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  1. PLEASE NOTE THAT ONE RECOVERY THREAD ONLY IS PREFERRED. PLEASE DON'T START ADDITIONAL THREADS ABOUT YOUR RECOVERY.

[TKR] Scar Tissue after Knee Replacement

Discussion in 'Knee Replacement Recovery Area' started by Zoie, Apr 9, 2013.

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  1. Zoie

    Zoie New Member

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    Had a knee replacement 10 weeks ago. Due to early scar tissue formation, had to have a manipulation at 5 weeks post-op. Initially, it looked like it worked (in first week), but by the second week, scar tissue was forming again. I now have a "frozen knee" and am stuck at 85 deg. bend and 10 deg. on the extension. My OS said he does not want to do a second manipulation (because the first one did not work) and is advocating scar tissue removal via surgery. Has anyone had this done and what has been their result? Has anyone had a second manipulation that worked? It doesn't seem like cutting into my knee and either surgically removing the scar tissue or "releasing" is a good idea......
     
  2. Campervan

    Campervan Sr Bonesmartie

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    Welcome to Bonesmart. I can't help with the scar tissue, but I can say that I've had a very slow recovery with gaining ROM. I was 90 when I left the hospital, 92 at 8 week appointment with OS even though physio measuring 102. Then 105 by physio at about 3 months and stuck there for months. at 10 months got to 110-112 and then finally at 14 months got to 120. I saw my OS at 15 months and he measured 118. I was told I'd get somewhere up to 130 as I don't have a high flex implant.

    I guess what I'm saying is that at 10 weeks you are still very early in your recovery and there is time to get the ROM you need.

    One the moderators will ask you a bunch of questions, which I'm sure will include:
    - how have they proved its scar tissue?
    - what medication are you taking?
    - how much exercise are you doing each day?
    - what daily living chores are you doing, such as cooking dinner, cleaning house etc?

    Hope that's all some help to you for now.
     
  3. Roy Gardiner

    Roy Gardiner Forum Advisor

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    hi, Zoie, welcome to BoneSmart.

    The BoneSmart consensus would have it that in general 5 weeks is far too early for MUA, and 10 weeks too early for more surgical intervention. But you need a real medical opinion, so I'll alert the Boss for you Josephine
     
  4. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator

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    And I bet you anything that your surgeon gleefully told you how he'd got an absolutely terrific result while you were under, didn't he? There are very simple and logical explanations for all this....
    a) 'scar tissue' (more properly named adhesions) does not form that quickly
    b) what was blocking your ROM was nothing more sinister than swelling and pain
    c) the MUA may have overcome the swelling initially but the aftermath of an MUA is, unsurprisingly, swelling and pain
    d) since it was swelling and pain that restricted your ROM in the first place, obviously the rebound swelling will block it even more.

    So you are still only 10 weeks out and still time to recoup the situation which, you will be pleased to know, will not involve any surgery or MUAs!

    The simplest thing for me to do (for me at any rate!) is to leave you with our set of recovery articles which should address all your concerns here. Read them all, digest them and if there are any points you want to discuss or clarify, please feel free to give me a shout. You can do that by adding the @ in front of my name and if you've done it correctly, when it's posted, it should turn into a blue hyperlink.

    Right, here goes

    First I have some questions to ask you:
    1. what medications have you been prescribed, how much are you taking and how often?
    2. how often are you icing your knee?
    3. how often and how high are you elevating your leg?
    4. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and PT?

    Then our BoneSmart mantra ....
    - rest, elevate, ice and take your pain meds by the clock
    - if it hurts, don't do it and don't allow anyone - especially a physiotherapist - to do it to you
    - if your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again
    - if you won't die if it's not done, don't do it
    - never stand when you can sit, never sit when you can lie down, never stay awake when you can go to sleep!

    And those crucial articles of which I spoke
    Swollen and stiff knee: what causes it?
    The importance of managing pain after a TKR and the pain chart
    Activity progression for TKRs
    Myth busting: no pain, no gain

    Healing: how long does it take?
    Chart representation of TKR recovery
    Energy drain for TKRs
    Elevation is the key
    Ice to control pain and swelling

    Home physio (PT)
    Myth busting: the "window of opportunity" in TKR
    Myth busting: on getting addicted to pain meds
    Post op blues is a reality - be prepared for it

    And finally, wise words from members who have shared their experiences ...
    Where are you in recovery?? (TKR)
    Five “P’s” of knee recovery
    TKR: work “smarter” and not “harder”
    Recovering a knee - from one who knows!
    It's never too late to get more ROM!
    It's worth the wait for ROM
     
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  5. Zoie

    Zoie New Member

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    Hello - thanks so much for the quick response! I am going to Physical Therapy three times/week where they push the knee as far as it will go in an effort to get more flexion and extension. They tell me that there is NO WAY they can break the scar tissue or dramatically improve it via physical therapy and that I need medical intervention. Now, from what you have told me, it makes sense to wait and work with PT. It is still swollen and red. I had my left knee replaced six years ago and had the same problem with scar tissue. I had a manipulation at 10 weeks post-op and it worked great - had no problems after that! Don't know why it hasn't worked this time!

    Now that I'm reading all these posts (I'm SO GRATEFUL to have found this forum), I see that I need to wait and just let things heal. I am very active - make dinner every night, go to PT, go to a therapeutic swimming pool and walk in water and take walks around my home. I'm also seeing an acupuncturist twice/week. I take Percocet for the pain which is still substantial. After talking to my doctor yesterday, he was VERY negative implying that I may be stuck like this for the rest of my life, so until I found this forum, I was VERY depressed (I'm only 64).

    Do you currently have a stiffness in your leg or is it completely normal?
     
  6. maryo52

    maryo52 Sr Bonesmartie

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    Zoie, been there done that. I guess I knew early on that I had arthrofibrosis because my ROM had a "hard stop." No matter what the status of my swelling was, my bend always stopped at the same place. It's important to really give a go at being gentle with the knee and addressing the swelling to see if any improvement comes. If it increases even to 90 after a couple of weeks of this kind of TLC, then you know that it's not scar.

    I had MUA at 8 weeks. The ortho felt 3 small pops and one big one when he did it, which validated the procedure in my eyes. I got to 97 at the first PT session afterward. My next measurement was 90. And then I refused to be measured because I could tell that it was less and less. By the time I had the arthrolysis, I was 70 and very discouraged.

    My ortho had already mentioned that some patients need the scar tissue taken out, so when he proposed it I was ready. It was arthroscopic (the preferred technique according to research), and took an hour. The recovery was no big deal. He found scar tissue obliterating everything, and a 1/4" band of tissue tethering my bone to my quad which explained the hard stop on my ROM. I have pictures!!

    One thing I will say is this: don't expect the ROM to initially improve a lot if you have this procedure. I was 10/85 after the procedure. That didn't change for a month. I actually went and got a second opinion, and that doctor didn't see much hope. But you know what? I just kept up with the steady but very gentle twice daily stretches (10 each session, holding the stretch 30-60 seconds), and kept taking pain medication along with NSAIDs, and stayed away from physical therapists. And finally I slipped past 90 and very slowly increased. When I reached 105 I was 6 months post-TKR mark and needed a vacation from the knee -- or rather, it needed a vacation from me. After that I gave up "trying" and took up living again and my ROM increased another 20 degrees without any effort at all.

    I hope this helps you feel better about what your doctor is proposing. I'm guessing you've been through some aggressive PT to get that knee bending, and I don't want to conclude without cautioning you that some people (me included) believe that PT that hurts provokes scar tissue formation if you have arthrofibrosis.

    I also want to mention that at 2 plus years out, I still have an effusion and my synovium is thickened. So my knee feels tight and looks larger than the other. My quad is also atrophied (due to the scar saga) but I'm working on that. Hopefully you'll be a little luckier than I was but I'm not complaining. My knee is good enough that I forget about it 99% of the time.
     
  7. maryo52

    maryo52 Sr Bonesmartie

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    One other thought: did your OS feels "pops" when he did your MUA? How many?
     
  8. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator

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    Do NOT let them do that1 It's not only unnecessary, it's counter-productive in the extreme. Like I said before, doing that only causes MORE swelling and makes your problem worse. Good ROM can take months to acquire. Did you read the articles I left you? Plenty of real evidence to that in there.
    Far, far too much far too soon! You are only 10 weeks out and should be resting more. Did you read the articles?
    Which goes to prove beyond a shadow of a doubt that all I have said before is correct. You should not be having 'substantial' pain at this stage. Far too much, far too soon.
    That is so cruel and totally UNTRUE! Did you read the articles? Many members reporting a continued improvement in ROM after a year and more (including me!) Read the articles! (or did I say that before! :heehee:)
     
  9. Zoie

    Zoie New Member

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    Hello - thanks so much for your information packed timely reply! You are right - my knee is still swollen and inflamed. They have given me an anti-inflammatory gel called Voltaren (diclofenac sodium topical gel 1%), but after about 10 days use, it doesn't seem to have done anything.
    To answer your questions:
    1) My medications are: Oxcodone 10-325-I take every 4-6 hours, Oxycontin 20 mg-I take every 12 hours. I did a 10 day course of Medrol (a steroid) about 3 weeks ago to try and reduce the inflammation (no change). I also take meds for pretty severe asthma, and acid reflux.
    2) I am going to Physical Therapy three times/week and I ice my knee after coming home. I have one of those ice machines that deliver constant cold to a pad that you wrap around your knee.
    3) I elevate my knee quite a bit - at least 3-4 hours per day as it feels better when I do.
    4) I'm pretty active now as my energy has recovered from the surgery. I had my sister here for 9 weeks, but she left last week. I'm retired, but I cook dinner every night. I just started driving, so I go to the grocery store, PT, doctor and acupuncture appts, etc. I'm also going to acupuncture twice per week and taking Chinese herbs. About 1-2 times per week, I go to a theraputic pool to walk for an hour. The pool is at 93 degrees and is just for people rehabilitating from mostly joint problems. Am I doing too much? I know it is a fine line between resting and activity. I don't want to lose the 85 deg that I already have in the bend (I'm 10 deg. from straight in flexion). I just thing if I am inactive, my leg/knee will get stiffer?
    I didn't quite understand your instructions about putting an @ in the front of your name to reply?
    I was so depressed yesterday after leaving my OS's office. My Physical Therapist had told me that there is really nothing more they can do for me - I've been stuck at the same point for the last 5 weeks - and that I need more medical intervention - probably a second manipulation. My OS doesn't want to do a second manipulation (is that MUA-don't quite understand your acronyms), because the first one didn't work. Interestingly enough, I had my left knee replaced six years ago and had this same scar tissue problem. My OS did a manipulation at 10 weeks post-op and it was fine after that and my left leg/knee is completely normal now -no stiffness at all! I content that he did the manipulation too early this time (at 5 weeks post-op). Now, my OS wants to go in and cut or release the scar tissue, but said it does not have a good success rate. He told me I may be stuck like this for the rest of my life. AND - the surgery may leave me worse off! (Don't worry, after reading all these threads, no way I'm going ahead with any surgery anytime soon!). I found this forum last night and I'm feeling better now after reading all this info I didn't know! (Thanks so much).
     
  10. Jamie

    Jamie Administrator

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    Hi, Zoie....welcome to BoneSmart!

    Please take Josephine's post to heart and read every spec of the information she provided. You are ONLY 10 weeks out from a major surgical procedure PLUS you have now had a manipulaiton which also irritated sensitive tissues that were trying to heal PLUS you have a therapist that's pushing you AND you are very, very active for this early in your recovery. Put that all together and it's no wonder that your knee is rebelling!!! It's telling you to slow down and be kind to yourself!!

    Tell the therapist to knock off the pushing and pain. You are in control of your recovery and you have to right to request that only gentle bending and stretches will be permitted until the swelling is under control. If the therapist can't abide by your wishes, find another. There are plenty of good ones out there who understand knee replacement recovery.

    Cut out all the activity unless it's something that absolutely MUST get done. Your number one priority is to get the swelling minimized. It's important to note that you cannot base anything about this recovery on your last one. Each knee does it's own thing, so just deal with each day as it comes and don't compare to past surgeries.

    I'm sorry to hear your surgeon is giving you the "gloom and doom" speech. Try not to let it get you down. I think you'll find things MUCH improved in a couple of weeks if you will just slow down, spend LOTS of time icing, resting and elevating, and be sure you're taking your pain meds on a schedule through the day and night. Your knee needs time, not more intervention at this point.
     
  11. maryo52

    maryo52 Sr Bonesmartie

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    Well you have way too many opinions and whatnot swirling around you. I remember how confused and discouraged I was in your shoes. VERY discouraged.

    Number one, you will not be stuck like this (I wish all medical professionals would remember that hope is everything when it comes to getting better). So that's factually untrue. Number two, the arthroscopy will work if it turns out you need it. Number three, I'd ditch PT. Pushing your leg to bend is pointless. Number four, voltaren didn't work for me either. I used celebrex. Number 5, are you elevating above your heart (which requires you to lay down)? The other self care measures will help you feel better, and help you feel as if you are doing something while the knee gets itself sorted out.

    Sorry to be another yapping voice in your ear but remember, I've been there. Please try to give your knee a good honest vacation. Once or twice a day do some gentle stretches. The definition of gentle that I like is no more than 3 on the 0-10 pain scale.
     
  12. Jamie

    Jamie Administrator

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    What Josephine was describing is the method we use to "tag" her or another member when you have specific questions. You type the "at" sign @ followed by the member's name with no space in between. Put this anywhere in your post and when you hit the POST REPLY button, you'll see the Zoie (or whoever's name you typed) turn blue, creating a link.

    Please don't worry about losing the ROM you have. It's not going anywhere. You have more ROM in there, but it's just hidden behind all that swelling. Also, don't worry about the release from your therapist. In many countries, patients have NO formal thereapy after a TKR and they do just fine. You can do this yourself by doing some gentle stretches and bends several times a day. Walking in the pool is fine, but I would NOT do a whole hour of it until your swelling is under control....maybe more like 15-20 minutes would be better. Doing some turns on a stationary bicycle is a good exercise too, but start off slow....5 minutes or less for the first week. At this point, you're not building any strength, you're just keeping your joint moving.

    I'll venture a guess that your previous surgery worked "in spite of" that manipulation, not necessarily because of it. So please don't assume that you are never going to have any more movement than you have now. We have members who gain ROM for as much as a couple of years following surgery. You'll feel better about all of this once you slow down and start seeing a reduction in your swelling.

    The anti-inflammant is fine, but really this early in your recovery the BEST thing to help swelling is to reduce your activity, ice and elevate. I've been going through this myself with my 5-week-old knee (my second TKR). It took me weeks to get the swelling under control and I still have to watch what I do. You want to ice not just 3-4 hours, but whenever you are sitting or lying down. I kept ice on my knee all through the night too until just a few days ago.

    Please keep in touch with your new BoneSmart family. We care about you and will help you see this through!!
     
  13. Zoie

    Zoie New Member

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    No - he did not hear any "pops" and anything that indicated that he had broken the scar tissue. In fact, he came out after the surgery and told my husband he was surprised how "easy" it was to move the knee through the scar tissue. This indicates to ME that it was too soon and that the scar tissue was soft and pliable and then all he did was stretch it, NOT break it (and it has contracted back). He has admitted to me that perhaps 5 weeks post-op was too soon which would say to me that doing a second manipulation (is that MUA?) now at 10-12 weeks post-op would be useful as the scar tissue would have hardened enought to break it?
     
  14. 60mom

    60mom Senior

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    I have a similar history so I will give you my story. I had my RTKR 15 wks ago. At 5 1/2 weeks I also had an MUA. I did get to 122 in PT that day but of course it dropped back to 90 after a few days from the swelling. I suffered in a lot of pain and swelling after my MUA. But I made some changes. I got a new PT who was very gentle and did more massage and gentle manipulation then over flexing my knee. I stopped really flexing my knee to pushing and just did it gently. I really used my exercise bike for my flexion and it always felt good. Occasionally slight pain but it would subside after a few rotations. I actually tried more to get on with my life and let my normal activities normalize flexion. Don't get me wrong I do a lot of leg strengthening in water and other exercises to increase my strength but I try not to do too much bending because it really causes me a lot of swelling still. I am now at 120-125. My PT does not check my flexion very often, last it was 120 and I think it has increased since then because it seems to bend now as far as my other knee which is at 125. I personally think my over zealous PT caused me to have so much swelling and that is why it wouldn't bend or was why I had adhesions if I did. I did loose that tight band after the MUA. I firmly believe now that this over doing it in the beginning just sets us off down a path of swelling, pain, and loss of flexion. I think some people get away with it and do well but not most of us. I think we actually slow down our recovery. I now need more surgery on mine for a different problem but will follow my recovery after my MUA. I can't even due to much flexing now as my knee catches and causes me a lot of pain so I do just the strengthening and ride my bike without full rotation so that it won't catch. Last night I checked to see if I was loosing flexion and it looks like I haven't so I would not worry about not doing much bending because I haven't been able to for 3 wks now and my flexion still seems to be the same. Hope this helps in some way. :)
     
  15. maryo52

    maryo52 Sr Bonesmartie

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    It seems you're getting your thoughts in order based on our comments. There's no harm in putting off further interventions in order to take time to see how kindness affects your knee and your bend.

    BTW I received a very different kind of advice when I came on this forum. Once in a while someone has true scar tissue and they need intervention, and I was one of them. With your further comments, it doesn't seem like that's true of you.

    The Tipping Point is a book which I never read, but I use the concept often. Sometimes small changes make a big difference.
     
  16. Zoie

    Zoie New Member

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    I have read all of the articles you referenced Josephine! Josephine (did I do that right?). All of this info has helped me so much! I see my OS again on Monday where I will tell him that I am refusing any further surgeries or MUA's! I'm going to follow the Bonesmart way! I wish I would have found this Forum before my recent MUA!
    Anyway - I'm going to be doing a whole lot more icing, elevating and resting. And - my emotional mood has completely changed for the better. After talking to my OS yesterday, I was a basketcase when my husband came home from work last night! He was kinda shocked as I am always so upbeat and optimistic - think I scared him a little! Then I found your Forum late last night because I could not sleep.
    I now know this will get better with time! I'm going to stop going to PT three times a week and back it off to once per week and just have her do very gentle things. It's been such a vicious cycle of aggressive PT appointments which results in swelling and more inflammation and no improvement in the bend & flexion. I now see clearly what has been happening!
    Thank you all of your input and I'll keep you posted as to my progress.
     
  17. maryo52

    maryo52 Sr Bonesmartie

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    Zoie, I see you are soaking up Bonesmart today. I am thinking of you. I remember how discouraged I was at your stage of the game. I am so impatient (many of us on here are). I was used to pretty much doing whatever I set my mind to (true of many others here). So the duldrums of a difficult recovery really affected me.

    It really is too bad that so many people in the knee replacement business are so aggressive with our TKRs. We on Bonesmart refer to the post-TKR knee as "injured." These knees have to heal as well as regain ability. But the healing is first and foremost and cannot be skimped on. We're always thrilled to be able to teach people the proper care and feeding of the post-TKR knee!
     
  18. maryo52

    maryo52 Sr Bonesmartie

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    Yeah, it would be interesting to see the most common time of day that people start their threads. I'm willing to bet 2 a.m. is a particularly popular one!!
     
  19. Campervan

    Campervan Sr Bonesmartie

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    Hi, an analogy I picked up from somewhere is to compare your knee to a hosepipe full of water. It won't bend till you let the water out. Same with the knee - it won't bend till you get the swelling down.
     
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  20. referee54

    referee54 Moderator

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    Patience is a tremendous virtue ---especially when dealing with a TKR recovery. Things will move slowly---sometimes so slowly that they appear to be not progressing.

    However, the harder yo work, or the harder you allow your PT to push either you or your knee, the slower (or standstill) your knee will heal and begin to regain its function. This is not a time to be pushed or to push yourself---you have to fight that temptation. Take it slowly, take it gently, and listen to your knee. Ice, elevate, and rest, as the others have said---and remember, we all heal at t different times and in different ways. Total recovery from a TKR can take upwards to a year, so there is plenty of time yet.

    for what it is worth, I also had adhesions, but I broke them myself---but, as others said, they did not reform---it just takes patience and gentleness in the approach to recovery.
     
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