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TKR Extension problems

Betsy Trotwood

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Can anyone help? I had a TKR and knee cap mend (lots of damage behind kneecap) on 11/7. My flexsion is 135 degrees but there is a 1 inch gap under my knee which i cannot seem to get rid of. It was 2 inches and thanks to PT have got it slightly improved. It is hard to work on strength etc without a straight leg. What if i had that op to straighten it out? Most people seem to have flexsion problens. I wish i could find someone with my problem. Am getting v demoralised.
 

sistersinhim

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Welcome to Bonesmart! :flwrysmile:Was your surgery November 7, 2020 or July 11, 2020? This is an international site and the dates are written differently for some of the countries.

It sounds like your ROM is doing great! Extension is sometimes slower to come in than the bend. Mine was. I never took PT for any of my knee surgeries, just did my daily activities. To work on my extension, at first, I used my walker and walked with a longer stride, touching my heel first then rolling until my toes. When I was more secure, I left off the walker. This gait stretches those large muscles and tendons in the back on the knee. It didn't happen for me overnight, but my extension did improve.

The following are our basic guidelines and should help get you started. As you read more on other members' recovery threads, you’ll get a better perspective of what to expect and what not to do, especially regarding PT.

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
ice
take your pain meds by prescription schedule (not when pain starts!)​
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. Here is a week-by-week guide for Activity progression for TKRs


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.
 

Celle

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Hello @Betsy Trotwood - and :welome:

I don't think you need to worry at all about your extension.
It's only just over a month since your surgery and it's not unusual for extension to take longer than flexion to achieve. That's because the big tendons and muscles at the back of your leg have to be stretched slowly and gradually.

It tales a full year for complete recovery of all your tissues after a knee replacement, although you'll be able to do most things long before that.
There's no need to rush to get ROM (Range of Motion) because it can continue to improve for all of that year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

Full extension will come, given time. Try to give your knee that time, even though it's hard to be patient.

Don't make the mistake of working hard at exercises, because that can sometimes be counter-productive.
It's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal.

You said it's hard to work on strengthening with a leg that won't extend fully. Well, at only just over a month from surgery, it's really too early to be thinking about strengthening.
Your knee needs to heal more first and during that time it will gradually get stronger, naturally, as you use it in your daily life.
Strengthening exercises are best left until about 3 months post-op.

Here's an article about extension that you might find useful:
Extension: how to estimate it and ways to improve it
 
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Betsy Trotwood

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Dear Celle, Thank you. Yes 12th July 2020, (this being England). I read your article; the extension measures at 10+ with the good knee being -10 because, ordinarily i am hypermobile. I could not move from about day 3 to 14 with the swelling, pain and blues. Then twice weekly PT with exercise to get more extension. If i walk more th 10 yards, i get swelling. With assistance i can get the knee flat to the floor, abd improve frim +20 down to +10 in 10 days. But now it seems stuck. The surgeon said extension would be my challebge but it scares me. Will i ever get it to zero?
 

Celle

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The surgeon said extension would be my challenge but it scares me. Will i ever get it to zero?
Yes, you will, but it is going to take time. That's OK because there's no need to rush. You have plenty of time - almost a year.

If anyone is telling you that you have to achieve zero by a certain time, just tell them you will get there in the end, but not on their schedule, and you don't want to be pressured about it.
 

leejaa

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You will get there but it takes time. Your knee has been traumatized with surgery and it needs time to heal and recover as does the rest of your body from this major surgery. Our bodies are great at healing if we give them time and are kind to them. Lots of rest and icing to keep inflammation down. Full recovery takes a while. The patience muscle gets a real work out with recovery and needs it more than the knee.
 
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Betsy Trotwood

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Thank you. I was told i only had six weeks to get it as straight as possible because of the scar tissue which would be too tough to shift after that. That is in 9 day's time. Before the op, i had a baker's cyst, lots of damage behind the knee cap and the serverest arthritis - all of which i put up with for six years too long. Maybe i should not expect much. It is only the extension. It is worrying though because if i cannot get it to zero it will lead to a host of other structural problems - which i am sure you know about. One can get away with 90 for the flexion but, i m reliably informed that i need to be able to get my leg straight. Thank you for getting back to me. The surgeon is so upbeat that i do not feel able to speak my worries.
 

Jockette

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I was told i only had six weeks to get it as straight as possible
This is absolutely not true and I don’t understand why so many medical professionals believe this. We have lots of members whose leg became straight much later than 6 weeks.

Right now swelling is blocking that extension, as your swelling goes down, your ROM will improve, and that timeframe is different for everyone.
 
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Betsy Trotwood

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Thank you. Part of my stress is the conflicting info from pros! The reason they say is that the scar tissue is too hard to break through after six weeks. But you are correct - the swelling and pain scupper things rather.
 

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There seem to be many myths about “scar tissue” most of which are not true. It is blamed for too many things. It doesn’t just grow and grow and become an eventual problem.

Yes, there will be scar tissue, but that’s a good thing. It’s a normal process that the body does in the healing process. If there wasn’t any scar tissue, you’d always have an open wound.

As the wound continues to heal, that scar tissue settles down and blends in and is not a problem.

There are occasions where there is too much scar tissue and it does become a problem, but those occasions are not common, and it’s due to certain circumstances that most of us don’t face.
 

Roy Gardiner

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I was told i only had six weeks to get it as straight as possible because of the scar tissue which would be too tough to shift after that
This is nonsense.
The reason they say is that the scar tissue is too hard to break through after six weeks
There is a difference between scarring and adhesion. Scarring is just the body rebuilding after trauma. Adhesion is where the swollen soft tissues stick together. The former is universal, the latter is quite uncommon. Scarring is not of itself an issue, only adhesion is a problem. You probably don't have adhesion, especially as your flexion is so good showing no adhesions in that part of the knee.
Before the op, i had a baker's cyst, lots of damage behind the knee cap and the serverest arthritis
Was that knee hypermobile, or did you have restricted movement? If the latter, there's your answer, the tissues have shortened and will take time to stretch, and will be part of the reason it's 'stuck'. The normal swelling after surgery is another, of course.

The key to gaining extension is time and stretching exercises. Time for healing to complete, stretching to help things along. You will get there.

My own ROM, Extension and Quad exercises http://bonesmart.org/forum/threads/rom-and-extension-stretches.13159
 
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Betsy Trotwood

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Thank you so much. This is a seriously helpful response. You have helped me so much. The only problem is tightness behind that dinosaur-sounding muscle, the one in the back of the thigh.

I am doing my best to stretch it passively but since the op, boy has it tightened. Before the op, (only about 6-8 weeks before) i had a baker's cyst and probably only zero extension. After the op the arthritic pain vanished but the dinosaur muscle hardened and shrank. The swelling was too bad to move for a good 10 days. My PT is currently only 95% sure i will get to full extension. It is extraordinarily uncomfortable to have the foot on a stool with a horizontal leg for more than 11 mins. I can manage 20 mins but only on 60 mg of codeine phosphates! (One can't do that every day) PT suggested a TENS machine but i am allergic to the pads. Just ordered the sensitive skin ones. Thank you for your thinking. It is v much appreciated.
 

sistersinhim

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My extension was slow to come in. I also have a Baker's Cyst that wants to flare up every so often. The best and easiest way I worked on my extension was to walk will a much longer stride with a heel to toe gait. I also always had either the walker so something close by that I could grab hold to because this would throw my balance off. Doing this stride and gait a few times a day helped to slowly stretch out those tight muscles and tendons in the back of my knee. I never put my foot on a stool and always elevated and had a slight bend in my knee. But, my extension did come in just fine. Now, it even hyperextends sometimes so I have to be careful.
 

Jockette

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I am doing my best to stretch it passively but since the op, boy has it tightened
Tightness is a normal occurrence after this kind of major surgery. Your surgeon did major carpentry work and disturbed every millimeter of soft tissue in this area. You aren't tight because your muscle is underused and needs to be stretched and rehabbed. You're tight because your tissue is healing...and full healing takes a full year or more.
 

Celle

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After the op the arthritic pain vanished but the dinosaur muscle hardened and shrank. The swelling was too bad to move for a good 10 days. My PT is currently only 95% sure i will get to full extension. It is extraordinarily uncomfortable to have the foot on a stool with a horizontal leg for more than 11 mins. I can manage 20 mins but only on 60 mg of codeine phosphates!
If your PT is really expecting you to do that for up to 20 minutes, that is part of your problem. You are only supposed to do it until it becomes painful. At that point, stop.

If you continue after that, you will be making the tissues at the back of your knee upset and swollen, which is definitely counter-productive. It will be making that problem muscle more inflamed and tighter.

Any PT that causes actual pain (rather than discomfort) is bad PT. And no PT at all is better than bad PT.
Remember, we advised you this:
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.​
I think you need a break from the pressure that's being put on you (and your knee) to meet an unrealistic schedule. Everyone seems to be rushing you when, in reality, you have all the time in the world.

This is your life and your knee. You are the only one with the right to say what happens to it. While others may advise, you also have the right to choose whether or not to accept that advice.
What others are asking you to do hasn't been working, has it? So you have nothing to lose by trying something different.

Try taking 2 weeks off PT - no sessions at all. Instead of doing lots of exercises, just let your normal Activities of Daily Living (ADLs) be your exercise.
Give your knee lots of rest, ice and elevation, to try to help it calm down and reduce its swelling.
Just in case you think you can't do that, read this article:
Saying no to therapy - am I allowed to?
 
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Betsy Trotwood

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Oh ok. Sorry for sounding a bit slow-witted. The tightess is so weird. It is generalised either side of the knee-cap and highly specific mid back of thigh, not even the calf. I can deal with the generalised stuff which i any case lessens every 3 days or so. I am trying to practice doing the splits to see if that will untighten the back of the thigh muscle. I just so so want a straight leg and not have to wait for a year for it. It is bad enough never having a break from it; like someone annoying has pitched up who says they are moving in for good. Great!
 
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Betsy Trotwood

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Well, the PT said i should try extending the time; it wasn't an order. I am more impatient than my PT. What you say makes sense tho -maybe i am pushing too hard which is making the back of the thigh muscle even harder/tighter. There is zero swelling on back of thigh; it is just taught like a leather strap and as hard.
 

Jockette

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I just so so want a straight leg and not have to wait for a year for it.
You most likely won’t have to wait a year to get your leg straight. That year is the average timeframe for complete healing. At about one month post op many of us were far from straight, but it came with time.
 
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Betsy Trotwood

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Okay then..... will heartily thank when the ruddy thing is straight. See ya
 

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