TKR 60 degrees ROM at 2 weeks. No progress at all :-( <

bertschb

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So glad I found this forum! Here's my depressing story. I'm 57 and was riding my mountain bike 100 miles a week right up until my TKR 2 weeks ago (10/24/2016). I considered myself in great shape. My surgeon is one of the few I've heard of who does not recommend PT. He said he sees similar results from folks doing their own PT at home. Anyway, my knee has been at about 60 degrees ROM since the day after surgery. At my first post op visit on day 10 the PA said I should be at 90 degrees and recommended PT. I told him I had tried the home exercises but my knee felt like it was locked in cement. Because of that, I could only do a few of them. I saw the PT for my first visit that afternoon. He gave me some strengthening exercises to do twice a day but those did not include any bending of the knee. I'm now scheduled for PT 3 days a week.

I'm EXTREMELY worried that I will need a manipulation because my knee simply stops bending at about 60 degrees. It hits a HARD wall at that point. I stopped taking pain meds a week after surgery because I just don't have any pain which I'm very thankful for. I know many folks are on pain meds for weeks and months following TKR. That's the only good news for me. I'm able to walk around the house without aids. I spend most of my day sitting either in the recliner with leg elevated or in bed which lets my leg lay flatter to help with extension. I use ice about ¾ of the time. I get up and walk around a bit every hour or so. Yesterday I went outside and walked probably 800 yards. That didn't seem to bother it and it didn't swell afterwards but I've since read that wasn't a good idea so I won't do that again for a while. Swelling has dropped a lot since surgery but my knee is still pretty swollen.

So my question is, is there any chance at all I will regain my ROM with just PT? I've read about so many people who leave the hospital at 90 degrees. I'm blown away that they are at 90 and I'm barely at 60. As far as I know I'm doing what I'm supposed to be doing but I've seen ZERO progress in my recovery and I'm wondering if I made a huge mistake to get my knee replaced. I know it's only been two weeks but my knee is so stinking stiff I just don't see how any PT guy is going to change that. I will do anything and endure any amount of pain to get my ROM back.

Has anybody else gone from 60 degrees at 2 weeks to full ROM without manipulation? If so, how long did it take?
 
At my first post op visit on day 10 the PA said I should be at 90 degrees
There is no 'should be' in this game, it varies dramatically. It's irresponsible to say so as it sends patients into a spin (doesn't it... :)?).

There is nothing that can have gone wrong so fast after surgery as to provide a 'hard' block. Scar tissue and/or adhesions can do this, but you won't have any yet. The reason it won't bend is simply because it's swollen. As this declines, ROM will improve.

Everything else you are doing looks right. Relax, recline, watch telly, everything is fine.
 
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I just don't see how any PT guy is going to change that. I will do anything and endure any amount of pain to get my ROM back.
NOOOOO! Pain is the enemy of recovery. If you had a broken leg you would do precisely NOTHING and allow the body to heal; you surely wouldn't stress it. Same with TKR. If the PT person tries to hurt you, stop at once and sack them.

Here is the Bonesmart recovery philosophy in a nutshell:

- rest, elevate, ice,take your pain meds by prescription schedule (not when pain starts!), don't overwork.
- If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you
- If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it.
- Take note of the BoneSmart view on exercise and how exercise may affect pain and swelling.
- If you won't die if it's not done, don't do it; if you must do it, short and sweet, not hours on your feet.
- Don't stand if you can sit; don't sit if you can lie down, don't stay awake when you can go to sleep

Then, the FAQ (frequently asked questions) and Library index

Further reading.

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

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) and activity progress: suggestions
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
Sleep deprivation is pretty much inevitable - but what causes it?

Finally some 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
 
Thanks for the quick replies. My wife is taking care of 100% of the household chores and is waiting on me hand and foot. I am spending virtually all day sitting around doing nothing while my knee is elevated and iced. I do plan to take pain meds an hour before each PT session and I will take them any time my knee hurts but right now there is really no pain at all. I've learned I either have a high pain tolerance or the surgery just didn't upset my tissue and bones as much as some other folks experience. I understand I shouldn't have pain during PT and if my PT guy does something that really hurts, I'll definitely speak up. My point is simply that I'm willing to do anything to get some ROM.
 
OK, message received.

But the lesson is this: you don't do anything to get ROM, it can't be hurried. You can do gentle stretching exercises to keep your leg moving, but anything that hurts is compounding the damage and worsening recovery. This is because your soft tissue has been damaged in surgery and needs to heal, not that your leg is unfit needing training. Please don't take painkillers before PT, it might enable you to overdo things, not what you want for the reasons I've outlined.

You will get ROM by waiting and allowing the body to work. The knee is in charge.

And if you can walk 800 yards without subsequent swelling, you are doing well. Although, as you say, I wouldn't recommend it!
 
My ROM was 61 at my first PT session, and now it is close to 110 at almost 7 weeks. You said your knee is still pretty swollen. That is probably what is keeping it from bending. Give it some time and try not to worrry.
 
I agree with what the others have said, give it time, your ROM will slowly increase.
Be sure to read the articles Roy left you, and follow the BoneSmart mantra:
Rest, Ice, Elevate, and Medicate on schedule as prescribed.
 
I told him I had tried the home exercises but my knee felt like it was locked in cement. I'm EXTREMELY worried that I will need a manipulation because my knee simply stops bending at about 60 degrees. It hits a HARD wall at that point.
Well, maybe you overdid the home exercises!
I stopped taking pain meds a week after surgery because I just don't have any pain which I'm very thankful for.
THAT was a big mistake. I think you are comparing this 'pain' to the arthritic pain you had before surgery. They are chalk and cheese. Pain also manifests as soreness, burning, stabbing, throbbing, aching, swelling and stiffness. If you're not treating that pain then the stiffness will mean a poor ROM.
I do plan to take pain meds an hour before each PT session
That is also a big mistake. Pain has a purpose in PT as it warns you when you are doing too much, being pushed too much and etc. Blocking or ignoring that means MORE swelling and therefore MORE stiffness. Read the articles Roy left you - also this one BoneSmart philosophy for sensible post op therapy.

Additionally, I'd like to ask you some questions if you don't mind, and it would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine)

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how swollen is your leg compared to these?
ai63.tinypic.com_eta39s.jpg


4. What is your ROM - that's flexion (bend) and extension (straightness)

5. are you icing your knee at all? If so, how often and for how long?

6. are you elevating your leg? If so how often and for how long?

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

8. what kind of PT exercises and exercises at home are you doing? How much and how often?
This is the most crucial question so please help me by using the format I have left as an example
(which means please make a list and not an essay!)

Exercises done at home: (how many sessions each day)
enter exercise then enter number of reps and sets
etc., etc.
 
Thanks again for the replies folks. Very helpful!
To respond to some comments- I didn't over-do any of the home exercises my surgeon gave me during the first ten days. I was barely able to do them. As for meds, are you suggesting I take meds even if there is no pain? When I say I have basically no pain, I'm not kidding. Before this surgery I thought I was a whimp when it came to pain but now I'm thinking otherwise. My knee only feels stiff when I try to bend it past say 60 degrees or so. I have read all of the articles and I'm following the mantra!

To your questions Josephine:

1- Current pain level - 1
2- I was prescribed 1-2 5mg Oxycodone every 4 hours as needed. I stopped taking them after the first week because there is no pain.
3- Swelling is moderate per the examples you posted.
4- ROM was measured at 65 and 10 today when PT started.
5- My knee is on ice about 85% of the time I'm awake.
6- My knee is elevated about 80% of the day. I sit/lay in bed the rest of the time to help straighten my leg and improve extension.
7- Zero activity. My amazing wife does everything for me.
8- Home PT exercises done twice daily as follows (but these only started last Friday when PT started):
- Assisted leg lift while on my back (10 reps)
- Side leg lifts held for 5 seconds (10 reps for each side)
- Leg lifts while on stomach held for 5 seconds (10 reps)
- Push knee down while sitting on floor (3 sets of 10)

I am feeling better after my second PT session this morning because my ROM was better afterwards. My PT guy didn't measure it but I'm guessing it was in the low 70's. He did bend my knee quite a bit for about a minute or so. It wasn't painful but it was pretty uncomfortable. All of the other stretching exercises he had me do I controlled the amount of stretching which I really liked. I bent the knee so it was uncomfortable but it didn't hurt. All I want is improvement. I don't care if it takes a year. I just want to know I'll regain use of my knee and I won't have to do a manipulation to get there.
 
You are so early on in the post-op recovery that a ROM of 60 is pretty normal...I was at that with both my TKR. Please be patient as it takes many weeks and sometimes months before we reach our goal.
Once the swelling goes down, you will notice improvement of ROM. It's just something you can't hurry.
If you have a stationary bike, adjust the seat up high & try and ride it slowly rocking your foot back and forth for a few weeks, until you are able to make a full rotation." Patience Grasshopper" as the saying goes:yes!:
 
My PT guy didn't measure it but I'm guessing it was in the low 70's.
All I want is improvement. I don't care if it takes a year. I just want to know I'll regain use of my knee and I won't have to do a manipulation to get there.
You're already at about 70 degrees, making slow improvement, so I don't think you need to worry at all about needing an MUA. You'll get there under your own steam.

Your therapist would probably like you to make faster progress with your ROM, but try not to worry about that. Your knee will do it in its own sweet time.
Sometimes, PTs get a bit obsessive about the numbers. That's because it's a way that they can demonstrate that their ministrations are effective.
That doesn't mean that you have to get caught up in the numbers game.

Did you know that ROM can continue to improve for a year, or even longer, after a TKR? There's no magic window of opportunity, within which time you have to achieve ROM, or all is lost.
Myth busting: the "window of opportunity" in TKR
 
I think my problem is I came into this expecting to be one of the people with better than average results, not way worse than average. I'm fairly young. I'm not overweight. I was riding my mountain bike 100 miles a week right up until the surgery. Up until the last year I was hiking, biking, kayaking, skiing, snowmobiling, scuba diving - you name it. I'm in decent shape and just did not expect to have such horrible ROM after the surgery. But, because of this forum and seeing some progress after today's PT session, I'm now hopeful!! I will be patient and I'll be grateful for every degree of ROM I regain!
 
It's often the way that people who are fit expect to recover faster. The problem is that your knee doesn't know that. It's suffered just as much trauma as any knee that has a TKR - and it is major trauma.
Your knee needs time and gentle treatment, so that it can heal without disturbance.

Very often your mind gets ahead of your knee and expects it to do better. Your knee knows what it's doing, though, so do try to be patient and "listen to the knee". It will tell you when you're trying to do more than it is ready for.
Where are you in recovery?? (TKR)
 
My PT guy didn't measure it but I'm guessing it was in the low 70's.
Do not worry about numbers---PT folks are quite an quantitative lot. What truly matters is what you can do with your new knee after you are fully recovered.

He did bend my knee quite a bit for about a minute or so. It wasn't painful but it was pretty uncomfortable.
Do not let him hurt you---ever. Pushing for more ROM is counter-productive.

I think my problem is I came into this expecting to be one of the people with better than average results, not way worse than average. I'm fairly young.
There is no such thing as "normal" when it comes to a TKR or a BTKR recovery. Everybody recovers differently---and even knees done at the same time do not recover in the same way---after my BTKR my right knee was much more troublesome than my left knee.

You have to be patient---my BTKR recovery took me six months to get to 80%-85%, and it was not to about eight months or so that I got to 90%-95%-approaching 100%. I also gained ROM in tiny increments well after my one year post-op anniversary.
ai1195.photobucket.com_albums_aa394_referee54_kungfu.jpg

Patience, Grasshopper, Patience!!!

There is no schedule here---your surgical knee has made the schedule for you and you just have to go along with it.
 
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Not sure if anyone else mentioned this, but don't let the PT push, pull or hold your knee in any position. ROM is about where you can get your knee under your own power. Taking pain meds before PT could lead to a further pain later because you'll be unable to tell when something is painful and need to stop. Just take pain meds on schedule. Stiffness is a form of pain, so you could try Tylenol throughout the day, just becareful not to go over the recommended allotment.
 
I am at 11 weeks tomorrow. I just hit the 92 ROM mark last week. They also told me I was to be at 90 when I had my staples removed at 2 weeks. Everyone heals differently. It takes time. I was very frustrated like you are. Just don't over do it and ice it a lot! No worries...it will come in time.
Karen
 
It is interesting that these folks who have never had a TKR are placing you on a schedule.

If they had a TKR, and were put on a schedule, they would quickly realize how frustrating and ridiculous it is.

The only thing that is normal in a TKR recovery is that there is no "normal." There have been a few on this forum during my time here that have amazingly quick recoveries, but those have been far and few in between. Most of us realize that we are truly in it for the "long haul" and that it will take longer than we expect and are prepared for.
 
They also told me I was to be at 90 when I had my staples removed at 2 weeks.
I was thinking about this---what are they going to do if you not?:heehee:

Everyone heals differently.
Yep, unfortunately, some of these folks seem to think that our recoveries must all be the same and regimented.

It takes time.
You bet---longer than we are prepared for and longer than we would like it to be. I was told that I could go back to the classroom at eight weeks---I thought that, at eight weeks, that would be my "magic number." Boy, did I have a lot to learn!

I was very frustrated like you are.
We have to come to a realization that the knee has been pretty much devastated during surgery. Once we understand that two bones have been sawed off, bones were possible filed, pounded and drilled, glued (this type of surgery is not at all gentle) and then you are finally closed up, we can then move on in a healthy manner with the idea that it will take longer than we originally thought it would to be fully recovered. I did gain ROM in tiny increments well after my one-year anniversary of my surgery.

Another thing about the frustration---come here and vent, rant, etc----that is what we are here for!
 
Hi bertschb!
Fellow Oregonian here from the other side of the mountains... you are getting super advice from everyone here! I am a "slow bender", too, but learned here that normal is whatever your knee decides. It's not a numbers game like some PTs think to try; you can't get better ROM by working hard. It's frustrating to those of us who've been active, were able to direct our bodies in athletic pursuits and now suddenly find that this is different. You will get there, but on your new baby knee's schedule, not your brain's, that's all. The "Patience, Grasshopper" meme is a good one for recovering from this surgery. Have you access to a stationary recumbent? Since you like to ride, my PT had me move the seat way out, and just had me go part-way around to where I needed to stop, spending maybe 10 min. doing that rocking back and forth. It felt really good! I didn't inflame it, but it felt so nice to very gently move my knee a teensy bit more each time I did it. But you won't be able to go far, and just let that be okay! You're probably not really ready for this yet, though; I was at 3 months when we started this... But, if there's a rec center or gym that has one of those recumbents, your body might like that movement once you get to a point that it is sensible... Hang in there and do read the articles you were sent, etc. The folks here really know their stuff as we've all been through it, and some of the moderators have medical backgrounds and have seen it all!
 

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