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[MUA] ROM and Manipulation Question

Discussion in 'Knee Replacement Recovery Area' started by Vicki Lynn, Feb 4, 2012.

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  1. Vicki Lynn

    Vicki Lynn New Member

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    :rolleyespink: Hello TKR family. My name is Vicki Lynn, and I had my surgery on the right knee replacement on Dec. 28th - so I am at 5 weeks plus a few days. For the first 3 weeks I had almost no control over the quad muscle but that has returned and I can lift my let off the bed and move it again. Whew. The ROM has also been slow. I am now at 60. I go to PT 3 times most weeks - have started massage therapy and do the excercises at home. The doctor has mentioned doing manipulation in a couple of weeks if this number does not improve a good deal. He did not give a number.

    This is NOT what I want to do of course - but I don't know what is wise. I have read in these postings to be patient and let the knee rule the way. I put it up and use the ice machine or ice it when it swells, etc. It seems that things are finally starting to improve and heal - and I sure don't want to go back to tge beginning again as far as pain and swelling. I also don't want to limit my ROM if manipulation is neccessary.

    I would appreciate any input you may have. I have read that ROM comes even after 3 months - but the PT and Doctor here have said that the scar tissue sets and you only have a "window" of time.

    If anyone has done manipulation - what was the outcome?

    Thank so much - Vicki Lynn 12/28/11 Surgery Date
  2. Roy Gardiner

    Roy Gardiner Forum Advisor

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    Is your knee still tender and swollen? I'd guess at 5 weeks the answer is a resounding YES. In which case, don't sweat it, don't hurt yourself in PT or exercises. As the swelling goes down, ROM will increase.


    http://www.youtube.com/watch?v=eHRWQ4Ulugs
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  3. Dhare63

    Dhare63 Sr Bonesmartie

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    Hi Vicki,

    The idea of a window of time is not true. You will gain rom for months. The issue is whether it's too early for a manipulation. I would say it is. I was at three months before I had one, mine for extension rather than flexion. I was concerned, like you, that it would set me back. The good news is, it will not. In fact it can help a great deal. But first, give your knee time for the swelling to subside. There is plenty of inflammation going on in the joint that you can't see.

    Welcome to Bonesmart and be patient. This is a difficult recovery and you are in the very early days. Read in the library and posts of those who have come before you. It will help. You're in the company of people who literally walked in your shoes and we care.

    Best to you,

    Dawn
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  4. FrogFeathers

    FrogFeathers Post-Grad

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    I gained ROM for months and months after mine. I'm three years out and I'm sure I can gain more.

    I had one at around 5 1/2 weeks. But I had serious ROM issues. With some serious stretching and using the TENS unit for fifteen minutes before, I could get it into the high 70s, low 80s, but within an hour of my appointment, it would slide back into the high 50s/low 60s. I needed a manipulation. And it did help.

    As soon as my ROM hit 90°, they released me from PT and said to just do my exercises on my own. I gained more and more as the months went by, not from doing their exercises, but doing my own stretching from PT that I had from an earlier knee issue (not related to the TKR). And now I'm bending normally.

    My surgeon told me, way back then, that till I could bend to a comfortable 90°, I "wouldn't be happy". I later figured out that he meant I wouldn't walk normal. Well, I'm fine now. :thumb:

    Good luck.
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  5. Josephine

    Josephine Administrator

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    Hi Vicky and welcome to BoneSmart. Evidence is that MUAs done too soon do not have lasting results as the ROM is limited by swelling and pain. Swelling acts like a plaster cast and effectively - very effectively - stops the knee from bending. There have been studies of MUAs done within the first three months and that whilst the surgeon reports a great increase in flexion under anaesthetic, it is not only quickly lost once the patient is awake again but the flexion actually gets worse. This is because of two things:
    1. because the lack of flexion was not due to adhesions at all but swelling and
    2. because the MUA simply creates more swelling which blocks the flexion - etc., etc.

    I suggest you first read these articles
    Myth busting: The "window of opportunity"
    MUA (manipulation under anaesthetic) and adhesions


    Then about pain meds, read this
    The importance of managing pain after a TKR and the pain chart

    As for icing, you should be icing to prevent swelling, not waiting until it occurs. And ice for long periods of time, not just an hour or so. Also elevate your leg at the same time. We have a mantra on here which is "rest, elevate, ice and take your pain meds by the clock!"

    PT should never ever cause you pain. If your PT does things that not only hurt at the time but for hours afterwards then it's not doing you any good. It's just stirring up already angry tissues. If/when your PT does anything that hurts tell them to stop - at once. If they come out with the old "no pain, no gain" rubbish, tell them that's for strength training, not recovery. The proper saying here is "no pain, MORE gain". Nothing, not one thing, should be done in pain or cause you pain. Not until you are at least 10 months post-op, preferably a year!

    Now read the rest of the articles
    The first set is essential reading, the second is useful and the third is good information, But you will need it all
    How Long Does Healing Take ......
    Chart representation of TKR recovery
    Energy drain for TKRs
    Elevating your leg to control swelling and pain
    Using ice

    Discussion on managing pain in TKR surgery
    Work “Smarter” and not “Harder”
    About recovering a knee - from one who knows!
    Some suggestions for home physio (PT) and activity progress

    It's never too late to get more ROM!
    It's Worth the Wait for ROM
    Myth busting: on getting addicted to pain meds
    Post op blues is a reality - be prepared for it
  6. jerseychick

    jerseychick Forum Advisor

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    Hi Vicky, Welcome to BoneSmart. There is no window for ROM. I am 17 months and still gaining. You are only 5 weeks which is very early. If you try to do too much your knee will rebel. Just take it easy, rest, ice, and elevate and your ROM will increase when the swelling in your knee goes down.
  7. maryo52

    maryo52 Sr Bonesmartie

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    Vicky,

    I agree with everyone else. You DO gain ROM for a long long time. However, if you have something obstructing progress, that normal gain in ROM does not happen.

    As early as two weeks, I felt something was wrong. But that was too early for other people who knew this business to identify a problem. I was informed by this forum that if I proceeded gently, ROM would improve. It does for most people. But not for me. And PT made no difference whatsoever except it caused me more misery. Had I done no PT, I wouldn't have been any worse off, and I would've needed less pain medication around the clock.

    At 5 weeks, I think anything much under 90 degrees suggests there's an obstruction, and the most common one is scar tissue.

    The "window of opportunity" for MUA is defined differently by each ortho. Some seem to think a year out is not too late. Many believe that the earlier an MUA is done, the better, because the scar tissue is softer.

    My MUA improved my ROM but then it immediately started going backwards. I'm not sure an earlier MUA would've made any difference for me because my arthrofibrosis was so aggressive. I needed it removed arthroscopically before I was able to discover that YES! gains in ROM go on for a long time.

    It won't hurt you to wait until the end of your ortho's "window of opportunity" to do your MUA and in the meantime you can try focusing on healing measures. After my last procedure I gave up strengthening exercises for a month and worked only on stretching (straightening and bending) - GENTLY - which I defined (based on some stuff I'd read) no pain beyond 3 on the 1-10 pain scale.

    Feel free to message me if you have further questions or need a little hand holding.
  8. Jamie

    Jamie Administrator

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    Hi, Vicky...welcome!

    How are you doing now? These folks gave you some great advice. I hope you hold off a bit on a manipulation and just work with gentle stretches and bends on your knee. Also.....ice, elevate and take pain meds on a schedule as Jo says. That have proven to work in almost 100% of the cases!!!
  9. RunA42K

    RunA42K Forum Advisor

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    I also concur that 5 weeks is just too early in your recovery to worry about a MUA. You are still very swollen and sore and that alone will prevent you form gaining a lot of ROM. I was slow with ROM too, and by the time I got to 7 months I got my best so far (137). That being said, others were peddling a bike at 2 to 4 weeks and it took me 8 weeks to make the peddles go around. Don't be in a rush, just ice and elevate and take your meds, most likely your knee will cooperate in good time as the swelling and goes down. :thumb:
  10. Vicki Lynn

    Vicki Lynn New Member

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    MUA or Surgery??

    :scratch:Hello fello travelers,

    I am back looking for thoughts and hoping for some wisdom as I am back to having to make a knee decision regarding a MUA or an additional surgery.

    My knee replacement surgery was Dec. 28th 2011. From the beginning I had problems with ROM and using the correct muscles to make my leg move. I am told (am now understand) my body learned to "guard" the knee. I had a MUA on Feb. 24th - which did not gain me any ROM. I am at maybe 60 and I also cannot get the leg straight. (That is maybe a 9)

    I have gone to therapy 2-3 times a week since the beginning and although my leg is stronger and I have found the right muscles - no change in ROM.

    The Dr that did my original surgery wants me to do another manipulation. This would be the easy solution - but what is the chance it would work this time? This Dr. says he got little resistance the first time he did the MUA and bent my leg all the way.

    I saw a corrective surgeon who thinks I need to go into the hospital - open the leg up and get rid of scar surgery and do a procedure that cuts the muscle in the back of the leg to get it straight. He would do a spinal to move the leg for 5 days and then start therapy. This is of course major surgery again.

    This surgeon does not do MUA's this far away from the surgery. (concern of breaking the leg)

    The ROM is so limited I really have to try something. I am told time would give me some range - but not good range. I can walk and drive - but sit with the leg out and have to hoist it into and out of the car. I can't do steps or even walk easily on uneven surfaces. And - I'm just now starting to feel better. It has taken a really long time for swelling to go down and pain to decrease.

    Has anyone had a similar experience? I'm not sure where to go for good advise as to which way to go.

    Thanks - it is as you know easy to get discouraged. As much as I like my therapists - its so hard to keep going and see nothing change.

    Vicki Lynn
  11. Minnie

    Minnie Junior Member

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    Re: MUA or Surgery??

    Hi Vicki Lynn,

    So sorry you are going through this. If I were you I would try and see one or two more doctors. It sounds like a difficult situation and both plans don't sound to be certain of the outcome.

    I am sure you will get some good advice here.

    Minnie:friends:
  12. kneesrus

    kneesrus Sr Bonesmartie

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    Re: MUA or Surgery??

    Tough situation to be in Vickie Lynn. Obvious the least invasive is the MUA. That maybe the route to go because if the OS reports he did not have difficulty bending your knee, like the first MUA, then he could decide if it is mechanical in nature. Like to see how others respond who have been in nearly the same situation.
    I feel you have made the best move by posting and receiving information from a big population. There is no substitue for experience.
    Wish you the best,
    David
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  13. Campervan

    Campervan Sr Bonesmartie

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    Re: MUA or Surgery??

    Sorry to hear things aren't so good for you. My only thought is that you want to be sure the right thing is going to be done, so I agree with Minnie that maybe a third opinion. I'm sure Josephine will be online sometime soon with better advice. And since I started writing this, I see David has posted above me with great advice.
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  14. Jamie

    Jamie Administrator

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    Re: MUA or Surgery??

    Vicki Lynn.....sorry you haven't gotten the improvements in ROM that you hoped for with that first MUA. That happens sometimes.

    If it was my knee, I'd try the MUA again to see if it might bring improvements. That is less invasive, obviously, and it may do the trick. If it doesn't, then I agree that you need one or two more opinions on what is going on with your knee. Just don't rush into another surgery without being sure that is your only option for improvements.

    I'll tag Josephine so that she can see your concerns. @Josephine:
  15. Cynthia07

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    Re: MUA or Surgery??

    Well, can you walk? Can you get around? You might try swimming...
    My rom isn't so hot either but luckily I can get around...I have this blind faith that things will
    Improve over time... It takes time, really
  16. Cynthia07

    Cynthia07 Member

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    Re: MUA or Surgery??

    I wonder why everyone gets so hyped up about the rom.. Maybe your physical therapist can give you a really good massage to get the kinks out.
  17. Dhare63

    Dhare63 Sr Bonesmartie

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    Re: MUA or Surgery??

    Hi Vicki Lynn,

    You have situation similar to mine, except my issues are totally around extension. I am stuck at 10-12, with a flexion of 105-110.

    The issue is with that limited ROM, it makes it difficult to simply do the daily things most people take for granted, like stairs, car trips, etc. I feel your pain.

    The second MUA is a decent option but I think I remember Josephine not being a big fan of a second MUA. Thankfully it is non-invasive and you can bounce back pretty quickly.

    The second option described as a capsular release I believe. It would be very invasive and will require more recovery time. At 5 months, perhaps its too early for that.

    You should try water therapy and perhaps yoga to stretch and lengthen muscles. Massage can be another option to help stretch those tight, shortened muscles. I would exhaust many of these ideas before heading into a complicated surgery like capsular release.

    I am now 9 1/2 months out from TKR. I am seeing my OS next week to have this exact conversation; MUA or capsular release. I had a good experience with MUA initially, but lost extension pretty quickly due to aggressive PT that made me swell up quickly. I think it would have worked if not for that.

    No easy answers on this; you have to soul search to determine how much you want to endure right now. Best of luck and keep us posted!

    Dawn
  18. Vicki Lynn

    Vicki Lynn New Member

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    Re: MUA or Surgery??

    I can walk (somewhat of a limp or gait) and drive and generally feel better. I've debated just waiting a bit longer - have tried massage and the pool opens soon so maybe water walking. I am truly grateful I can walk - but I am pretty limited. Maybe I have not been patient for long enough - I had terrible swelling for a long time. It's much better - and I sleep at night!

    Thanks
  19. Vicki Lynn

    Vicki Lynn New Member

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    Re: MUA or Surgery??

    Hi Cynthia,

    Do you think the ROM will improve in time and I am being impatient? This could certainly be the case as I have learned I really did not understand how long recovery takes! I think I focus on ROM alot because the Dr and therapist say over and over it won't improve much after a certain amount of time.

    Thanks - Vicki
  20. Roy Gardiner

    Roy Gardiner Forum Advisor

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    Re: MUA or Surgery??

    You won't get good flexion or extension if your knees are swollen or painful. Has the swelling disappeared now?

    You don't say what you are doing apart from PT. You should be doing stretches, gently, many times a day; if you are not, this may be the answer. I'd suggest a programme of stretching for at least a month before even thinking about further surgery.
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