Extension problems?

[Nancy Harkey]

I have been reading a lot here about problems with getting enough flexion in the knee after TKR, but haven't seen much about problems getting the leg to straighten or extend properly. Bending is going quite well for me, but extension is not. PT can get the leg straight for a moment with torturous pressure, but it bounces right back (about 8-10 degrees off of straight.)

Even more confusing, my Dr. seems to believe that this will just take care of itself over time, while the therapist thinks it will become permanent if not taken care of in therapy.

Any information about this, out there?

Nancy

 

[ttlncsc]

Hello Nancy,
Prior to surgery, I had fairly normal range of motion. Max bend was about 135 and extension was -1. I had my surgery because I had poor stability due to a significant basketball injury and poor repair in 1970. Pain was not a significant part of my problem. I only had a very small amount of cartilage and was bone on bone.
When I started Pt, my extension was -7. In other words I had trouble straightening the knee. Granted, I am 6 ft 4 in and was told that extension was the hardest thing for tall folks to get back. After aggressively going after it with extension exercises including letting my wife press my knee downward while the heel was elevated on a rolled towel placed on top of a pillow. As she pressed down while the leg was relaxed, I told her when the pressure was enough to cause me pain. At that point she held it for 1 minute.

Today my extension is - 1 1/2. I also used a lanyard to wrap around my shoe (toe area) and pull back while trying to sit up with my left leg off the bed. I was pulling on my rt foot toe area. I held this position for 30 seconds.

I was a medical/surgical rep and had a good background in medicine. My bias would be to listen to the PT for rehab. While most MDs are great clinicians, the PT specializes in returning our ROM by taking them down the exercise and weight programs. I'm not slamming any MDs, I just know that folks that specialize in returning ROM seem to put those of us in need of their services on the right Tract. Just my opinion, you have everything to gain. Good Luck, Tom

 

[Josephine]

There was some discussion about this in here a few months back along with the suggestion that it helps to put your foot on the coffee table or stool whilst watching TV or something and let gravity help. Quite a few seemed to find that beneficial even to the point of hanging a light weight on the knee to aid the extension. The trick is to let it happen over a period of about 20-30 mins if you can bear it that long.

 

[Gretchendz]

Hi Nancy,

My initial problem was extension. Seriously, I wasn't sure for several weeks if I'd get it past 10. It took several weeks of my macho PT practically jumping on it. Now it's fine and we're working on bending.Once we got it straight, walking properly became so much easier for me.

I agree with Tom about the PT/MD thing. I think it would be unwise to ignore it and hope it sorts out.

For me, a helpful thing was the "prone hang." Lying on tummy on bed with leg over edge. (knee hanging off edge actually) At first just holding it there as long as I could (at first only 20 seconds) As it got better, I added ankle weights to the surgical leg. Easy exercise too cause I could lie there and read...


GOOD LUCK!

 

[exjock]

I am 4 weeks post op and my extension is only +7. The therapist can force it straight but it bounces back. She tells me that the fact that it can be forced straight is a good sign and it will eventually come in time. From past surgeries I never worried about extension and it always came back on its own.

 

[DaveW]

Hello Nancy,
Prior to surgery, I had fairly normal range of motion. Max bend was about 135 and extension was -1. I had my surgery because I had poor stability due to a significant basketball injury and poor repair in 1970. Pain was not a significant part of my problem. I only had a very small amount of cartilage and was bone on bone.
When I started Pt, my extension was -7. In other words I had trouble straightening the knee. Granted, I am 6 ft 4 in and was told that extension was the hardest thing for tall folks to get back. After aggressively going after it with extension exercises including letting my wife press my knee downward while the heel was elevated on a rolled towel placed on top of a pillow. As she pressed down while the leg was relaxed, I told her when the pressure was enough to cause me pain. At that point she held it for 1 minute.

Today my extension is - 1 1/2. I also used a lanyard to wrap around my shoe (toe area) and pull back while trying to sit up with my left leg off the bed. I was pulling on my rt foot toe area. I held this position for 30 seconds.

I was a medical/surgical rep and had a good background in medicine. My bias would be to listen to the PT for rehab. While most MDs are great clinicians, the PT specializes in returning our ROM by taking them down the exercise and weight programs. I'm not slamming any MDs, I just know that folks that specialize in returning ROM seem to put those of us in need of their services on the right Tract. Just my opinion, you have everything to gain. Good Luck, Tom

According to OS and 2nd opinion Surgeon the issue needs to be addressed within 2-3 weeks after surgery or the chance of regaining full extension is a real issue, meaning your leg may not get full extension. Left which was done at same time has absolutely no problems with extension.

There are two devices that I have heard about; Dynasplint and JAS. I am currently trying the JAS with little expectation of improvement 18 weeks after surgery. Dynasplint needs to be worn 6-8 hours per day and people I have spoken with said this is almost impossible to achieve as they can not sleep with the device on. The JAS is worn 3 times per day for 30 minutes per occurance. It is cumbersome and somewhat difficult to put on but easy to use. There are threads on both devices on the Forum.

Lack of extension (best case is 14 degrees) in my case comes from the prothesis being put in improperly for one of 2 reasons. Either the device itself was too thick meaning the space the OS allowed was inadequate because they did not check the pads for a deviation in thickness prior to surgery. Nor did they check extension afterwards. Or they did not grind enough off allowing for proper spacing.

OS surgeon mentioned that they have heard of this problem with the Nephew&Smith Journey. See thread I started. As a result I will probably have to have my RKTR redone, a really thrilling thought. NExt appointment with 2nd surgeon is September 9th.

PM if you want to discuss further.

Best wishes

Dave

 

[Josephine]

Either the device itself was too thick meaning the space the OS allowed was inadequate because they did not check the pads for a deviation in thickness prior to surgery. Nor did they check extension afterwards. Or they did not grind enough off allowing for proper spacing.

I think that is pretty much the same thing, Dave - trimming the bone and/or allowing space. The only item that varies in thickness is the tibial insert. I'd be surprised if they didn't check the extension as it is a seminal part of the procedure. Most surgeons I worked with would try out 2 and sometimes 3 different spacers, extending with each trial in place to check which was the best fit.

It can also be that the patient being very relaxed whilst under anaesthetic, the extension seems more easily achieved than post-op.


Either way, I'm sorry for your circumstances. It's all well and good being told the problems are x% until you end up being in that slot!

OS surgeon mentioned that they have heard of this problem with the Nephew&Smith Journey. See thread I started. As a result I will probably have to have my RKTR redone, a really thrilling thought. NExt appointment with 2nd surgeon is September 9th.

PM if you want to discuss further.

Best wishes

Dave

Oh please - do discuss it here. You may be able to offer info that would be of use to other members, not to mention me!

 

[Simon]

I also have extension problems post op the right side was -15 and today it is about -7. The left one is closer to zero. part of my problem is preop I had a 10 degree flexion contraction which did not help.

Here are the 2 exercises my PT gave me.

Lay on your stomach with knees off the edge. As you get stronger start with a weight around your calf or higher. As that gets easy move the weight down till it is at your ankle. Try for at least 7 to 10 minutes before taking a break. It will take time to work up to this.

Number 2 is stand against the wall with a chair, walker or something to hold onto in front of you. Use your good leg to push the bed leg back flat against the wall and hold it for at least a minute (this is why you need something to hold on to) and work up to 3 to 4 minutes. Repeat 2 or 3 times.

Others I have seen is sit in one chair and have another chair in front of you and put your heel on that chair and let gravity work. Important thing is to make sure the leg is "even" i.e. what ever you are using to put your heel on should be at the same height as what you are sitting on.

When you are sitting and have your leg out use pillows to keep everything straight.

If you have someone that can help you out you can have them push down on the leg.

Hope this helps.

Simon

 

[ship4]

My PT suggested I sit on my short kitchen stool (19 inches) and put my heel on the seat of my (24 inch off the ground ) kitchen bar stool and extend the knee. It was not even....... It worked out fine. I continue to do this exercise as it is easy to do and convenient for me to do with the children in care. I do 2 sets of 10 with each leg daily.
Best,
Crystal

 

[Nancy Harkey]

Thanks to all for the many suggestions. I am continuing to work hard at this, and my PT says she is getting the same extension stretch when she bears down, with less discomfort on my part. It is hard to know when your PT is just being gentle, and when the same pressure hurts less, but I am hopeful!