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MUA Four weeks out - Terrible Flexion - Terrified

Sweener24

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Hi,

I am just over 4 weeks out and my flexion after PT today was 42 degrees. Stopped Oxys 3 days post surgery with no problems. Currently taking Alieve 2x day. Really no pain at all just discomfort and tightness. Swelling is acceptable (just over 1" difference between the two knees) Extension and strength are very good. Scar looks pretty amazing and is healing great. Do NOT want MUA.

Current therapy:

- Bike (half circles) 3x daily 12 minutes each
- Two 20 minute walks, mostly without assistance
- Icing and elevation at least 3x day, 20 minutes
- Knee "hangs" 7-10 minutes, 3x day with 4 pound ankle weight
- Calf and hamstring stretches
- Step ups
- Step ups with stretch bend
- Massage

At PT (3x week), bike, bending, hang, seated bench press, massage. PT says lack of flexion is NOT MY FAULT I am doing everything I can to make this happen.

I can't get past 40-42 degrees. What gives? So demoralized. Have followup with a surgeon on the 18th of November.

Suggestions?
 

Celle

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Hello @Sweener24 - and :welome:

Your PT is right. Your lack of extension is not your fault.
I think your problem is that both you and your PT have both been working your knee far too hard, in an attempt to make it bend more.

The amount of exercise you are putting your new knee through is too much and it's having the opposite effect to what you want. It's keeping your knee upset and inflamed and probably swollen internally.

That poor knee has been through one of the most major surgeries it can have and it needs time and gentle treatment, so it can heal, before you put it through a demanding exercise regime.
It isn't lazy or unfit - it's wounded.

I think this article may help to explain: Knee recovery - Lose the Work Ethic!!

Your knee doesn't need a lot of exercises to make it bend better.
It's not exercising that gets you your Range of Motion (ROM) - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee has the potential to achieve good ROM right from the start, but it's prevented from doing so by swelling and pain. As it heals and the swelling goes down, your ROM (both flexion and extension) will gradually increase.

Here's another thing:
There's no need to rush to get ROM because it can continue to improve for a 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

I suggest that for the next two weeks you stop all PT sessions and exercises and spend much more time resting, icing and elevating your knee, to help it calm down and heal.

You need to ice for 45 to60 minutes each session. For this recovery, 20 minutes is not long enough. You'll do no harm by icing for longer, as long as you have something between your skin and the icing medium, to prevent frost bite. There are articles about icing and elevating in the recovery guidelines, which I will give you ion my next post.

What you've been doing so far for your knee hasn't worked well, so you have nothing to lose by trying something different. It's your knee and you have the right to choose what happens to it.
Saying no to therapy - am I allowed to?

Just to reassure you that you won't do any harm by changing tactics, I'll tell you this:
My surgeon doesn't allow any formal PT at all for the first month after a knee replacement. He says your knee needs that time, to start on its journey of healing. For that month, we rest, ice and elevate our leg, and walk around the house. The walking is our exercise and we increase it a little each week.

After that month, we just go to PT once every 2 weeks, where we are shown a few new exercises to do at home each day.

His patients all do well and achieve good ROM, as I did, and he hasn't had to do a manipulation to help with ROM for the past 4 years. I think that speaks for itself.
 
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Celle

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And here are the promised recovery guidelines:
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. Try to follow this

6. Access to 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 the 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 the member’s history before providing advice, so please post any updates or questions you have right here in this thread.
 

Roy Gardiner

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you and your PT have both been working your knee far too hard, in an attempt to make it bend more.
Absolutely agree

Current therapy:

- Bike (half circles) 3x daily 12 minutes each OK but see below
- Two 20 minute walks, mostly without assistance Not necessary IMO, too far. 1x10 mins would do
- Icing and elevation at least 3x day, 20 minutes More than 20 minutes would be good.
- Knee "hangs" 7-10 minutes, 3x day with 4 pound ankle weight NOOOOO! see below
- Calf and hamstring stretches yes, as long as they don't hurt
- Step ups No need, too early for strength training
- Step ups with stretch bend No need
- Massage excellent.

Knee 'hangs' to gain extension like that just don't work. The stretch bible is Bob Anderson, Stretching, ISBN 0-7207-1351-X

Right at the beginning he states that stretches should be held for 10-30sec only. As long as you don’t break this rule never go to the point of pain, you can stretch as often as you like.

But Anderson emphasises that holding a stretch for many minutes is not the way to do it. My personal view is that the popular exercise of laying prone on a bed with one's leg hanging off the end, being borne down by its own weight, is is much too aggressive – too much weight and held much too long

Here’s more, with some pix https://bonesmart.org/forum/threads/rom-and-extension-stretches.13159/

Using a bike to gain ROM is pretty simple:
  • Set the bike to zero resistance
  • Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
  • Gently turn the pedals, through discomfort but without pain.
  • Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
  • Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
  • Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
  • And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't
 

sistersinhim

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Oh, your poor knee. No wonder your bend isn't where you want it to be. Even though you don't see a lot of swelling outside there is swelling inside your knee that inhibits your ability to bend well.

Many of us never took formal PT or did any exercises. I am one of them. I had 12 knee surgeries, 2 of them kneecap removals, and 1 tkr. Even after those I never took formal PT. But, I didn't just sit around and do nothing. I used my knee as it was intended to be used by walking around to take care of my daily needs. As I healed I was able to do more. Icing and elevation were a huge part of my recovery.

Listen to your knee. It will tell you if you're doing too much by increased pain and swelling. When that happened to me, I found that resting, icing, and elevating helped. Your knee knows how to rehab itself without being told what to do.
 
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Sweener24

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Thanks everyone! This is so counter-intuitive to everything I’ve heard especially with regard to scar tissue forming. That’s what the PT thinks it is. Scar tissue in the joint. My kneecap is not very easily manipulated either. I have xrays next week and a followup on the 18th.
 

Celle

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Your PT is misinformed. She was taught wrong.

Of course your knee is going to form scar tissue. That's part of normal healing and the scar tissue is what holds your knee together. Without it, you'd still have an open wound.

What she is talking about - the "bad" scar tissue - is more properly called adhesions. It doesn't form easily and it isn't just sitting there, waiting to pounce if you don't exercise hard enough.

In fact, working too hard in the early days of recovery is likely to form bad scar tissue more easily. Why is that? Because over-exercising keeps your wounded tissues hot and inflamed. Hot tissues are drier than normal tissues and dry tissues are more likely to stick together and form adhesions.
Scar tissue and adhesions - what's the difference?
MUA (Manipulation under Anaesthetic) and Adhesions
 

Celle

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My kneecap is not very easily manipulated either.
That's also normal at only 4 weeks post-op.

I'll never understand why PT therapists feel they need to manipulate the kneecap.
If your knee is left alone, to heal on its own agenda, your kneecap will gradually become mobile, totally without outside interference.

There is no need at all for your therapist to touch your knee.
 

eaglemom

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As the other's have said, way way too much for that baby knee. It needs ice & elevation. Nothing wrong with using walker / cane to walk 5 minutes from your house and back. No farther. Please stop the 'hanging' as that is simply hurting you & not helping.

I know, I've been there. The PT & surgeon stress rehab and you just have to agree with them. Then do your own thing. Personally you don't need the PT - do that on your own. I think you've just got the knee very unhappy. This is a major surgery, you need time (a year) to heal.
 

kneeper

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Hi,

I am just over 4 weeks out and my flexion after PT today was 42 degrees. Stopped Oxys 3 days post surgery with no problems. Currently taking Alieve 2x day. Really no pain at all just discomfort and tightness.
After the first couple of weeks my pain came in the form of what I call a "stiff achy-ness." Properly medicated (either narcotics or later tylenol throughout the day) --and icing and elevating-- that stiffness improved and I could bend/move more.
Finding a balance between moving and resting is also important.
Listen to Roy Gardiner's tips.
 
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Sweener24

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Had MUA at 6 weeks. In the three weeks since, my ROM is 111/0. Doing stairs, squats, leg press, and Peloton classes. Still working on fluidity and confidence but I am moving forward and every day is a little better. Also got a Dynasplint and wear it 3-5x a day for 45 minutes. Huge help.

Good luck to all TKR peeps healing and finding their way. Do what’s right for you. For me it was MUA, PT, Dynasplint and Peloton. Luckily not much pain and able to sleep after first three weeks. ✌
 

Celle

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Please tell us what date you had the MUA and we'll add that to your signature.

Doing stairs, squats, leg press, and Peloton classes.
Please don't do these. They are far too aggressive for a newly-wounded knee. Yes, while the MUA increased your flexion, it did so by tearing some soft tissues and your knee needs more gentle treatment, so it can heal from the MUA. There is no need to do lots of exercises. Just keeping your knee moving gently is sufficient.
 
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Sweener24

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I updated my signature, thanks. My knee feels great. Making progress, building strength, massage and ice are also a part of the program. I appreciate your concern and right now, I am pushing what my knee can do. I am in no pain and I do not push myself to that level. Just like some prefer and respond to gentle healing, some also heal better with more activity. As is pointed out here, everyone’s knee is different and only you know what works for your body.
 
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Celle

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As long as you listen to the messages your knee is giving you, that's OK.
 
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Sweener24

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Final post (hopefully). Day 138. Graduated from PT yesterday. 130/0 flexion and extension, respectively. Still room for improvement, strength and confidence. I didn't have the time or willingness to just sit around and move gently and hope that was the right solution for me. Best of luck to those of you who feel like dragging out this whole thing.

In reality, within the first week I had adhesions so badly that I had to wait five more weeks to get an MUA which changed EVERYTHING. I was terrified about the procedure but went to PT 4 hours after the MUA and that set me up for success. As did having a Dynasplint and working my butt off. My surgeon only got to 115 degrees on the MUA which is indicative of where they think you will end up. Well, I beat that by 15 degrees and know I can get close to 140.

Peace out, Bonesmart. While I appreciate your advice, it absolutely was the wrong direction for me to take in my recovery. Best of luck to everyone out there. TKR is a bear and there is very little advice and direction out there.
 
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Roy Gardiner

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Coments below are for readers other than Sweener24, who is not the first to do well not taking BoneSmart's advice!
While I appreciate your advice, it absolutely was the wrong direction for me to take in my recovery
The first and defining piece of BoneSmart advice is 'What works for YOU is key'.
TKR is a bear and there is very little advice and direction out there.
BoneSmart has a great deal of advice and direction; you felt it didn't suit you, and your approach worked. That's great, of course.
I didn't have the time or willingness to just sit around and move gently and hope that was the right solution for me.
You found that you could be more proactive, and it suited you. Brilliant!
Best of luck to those of you who feel like dragging out this whole thing.
For people for whom pushing will cause swelling and pain, they will lose much more going that way than they would lose by underdoing things; underdoing, for most, doesn't 'drag things out'.

This is the reason for my comments; everyone is different. Find your own way!
 
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Jamie

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@Sweener24 .... I'm glad to hear you're doing so well. Bravo for determining what YOUR body needed to do to recover properly.

As the posts just above indicate, BoneSmart's philosophy in a nutshell is to do just that, listen to your body and respond accordingly. If recovery was the same for everyone, there would be no need for any of us here at BoneSmart, as surgeons could just print a card with what a patient should do and that would be it. Unfortunately, since our bodies are all unique, that doesn't work. Recovery is much more successful if you take the approach that allows your body to heal in its own way. That can mean a slower time table for some and a more aggressive exercise program for others. As long as you're not increasing your pain and swelling with whatever you're doing, we're going to cheer you on every step of the way. "Listen to your body and respond accordingly" will continue to be our first recommendation.

Sweener24, I hope you enjoy your new knee. We'd love to see some photos of you when you're back to doing the things in life that you love.
 

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