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[TKR] cmma01 with two new knees^

Discussion in 'Knee Replacement Recovery Area' started by cmma01, May 11, 2019.

  1. cmma01

    cmma01 new member
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    Hi everyone.

    This BoneSmart forum has been a wonderful resource for me over the months. Thank you. Also the Bob and Brad physiotherapists' daily videos on YouTube.

    I had a left TKR in October 2018 and fortunately seemed to fly through that one no problem. Yes of course it was sore for a while post op but with gentle exercise and long extension holds and bends, I was back at full ROM very quickly, walking and exercise biking well and I was discharged by my physio after just 4 sessions with a print-out of strengthening exercises. Walking was no problem (with that leg).

    Then I had my right knee done in March 2019 and wow ! what a different experience! Same surgeon, same hospital. Same physios.

    This right knee recovery is so very much more painful than the left knee that if I'd had it done first, I probably wouldn't have had a second tkr done! The joint is incredibly painful and stiff and resistant to the physio extension work. My surgeon says there's no infection there.

    It's not particularly swollen anymore, and icing and heat pads aren't helping. Due to kidney problems, I'm not allowed NSAIDs any stronger than ibuprofen and opiate-based painkillers make me nauseous and hyper. So sadly I'm stuck with ibuprofen and paracetamol. Turmeric and Curcumin, which people seem to swear by, unfortunately hasn't worked at all for me.

    My right leg is now stuck in a slightly bent position, and my surgeon says I will need to have an MUA done under general anaesthetic very soon to get the leg flat. A 15-minute procedure, he says, but I'd imagine very painful afterwards??? Any comments on this?

    With the left knee, once the staples were removed and after regularly massaging the scar using bio oil, the scar faded and became painless and very soft quickly, However, the right knee scar is hard and the same massage isn't changing things much. With this knee, when the staples were taken out, there was no pain relief at all and the subcutaneous stitch line could be felt like hard, lumpy, wavy string.

    Now, 7 weeks after the op, this long stitch is just starting to dissolve, but the skin wound still feels incredibly tight. I can bend my knee ok but it feels weird and the stretch on the skin feels so tight that although I know it won't, it feels like the wound will split open

    Recently, on one tiny, tiny section of the scar, over the knee cap, there is what I think must be a nerve pain triggered by the very lightest touch, a brushing against clothing or a bed sheet. It is like a needle being poked sharply into the skin and it is horrible. Will this go? Any searches I've done about post TKR nerve issues, seem to focus on either numbness or nerve pain within the knee interior. So what is this acute needle like pain on the skin surface? There's no heat or swelling there. Just a highly sensitive area of skin.

    Finally, although I can now walk well, climb and descend stairs normally etc, (apart from the bent knee), simply standing still is extremely uncomfortable and if I have to stand for longer than 5 minutes, I just have to sit down to rest. Why is this?

    I would really appreciate comments suggestions. Thanking you all in anticipation.
     
    Last edited: May 11, 2019
  2. Jaycey

    Jaycey SUPER MODERATOR Moderator

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    @cmma01 Welcome to BoneSmart! Can you please give me the exact dates of your surgeries? I'll put them in your signature for you.

    Your right knee is proof that no two TKR are the same - even on the same person. Does rest and ice ease this - by rest I mean stopping any exercise or PT.

    Regarding manipulation - sound like you really need to give that knee a chance to settle. MUA will only add to your current problem. There is really no timeline for gaining ROM. For some it can take many months.

    Here's a bit of reading for you. The articles are not long. But they may answers questions you have. See the article below on "Window of Opportunity".

    Knee Recovery: The Guidelines

    1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary

    2. Control discomfort:
    rest
    elevate
    ice
    take your pain meds by prescription schedule (not when pain starts!)
    don't overwork

    3. Do what you want to do BUT
    a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you
    b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

    4. PT or exercise can be useful BUT take note of these

    5. At week 4 and after you should follow this Activity progression for TKRs

    6. Access these pages on the website

    The Recovery articles:
    The importance of managing pain after a TKR and the pain chart
    Swollen and stiff knee: what causes it?

    Energy drain for TKRs

    Elevation is the key

    Ice to control pain and swelling

    Heel slides and how to do them properly

    Chart representation of TKR recovery

    Healing: how long does it take?

    Post op blues is a reality - be prepared for it
    Sleep deprivation is pretty much inevitable - but what causes it?

    There are also some cautionary articles here
    Myth busting: no pain, no gain
    Myth busting: the "window of opportunity" in TKR
    Myth busting: on getting addicted to pain meds

    We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

    While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.
     
  3. possum65

    possum65 junior member

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    First, no two knees progress exactly the same after TKR. I had bilaterals in March 2019, and the left knee was slower to get good flexion and extension than the right. It was also more painful. I think that sharp needle like pain you have sounds like nerve pain, and this should gradually improve. I experienced excruciating sensitivity on the skin to the inside of my knees, which has gone now. Also, my scars did not improve at an equal pace, and this is normal. It seems early in your recovery to be talking about manipulation of the joint under anaesthesia? How bent is your leg? Standing still is not comfortable for me yet, much better if I keep moving!
     
  4. cmma01

    cmma01 new member
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    Op 1 (left knee) was 13th October 2018. Op 2 (right knee) was 16th March 2019.

    And no - rest and stopping exercise makes no difference. I'm also coming to realise that the small skin area on my right kneecap that has become so sensitized to the lightest touch, is being rubbed by clothing and that adds to the discomfort, so when the decent weather comes back, I'll be keeping my knees uncovered!

    The surgeon is a trainer of other surgeons and is quite a stickler for post operative ROM timings so I just decided to trust his decision and am awaiting the date. He said there will be a bit of ham string stretching and also dealing with any scar tissue that has adhered.

    Depending on the way the measurement is done, I'd say, at a guess, that the angle of the bent leg is either about 145 degrees (visually as in geometry!) or 35 degrees done with the flexion measuring tool used to measure how bent you can actually get the knee. But as I say, these numbers are guesses - based on Google images actually :).

    In the meantime, I'm doing ham string stretches the physio showed me anyway. No change as yet.
     
  5. Jockette

    Jockette FORUM ADVISOR Forum Advisor

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    I am going to tag @Josephine
    our forum administrator and nurse director to address your concerns.
    Standing still was painful for me for months, it improved as I healed.
    Each knee is different and you can’t put a specific time for each achievement. We all achieve ROM (flexion and extension) at various times, as we heal. And, there is no window of opportunity to regain ROM, mine continued to improve in my second year post op, as has many of our other members.
     
  6. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Sounds to me like you're getting a funny kind of care there. To start with, I'd suggest you don't accept the MUA - it is your right to say no if you wish. If you are concerned about refusing to do therapy, you need to read this Saying no to therapy - am I allowed to?

    I'd really like to offer you some structured advice but in order to do that, I also need to ask you some questions. Are you willing for me to do that?
     
  7. cmma01

    cmma01 new member
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    Sure - ask away.

    I'm actually not afraid of refusing any kind of treatment. I rescheduled all my dates for both ops to suit my calendar rather than theirs and haven't felt pressurised at all at any point to comply with anything. I've also very much been in charge of my physio sessions and they have respected my choices. The MUA was suggested by the surgeon after examining my leg, and I accepted because I had no particular reason to refuse it. So apart from it seeming early on in the recovery as one poster has said, what are the specific reasons for concern about this procedure at this time?
     
  8. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    The reasons are thus: the frequently given statement that because a person had stiffness or poor ROM that it MUST perforce be 'scar tissue' is wrong and misguided. For a start, the 'scar tissue' is more correctly referred to as adhesions and these are actually quite rare in knee surgery. To hear some surgeons and PT talk, you'd think that almost every other person in Christendom suffered from adhesions and that's just not born up by statistics.

    The main reason a person had low ROM and stiffness is because of swelling and pain and this is because of doing too much exercising which in itself will worsen the swelling, pain and stiffness. So the eagerness with which some surgeons seem to launch into an MUA worries me because the procedure is not without danger and complications. Not least of which is getting a bony fracture. Secondly can be excessive bruising and pain which inevitably resets the recovery clock. Most MUAs are totally UNnecessary.


    But the questions: here y'go then!

    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. And don't forget to factor in other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness).

    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. are you doing any exercises at home? If so what 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 you do each day
    - enter exercise by name then number of repetitions of each
    etc., etc.

    Anything done at PT
    - how many times a week
    - enter exercise by name then number of repetitions of each
    etc., etc.
     
  9. cmma01

    cmma01 new member
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    First let me clarify. My surgeon, who told me he was always concerned about the 6-week point for scar tissue, has no real concerns about scar tissue being the main problem with my bent leg. It’s really the short ham string which he wants to manipulate. I brought this up at my last physio appointment and the PT agreed that my ham string on the right leg is very tight. He did some work on it (only mildly painful) and got the extension slightly improved but it’s jumped back since that session. The surgeon wanted me to go in end of this month, but I’m away, so can’t go. In the meantime, I’m working on ham string stretches because that leg is just stuck in the bend. If there’s no improvement, I’ll go with the MUA. If extension improves, I won’t.

    NOW TO YOUR QUESTIONS
    I’m not a model patient as you’ll see from my replies below. Answers in red italics.

    1. pain
    Daytime Level 2 to 3 – after standing still for a while
    Level 2 when I stand up and walk after sitting with my knee bent for a while.
    Also mildly painful going downstairs right foot first (my choice)
    Nighttime:
    Level 4 – Joint line soreness and inner knee soreness
    Level 4 to 5 - Stabbing nerve pain in skin covering knee cap on the incision mark.

    2. medications
    Ibuprofen 200mg, 2 tablets, 3 times a day
    Paracetamol 500mg, 2 tablets, 4 times a day (once during the night)

    3. Slight swelling, reducing on a daily basis!

    4. 105/35

    5. icing - iced for 20 minutes at a time, 3 times a day because that knee was more painful and stiff than last time. Then I stopped icing because I didn't find it helpful. Instead I used heated wraps to reduce the pain, 3 or 4 times a day. Stopped that as well now.

    6. elevating Nope. Both times throughout the evening just lifted on a regular chair recliner, not propped up at all.

    7. What is your activity level? Washing and ironing once a week, stroll round the local supermarket leaning on a trolley twice a week, cook with my husband, driving within 3 weeks with both legs (automatic car).Walk up and down stairs as part of routine trips, not in order to exercise.

    8.
    FLOOR SCRUBS: Using the sliding plastic foot dish - 10 times, 3 times a day for a week, then I stopped.
    HOLDING STRETCHES: 3 only, I did these twice a day. As below:
    10 minutes with my extended leg propped up on a small football. Then stopped after that single week both times.
    10 minutes holding my leg more bent than it naturally wanted to be. Then stopped after that single week both times.
    STEP UPS 20 times, once a day until I could walk up and down stairs one leg after the other. Then I stopped these.
    And that’s the lot!

    Anything done at PT
    Attended for one half an hour session per week for 5 weeks.
    Different each time because I've told them what I feel I'd like to do. It’s not prescriptive. I'm in charge of my regime although they do suggest options to help me think about what I'd like.
    • Week 1: floor scrubs x 10, then we chatted about the op, any concerns I had, and exercises I might like to do at home. I was given a print-out with instructions. Didn’t do any of them!!!
    • Week 2: Asked for a lymphatic massage to reduce swelling. This took the whole session - awesome!
    • Week 3:
      • 10 times, quad strengthening extensions with a pillow under my thigh to knee area.
      • Then the same x 10 without the pillow.
      • Slow backward pedalling on exercise bike for a few minutes.
      • Step ups x 10
    • Week 4:
      • 10 times, quad strengthening extensions with a pillow under my thigh to knee area.
      • Then the same x 10 without the pillow.
      • Sitting on a Pilates ball and rolling back and forth to strengthen my knee bend.
      • Exercise bike back-pedalling for several minutes.
      • Exercise bike front-pedalling for several minutes, low resistance
    • Week 5:
      • Forward pedaling on the exercise bike for 10 minutes, going slow then going faster and increasing resistance setting because I asked for that.
      • Sitting on a ball with my leg supported on another ball to help extension.
      • Ham string stretches
    I’ve now graduated to the 45-minute Group Knee Circuit Class which is a mixture of things with the same physios and I’m going later this week. No idea what that will be , but if it doesn't suit me, I'll stop going.
     
    Last edited: May 13, 2019
  10. cmma01

    cmma01 new member
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    Oops, I had remembered my extension 'score' incorrectly at 30° in my last post. It was not. It was 20°.

    Also, another thing I'd like to share:
    In the months between having my right and left knee TKRs done, when the right knee inflammation pain was dreadful and my left knee was still very painful during op recovery, AND because I can't cope with opiod or codeine-based painkillers, I decided to do a 5-day water fast (consuming nothing but water). My pain levels plummeted! I did the fast sensibly and introduced food again very gradually, following re-feeding guidelines.

    I have now atttended my first Group Knee PT session which is a circuit and more structured than my one on one PT sessions as everyone is doing the same. We can stop at any point if we wish.

    3 mins on each of :
    • Treadmill
    • Step-ups
    • Seated pilates ball knee-bend rolls
    • Exercise bike forward pedalling
    • Stand ups from a chair without using hands
    • Squats
    • Calf stretch over the edge of a step
    At the session end, I was measured and my right knee extension is now 15° and right knee flexion is 116°.

    At home, I have to concentrate on stretching the right ham string by sitting with my right leg extended and propping my heel up on something for a few minutes, 5 times a day to allow gravity to exert a pull on the ham string. That is the only 'prescribed' exercise I need to do and they will check the extension measurement again next week. If this works, I can avoid the MUA.
     
  11. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    More detail needed please
     
  12. cmma01

    cmma01 new member
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    Thank you possum65 for your reply.

    Nerve pain is reducing thank goodness.

    I have general joint-line pain which varies in intensity but as I had that with my other knee, I know that will improve with time.

    There's a new jabbing pain started under (I think) my knee cap when I walk, and I'm really hoping that this new pain will also be a temporary issue as otherwise things are progressing fairly well pain-wise and mobility-wise.

    As of 2 days ago, my right leg measured 122° flexion and 17° extension. The flexion gets better week by week. According to my surgeon, the extension difficulty is a tight ham string issue, and 2 separate physio practitioners hold the same view. For the past two weeks I've had to do 5 sets of ham string stretches per day, but they aren't really helping with getting the leg straight. The swelling is very minimal now, so I don't think that swelling is an issue. My left leg bent and straightened very quickly even while it was really swollen.

    I'm still undecided about the MUA particularly as I have a vacation coming up next month and I don't know the recovery time on an MUA. I was offered tomorrow's date, but am out of town so didn't accept that date. I really want to get the leg straight and I am prepared to continue doing the ham string stretches to achieve that, but so far they're not helping. IF the MUA will help straighten my leg, other than temporarily, I reckon I'm up for it. The choices and decisions are mine and I'm not feeling pressurised to decide either way.

    What I want to know - from people on this site who have actually had this procedure done - is (a) did it help straighten your leg long term, and (b) what kind of set back, if any, did having the procedure cause in your general tkr recovery process?
     
    Last edited: May 23, 2019 at 11:55 PM
  13. Jockette

    Jockette FORUM ADVISOR Forum Advisor

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    Lets ask @Josephine if an MUA will help extension.
     
  14. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Will MUA improve extension? Short answer is - no, it cannot. An MUA is, by definition, a flexion procedure as shown here

    MUA 1-horz.jpg

    Apart from pressing on the knee while it's flat on the table, which is largely ineffective, there is nothing more that can be done. But your normal ADLs will achieve that.

    Besides which, you are only 10 weeks out which is very, very early to even be thinking about this. Extension can take upwards of 3-6 months to improve so don't be in any rush to hurry it on like this. You flexion is excellent and I wouldn't think your extension is that bad.

    Overall, I think an MUA now will just leave you in more pain and swelling which will, of necessity, hinder your progress even further.
     
  15. cmma01

    cmma01 new member
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    Nonetheless I would still like to hear from someone who has had one to get a personal experience view.

    I am of the view that my highly experienced orthopedic surgeon probably knows exactly why he is suggesting the MUA and he also knows that my flexion is good, so it's not for that reason.
     
    Last edited: May 24, 2019 at 5:45 AM
  16. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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