TKR 16+ weeks out and ROM of 90 degrees!

[maryo52]

It would be good to wake up your quad before doing MUA. There's something called "athrogenic muscle inhibition" that often happens to quad muscles when there's something awry in the knee. Basically the body reads a signal that the knee is bad and spares the knee by shutting down innervation of the quad. I worked with a physiatrist to get mine going again. The other thing you can do is get a second opinion.

MUA is a good option. 95% of the procedure involves all the anesthesia business. There's almost nothing to the procedure. I would not want to have to focus on getting the quad functioning after MUA. My emphasis was only on getting the leg bending the first month after MUA. Thus my suggestion you solve the "unable to lift leg" problem. But, hey, let's ask Josephine.

 

[sparkie]

Thank you maryo52, I really did not know that about needing to wakeup my quad. But what you describe about it just not functioning sounds about right. I really thought I would have some strength back in it by now. All that happens when I try to do the straightening exercises is a lot of puffing, panting and leg shaking!
no lift at all. It would be funny, if it wasn't so frustrating.
I see you had an MUA. How was it afterwards? Did you have to take more pain medication? I can only take minimum pain meds due to kidney condition and my OS says that unless I can control the pain after the MUA, it will be a waste of time.
Thanks again

 

[maryo52]

The pain after MUA was not bad. I scanned my old recovery thread yesterday and notice that I had the same worry. I would respectfully disagree with your OS. There is a widely held belief that inadequate analgesia contributes to scar formation. However, if you were to be really BoneSmart and just stick to gentle stretches after MUA, you wouldn't need much pain relief. You know, icing, elevation, rest, and once or twice a day going for some good stretches that are not in the pain zone. Not sure how things work in the U.K. but you should be getting help with that quad.

 

[sparkie]

Thanks again. I have just given up on 24 weeks of seeing an osteopath and he never mentioned the quad thing, so I am going off to email him and ask what he thought. Perhaps I have been a bit slow in asking questions? Although I have had some positive/happy moments, I have been taken aback by how much having this knee done has got me down. I was so positive before hand and ready for recovery knowing it was up to me. Now I know it is up to my knee! Believe it or not I was on what the hospital called a "rapid Recovery Program"! The only rapid part of it was how quick they got me up and walking and out of the hospital. I was just sent home and that was it.
I will make inquiries about my quad now. Thanks again.

 

[Josephine]

I do not seem to have made any progress at all since my last post. I can still only bend to 90 Degrees + a tiny bit more if he pushed on it.

Then it sounds like an MUA is appropriate after all.

I thought scar tissue that could reduce bend would take so much longer to form than this?

When people talk about 'scar tissue' they are invariably meaning two different things. There is the normal scarring where structures that have been separated, nature has to stitch together again just like the cut you get on your finger in the kitchen. This is scar tissue that is necessary else the wound wouldn't close up. The other type (and I hope you read the article about MUA and adhesions I left you earlier) is where structures that are supposed to glide against one another get stuck down because they loose their 'glideability'. This is adhesions. I don't think you have adhesions but I do think you have an excess of scarring which has become stiff and unyielding. This may have been caused by your early enthusiasm with exercising, or the lack of pain meds and icing, it may also have been helped along by your returning to work early - who knows? Could be any, all or none of the above.

No x-rays or scans to see what is going on in my knee and no information on whether the MUA would make things better or worse for me.

One thing we do know is that there is no scan or xray that will show up soft tissues to a diagnostic degree. Your surgeon has diagnostic skills and generally doesn't need such things to confirm such things as this.

I know in a previous post I was urging you to forestall this procedure but as time has gone on and things appear to have stalled, so I will beg your pardon by now saying the opposite. It seems that an MUA would be the appropriate thing to do now. You will find it's not such a big deal, it can be quite painful in the first 24hrs or so hours but you will be rewarded by a significant increase in flexion. Don't fear it. It will probably be your salvation.

 

[sparkie]

Sorry Josephine, I should have used the term "adhesions", not scar tissue. The OS keeps saying "scar tissue" and I have picked up on that.
I did read the articles and have just done so again. But I am not re-assured. One statement says that the pain will be controlled with morphine, which I am allergic to. I can only take paracetamol.
The OS wants me to have a spinal anaesthetic, of which I am totally petrified and will not have under any circumstances. l will have a general anaesthetic only.
I have read so much about MUA's and for some they work out well and in others not so good.
I mean; can I end up worse off? I am terrified of this happening. I have come so far and been through quite enough with this knee and I feel that I am one of the lucky one's in that I have had a relatively easy recovery compared to some, except for the limited ROM.
So as you can see, I do not know which way to turn and all the tears and fears have reared their ugly heads. Everyone I know, including my husband and close family + the osteopath keep telling me not to have the MUA and I am so torn.
Is there a chance this will ever get better on its own or is an MUA the only answer?
As you can tell I am in a bit of a mess about this decision.

 

[maryo52]

I do think it's unwise to advise a client or patient in a way that causes them to be conflicted. As nurses, doctors, osteopaths, etc., our job is to support people to move forward while respecting our patients/clients' process.

Sit down with paper and write down the pros and cons of each option. This helps keep the emotion out of the decision.

I don't know about you, but having my leg bend no more than 80 degrees, which was for weeks, felt very discouraging. I too experienced a mountain of uncertainty going through with MUA. Much more than with my TKR.

I had my PT telling me that MUA was wrong and I would get ROM with "hard work." Ultimately I dropped that PT because, well, HE was wrong. It turned out my knee was full of arthrofibrosis.

The pain after MUA was not bad although I was quite worried about it. You can ask your surgeon to specifically describe the procedure. I think visions of violently bending the leg come to mind. My ortho said he puts the patient on the stretcher on their back, grabs around the leg just under the knee, and gently but firmly bends the leg. Grabbing just under the knee prevents too much force from being used. The surgeon can feel the adhesions breaking. In my case there were 3 small adhesions and one large one that broke. There is no other way of breaking these adhesions that I know of. They can arthroscopically remove significant adhesions (which I required). But that would be the next intervention if MUA didn't work.

 

[sparkie]

maryo52 - thank you so much for taking the time to answer - you are so right. The indecision and uncertainty is greater now than when facing the TKR. Mainly because at that point I was in constant pain, could only walk short distances and as I know now, clearly uninformed. I thought "things can only get better". I wasn't warned about stiffness or limited ROM. Indeed I was told of a lady that was so flexible after her TKR that she went back to salsa dancing. SO as you can imagine, my expectations were far greater than my experience so far.
I have been able to bend reasonably easily to 90 degrees since about 8 weeks out (if I remember correctly) and there has been so little improvement since then. I can get to 95 degrees in the mornings when the swelling has gone down a bit overnight and my osteopath has pushed it to 100 which made me think there was hope and I don't need an MUA. Am I giving up on the bend too soon at 6 months out? But, I have had the same bump on the top left hand side of my knee since day 1 and this is where it hurts most and goes so tight it feels like it will burst if I try to go further. My knee is also very stiff when I stand up and it takes me about 30 seconds to stretch a bit before I can walk off.
Thank you for the describing the process and giving me the benefit of your experience too. I hope your progress continues.
Kindest regards

 

[maryo52]

It was very validating of my experience when the ortho told me he removed a 1/4" band tethering my a tendon to my femur. I had that same kneecap tightness.

I am three years out (almost) and have recently been able to run from my garden, up 10 steps and into the kitchen to answer the phone. So I guess forgetting to take the portable out with me has been good for the knee!

 

[Josephine]

One statement says that the pain will be controlled with morphine, which I am allergic to. I can only take paracetamol.

Actually, morphine sensitivity is not that uncommon. For most it's just a reaction in the arm where the IV is sited but others can have breathing issues. And morphine is not the only analgesic drug. As it happens, we have an intravenous form of paracetamol which is ace!

The OS wants me to have a spinal anaesthetic, of which I am totally petrified and will not have under any circumstances. l will have a general anaesthetic only.

What's made you phobic about spinals? Have you had a bad experience? I was always very anxious about the spinal but when it came to it, like a lot of other things, it wasn't any where near as bad as I'd imagined.

I have read so much about MUA's and for some they work out well and in others not so good. I mean; can I end up worse off? I am terrified of this happening.

My reading in the Journal of Bone and Joint Surgery (looked for it but sorry, cannot find it) that in general, TKR MUAs have around 85% excellent outcome with the remaining 15% ranging from very good, good, fair and poor. Not one of them was reported as actually being worse off after MUA.

 

[sparkie]

My reading in the Journal of Bone and Joint Surgery (looked for it but sorry, cannot find it) that in general, TKR MUAs have around 85% excellent outcome with the remaining 15% ranging from very good, good, fair and poor. Not one of them was reported as actually being worse off after MUA.

I was told that only 1% of TKRs need an MUA and I am one of the 1%, so what are my chances of being one of the few that is set back and then has no improvement at all?

What's made you phobic about spinals? Have you had a bad experience? I was always very anxious about the spinal but when it came to it, like a lot of other things, it wasn't any where near as bad as I'd imagined.

I read up about it and the increased risk of stroke. Also, as a premature baby I had some nerve development issues in that area and am terrified that things aren't where they should be and permanent damage could be caused? (what I know about this is nothing, so my fear is possibly just irrational, but I do not want to find out the hard way!) Also, I have never had a spinal but I have had about 12 generals with no ill effects, so feel I should go with what I know.

Thanks for your responses Josephine. I am really grateful for them.

I am slowly coming to terms that I will have to be brave and have the MUA. Even my husband is starting to admit that it is the only thing left to try.
I am booked in for it on 31st October and will just hope and pray that it goes my way.

Now my questions are this: surgeon says I have to keep bending my leg back and forth as far and as much as possible for at least 2 weeks post MUA. What do you think about this advice? My guess is that my still swollen knee will be even more swollen and painful. Should I follow the mantra of rest, ice and elevation or move as much as possible? Or a bit of both? What would be the best methods of getting that bend to work for me?

Sorry it took a while to answer. I am so up and down with this that I just needed to get my head around this.
all the best

 

[maryo52]

I was told that only 1% of TKRs need an MUA and I am one of the 1%, so what are my chances of being one of the few that is set back and then has no improvement at all?

Well that happened to me, and it's very rare, and was successfully addressed via an arthroscopic procedure.

I think it would be useful to recognize that your situation (and I was there too at one point) involves charting new territory for you at a time when you're quite vulnerable. It's makes us worry and dread, lose hope and be discouraged, which in turn colors our views on perfectly reasonable interventions.

 

[StillShortie]

Hi sparkie this sounds so much like me! Except I have buried my head for a little longer as i don't want to admit to myself or my family that my knee isn't great, in fact if anyone asks me i say 'it is great, i can walk it is just a bit stiff!' my LTKR was 18th March this year taking the 'ignore it and it will get better' and 'its better than it was so am i expecting too much' and 'get on with doing stuff of course it will hurt' approach and trying to carry on regardlessly of pain and reduced ROM!

I don't have a review appointment until November 14th but will be watching your thread keenly to see how you get on!

Sorry I can't add any advice (although it sounds like you have had some fantastic advice so far).

Take care
Shortie x

 

[maryo52]

There are articles in the library here about rehab after MUA. Generally surgeons tell patients to be aggressive with bending. I think that was part of my problem after MUA; I should have been icing and elevating a lot and doing gentle bends every day.

The basic concept that is important to grasp is that adhesions proliferate where there's inflammation. If you do as that doctor instructed, you will cause a lot of inflammation and that will be fertile ground for adhesion activity. You have to keep these tissues cool. Here is a great article to help you understand why.

This link takes you to an outline of a three part article. You have to click on each part to read the article. https://www.kneeguru.co.uk/KNEEnote...sis-rehab-tutorials-dirk-kokmeyer-pt-scs-comt

 

[sparkie]

Hi Shortie and maryo52,

Shortie, You have summed it up exactly. It is better than it was and time will make it better, I'll see how I go. For me, there has been no improvement. I will keep posting as I go. I am still awaiting answers from my OS regarding the questions I sent him over a week ago, but will the mua will still go-ahead on 31st October.

maryo52, interesting article and I can see where the advice I was given by my OS and hospital PT has basically set me up for adhesions. I was told that I should move and walk as much as possible but not over do it? no actual guidance of what "over doing it" means.
I didn't walk too much in the early weeks as I could barely move my leg and was on crutches. I know I did not ice as much as I should have as I was told by the hospital PT that I could use ice to hep with pain and swelling if I wanted to, but not to leave it on for more than 15 minutes in any one hour and not more than four times a day as I would get "ice burn" which would cause more pain. I thought that the burning in my legs over night was due to me icing too much and kept off it. I had no info' telling me that the heat in my legs was nothing to do with the ice.
I so wish I had found this forum earlier, but as the hospital had armed me with all manner of literature (none of it aligns with reality I now know) I had no need to search on-line. The hospitals booklet actual states that "your knee may swell for a week or two and if it does, rest it! A week or 2! I am 6 months out and my knee is still swollen!

I will be following the advice and exercises in the article post mua and will let you know how I get on.

Thanks so much
best regards

 

[sparkie]

What was that!!! Ouch

Can anyone tell me what happened last night? I was asleep in bed and I think I must have turned over? I then had the most terrific pain horizontally around my leg just below my knee and vertically down the back of my leg and around and down in to my shin and top of my foot. I think it may have been cramp as it went off for a moment and then came back with a vengeance. I mean, it was so painful I screamed out. I was in tears. My poor husband leapt out of bed and rushed around the bed to me asking what he could do and I just yelled "don't touch it" as he thought rubbing my leg would help.

Was it cramp? My "old" knee used to lock up causing similar terrific pain, but can my new one lock up? I thought those days were over?

I don't seem to have gained or lost any ROM, just gained a leg that is aching like who knows what today!

It would be helpful to know what may have happened and if it could happen again? I guess if it was just cramp, then it could happen time and again?

Thanks

 

[Roy Gardiner]

but can my new one lock up?

No, all that material is now in a bin somewhere . It must be a soft tissue thing of some sort, like the cramp you suggest.

 

[maryo52]

I'm with Roy. I think a cramp. However, it is possible for soft tissue in the knee joint to get swollen and inflamed (if you're doing too much) and get pinched in the knee mechanism, the way pieces of meniscus do. If that's the case, following the mantra will take care of it.

 

[maggie may]

Yes, a cramp I think. I have had some. As my PT says TKR is major trauma to the entire leg and involves all sorts of bones, soft tissue, muscles,etc. all very angry. Sigh.


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[sparkie]

Hi,
I thought it might be a sort of cramp, but wow it was something else in the pain department! Is it common? what causes it? I hope it was a one-off!

Thanks so much for your feedbacks. I really appreciate having somewhere to go with this.