we should be asking “what do we want them to be able to do afterwards, and how are we going to help them achieve it?”
What can surgery achieve?
In people with cerebral palsy and other neurological conditions, muscle contractures, joint deformities, bone torsion or malalignment can develop progressively.
Depending on each situation, orthopaedic surgery can act on muscles and tendons, bones or joints with different goals: improving the available mobility, correcting certain deformities, encouraging better alignment or creating more favourable biomechanical conditions for standing and gait.
But improving a structure is not automatically the same as improving an activity.
For example, we may enable an ankle in equinus, with limited dorsiflexion, to gain greater dorsiflexion after a procedure. That changes its mechanical possibilities. Now we need the rest of the body to learn to use them.
Strength, balance, motor control and coordination do not appear during the operation. Nor do the compensatory strategies used for years automatically disappear.
Surgery can create an opportunity.
Rehabilitation helps turn that opportunity into function.
Where we start from
After the operation the body does not start from scratch, but it does not start from the same place either.
Before a procedure, a person may have spent years using certain strategies to stand up or walk. For example, they may have had to lean the trunk forward, keep the knees bent, walk on tiptoe or use pelvic rotation to move forward.
The nervous system has learned to solve a task using the body it has. When we change its biomechanical conditions through surgery, the previous motor solution may no longer be necessary, effective or even possible.
The post-operative period can also bring pain, reduced activity, loss of strength and a temporary decline in function.
That is why there is no universal post-surgical protocol. The surgical team's instructions on mobilisation, weight-bearing, orthoses and progression of activity must always be the starting point.
The immediate post-operative period
After significant orthopaedic surgery, the patient may need more help with transfers, walk more slowly, cover shorter distances or temporarily use an aid they did not need before.
That does not necessarily mean the operation has gone wrong.
In a five-year prospective study of children with bilateral spastic cerebral palsy, GMFCS II-III, after multilevel surgery, Thomason et al. observed significant improvements in gait at 12 months, whereas improvement in gross motor function (GMFM-66) did not appear until two years. (Thomason P, Selber P, Graham HK. Single Event Multilevel Surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. Gait Posture. 2013;37(1):23-28.)
That is why we must set realistic expectations: recovery is not always linear, and we cannot judge the final result by looking only at the first weeks or months.
Regaining mobility… but also strength
After certain procedures, regaining or preserving range of motion is important. But having passive movement does not necessarily mean being able to use it actively.
We need strength. Muscle weakness may be present before surgery and increase as a result of reduced activity during the post-operative period.
That is why rehabilitation must progress as the surgical restrictions allow. At first, the priority may be managing pain, protecting the structures operated on and regaining mobility. Later we can gradually increase active work, weight-bearing, transfers, standing and functional activities.
We do not simply want a joint to move more; we want the person to be able to control and use that movement.
Bearing weight and standing up again
When it is allowed, gradually returning to weight-bearing can become an important part of rehabilitation. Standing up involves much more than putting a person in an upright position. We need to assess how they distribute their weight, what happens at the feet, knees, hips, pelvis and trunk, how much support they need and how much they can actively take part.
We can use standing frames, parallel bars, walkers, transfer aids or robotic therapy devices depending on each person's needs. But when we use technology, the device should never become the goal. The question is not “how long have they been on this machine?” but “what are we trying to achieve while they use it?”
To walk again, you have to practise walking again
Motor learning needs practice.
Once the medical team allows progression towards walking, it is not enough to recover strength, range of motion and balance separately and expect walking to appear spontaneously.
To improve an activity, we need to practise that activity. This may involve walking, getting up from a chair, doing transfers, stepping up a step or moving across different surfaces. In certain situations, a treadmill, a robotic device or a body-weight support system can make it possible to increase repetitions or to practise when it would not yet be possible to do so entirely without help.
Technology is at the service of practice, not practice at the service of technology.
Repetition, yes. But what we repeat matters
After surgery we have an opportunity to change movement strategies that may have become ingrained over years. That is why we should not focus only on whether they walk again, but also on how they walk.
What happens with foot contact? Can they extend the knee better? What position does the pelvis take? Do they need to lean the trunk? Do rotations appear? How much effort do they need? What happens when they get tired?
This does not mean chasing an aesthetically perfect gait. A compensation may be necessary and functional. The aim is to achieve the greatest possible participation through efficient, comfortable and sustainable movement, making the most of the new biomechanical possibilities that surgery has created.
Intensity: creating opportunities to practise
Intensity does not simply mean piling up hours of treatment.
An intensive intervention should provide enough opportunities to practise what we want to improve, with specific goals and a level of difficulty adapted to the person's ability.
In the post-surgical period, that intensity must evolve. There will be times when the body needs recovery and protection, and others when we can increase repetitions, weight-bearing and complexity.
This does not mean that “more is always better”. It means that rehabilitation matters and needs enough time and practice opportunities to support a process that can be long.
From surgery to function: two real examples
The results of surgery should not be judged only by looking at an X-ray or measuring a range of motion. We also need to look at the person.
How do they move? What can they do now? Has the way they walk changed? Can they walk further? Do they need less effort? Have they gained new opportunities to take part?
These two examples show the functional progress of two children six months after different surgical procedures.
Case 1. Progress six months after an Achilles tendon tenotomy
A 6-year-old boy who underwent a right Achilles tendon tenotomy. When looking at his post-surgical progress, it is worth looking well beyond the foot that was operated on.
One month after surgery, he can already place his whole foot on the ground and reaches up to 10 degrees of dorsiflexion.
Six months after surgery, he walks and runs independently, with a clear improvement in foot contact and in his overall gait pattern compared with before the operation.
Beyond the gain in ankle mobility, what makes this case interesting is seeing how the new biomechanical possibilities have gradually translated into functional improvement.
Case 2. Progress six months after a psoas tenotomy
A 15-year-old girl diagnosed with Sanfilippo syndrome, who underwent a psoas tenotomy and excision of two femoral osteochondromas. The main aim of the surgery was to allow her legs to open further, to make nappy changes, hygiene and washing easier and reduce the pain associated with these activities.
Her subsequent progress also brought functional gains that went beyond the initial aim. One month after surgery she could fully extend her knee and hip while weight-bearing and tolerate active-assisted standing. Six months later, she is able to get around outdoors using a stabilising, reciprocating device, and her pain has decreased significantly.
This case shows how a procedure initially aimed at improving positioning, making care easier and reducing pain can also create new possibilities for movement and participation, when post-surgical recovery and rehabilitation make it possible to take advantage of the new biomechanical conditions.
Every case is different, and these examples cannot predict anyone else's outcome. Their value lies precisely in showing something we sometimes forget: between surgery and functional outcome there is a process of rehabilitation and learning.
Better biomechanics does not automatically mean more function
Studies on multilevel surgery in cerebral palsy show that we can significantly improve various gait parameters without necessarily obtaining an equivalent improvement in every measure of function.
Systematic reviews and meta-analyses have found improvements in kinematic and spatiotemporal gait parameters after surgery, whereas changes in more global measures of motor function, such as the GMFM-66, are less consistent (McGinley et al., 2012; Lamberts et al., 2016; Wang et al., 2025).
This does not mean that surgery does not work. It means that structure, biomechanics, capacity and participation are different dimensions. That is why we need to establish before the procedure what we want to achieve and, afterwards, measure what really matters. We should not limit ourselves to measuring ranges of motion, but assess what the person can do now that they could not do before, or what they can do better.
The operation is only the beginning
Orthopaedic surgery can change structure and create new biomechanical possibilities, but afterwards they have to be turned into function.
Regaining mobility and strength, bearing weight again, standing up, practising, adapting and gaining confidence are all part of a process that can take months. That is why post-surgical rehabilitation must be individualised, coordinated with the medical team and directed towards goals agreed with the patient and their family.
Success should not be measured only by how much we have corrected a structure, but by the new possibilities that change has created in the person's life. Surgery can create the opportunity. Rehabilitation helps transform it into movement, function and participation.
Because the operation is not the end of treatment.
It is the beginning of learning what we can do now with a body that has changed.
We'll let you know when the next guide is out.
Occasional updates and guides for families. Unsubscribe whenever you like.
Would you like us to review it with you?
We guide you on the best option for your case, without obligation.