Revision TKR Hmm. Not thrilled with the revision yet

[Celle]

It's normal to feel tired, as sistersinhim said. That's because almost all your body's energy is being directed towards healing your knee and there isn't much left for anything else. Learn to accept it, because it is what your knee needs right now.
Re-read the article on Energy Drain that was in the post-op reading list you were given:
Energy drain for TKRs
https://bonesmart.org/forum/threads/activity-progression-for-tkrs.14334/
It might be a good idea to re-read this article, too:
Activity progression for TKRs

Extension - let's have a discussion. I'm not there, it feels like I'll never get there. I just can't get my leg straight, for long. Of course its still swollen, and I take that into consideration, but I'm a little concerned about it. Once I do get my leg relaxed enough for good extension, it doesn't last long at all. Its like my hamstring & IT bands are making fun of me!! Any tips to help me out?

It's only a month since you had this surgery and it's normal for extension to take longer to achieve than flexion, but it will come, given time. Certainly, it's too early to be worrying about it. Slow and steady progress is what you want with extension.
Here's an article, with some suggestions for exercises to help. Just choose one or two exercises and do them gently.
Don't do the one with weights until at least 4 month.
https://bonesmart.org/forum/threads/extension-how-to-estimate-it-and-ways-to-improve-it.9529/

 

[KarriB]

I felt the energy drain for months, but I was dealing with a bit more. Still, it can take a while for stamina to return and there's really nothing you can do to hurry it. The best thing you can do s sleep whenever you can.

As everyone has said, extention can take a while. I found letting my TKR leg bridge between the chair and ottoman helped. I just started out a few minutes a day and let gravity do its thing. Don be surprised if it takes a few months.

 

[Pheebs52]

Tired had been my new *normal* for the first three week and has improved a bit during this 4th week. Now I don't need a nap after brushing my hair, but I may just 2 hours later, lol. On days I don't nap, I may as well be 'cuz I'm just lounging about in general. Today I had to force myself to do my home exercises because....I was tired. So, in my newbie opinion, yes exhausted is just a fact for awhile. That said, it could be worse, eh? I'm so grateful I am retired and don't have to worry about a too early, return to work date. I CAN nap, wherever and whenever I'd like, and I do.

 

[eaglemom]

Thanks for the encouragement guys. I think I might have been slightly naive in thinking my revision would be similar to my total replacement. Today is week 5 of recovery. It is slow going, that is for sure. And a very delicate balance between doing too much or not enough. I've found that I'm much better if I put myself down for a nap after lunch!!! If I try to do things around the house I'm miserable and falling asleep so what's the point?

I have an appointment with the surgeon at the end of the week. One thing I will say is this is the best looking knee scar I've ever seen!!! Hopefully I'll be released to get in the pool - that will help mentally & physically. I've even taken to sitting outside in the morning just to feel the sun on my face - good old natural vitamin D.

I have questions about the tightness of the knee / IT band. It is worst in the evening when I'm in bed. I simply can't get my leg comfortable. Hopefully I'll at least be released to drive near home - not that I've minded not driving at all. Since hubby doesn't drive I thought it would be problematic, it hasn't been.

Lookie hear - nap time!!! Yea.

 

[Pheebs52]

Have you tried some heat on your quads and IT band, followed by some gentle massage? Fingers or a rolling pin work very well.

 

[KarriB]

Here's some info on IT band. Often though if you're having pain at night it can be because you've over done things through the day and expected too much from your new knee. Try stepping back from some activity and see if that helps at night.

https://bonesmart.org/forum/threads/itb-ilio-tibial-band-issues-and-treatments.18936/

 

[Celle]

I've found that I'm much better if I put myself down for a nap after lunch!!! If I try to do things around the house I'm miserable and falling asleep so what's the point?

I'm a bit concerned about this, because it sounds as if you feel you should be up and doing things around the house. No, you should still be spending almost all of your time resting, and that includes daytime napping.
Check your activity against this article: Activity progression for TKRs

I have questions about the tightness of the knee / IT band. It is worst in the evening when I'm in bed. I simply can't get my leg comfortable.

I agree with KarriB. It's another indication that you are probably trying to do too much for this stage of recovery.

I'm going to ask @Josephine , our Nurse Director, to advise you. She'll probably ask a lot of questions. Do try to answer them as fully as possible, so that she has all the information she needs, to advise you appropriately.

 

[Josephine]

Before I can offer an opinion, I need to ask you some questions

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?

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.

 

[Pheebs52]

Great info on the IT Band @KarriB! I find I can do the standing stretches and I think they are helping, along with massage at PT and at home.

 

[eaglemom]

Here you go, I'm going to answer the questions. Let me just say - thank you to everyone for the help.

1. pain - around a 4 or 5. That seems to be where I am most of the time. I go down to a 3 occasionally.

2. medication - hydrocodone/acrtaminophen 10-325 mg every 4 to 6 hr. I'm taking 2 per day - one prior to doing my PT and the other at bedtime.
flexeril 10 mg - up to 3 daily - I'm taking 2 - pre PT and bedtime
I have some tramadol 50 mg - 1 every 4 hr. as needed. I'm usually taking 1 about midday.

3. swollen - moderate.

4. ROM - extension just shy of 100 at last measurement, probably past 100 now.

5. icing - I use the ice machine from the hospital at least 1x daily, usually 2x's. I leave it on a couple of hours - it isn't directly on my skin. (It feels so good when I am icing, but I find I'm incredibly stiff afterwards)

6. elevation. I'm an epic fail here and admit it. I elevate, but not to the level in which I should. I can't get comfy when elevated more than one pillow high.

7. activity level - I make the bed, pickup the kitchen and prepare 2 meals daily. Lunch isn't much - usually reheating something. Dinner I'm making daily - I find I sit a lot while doing so. Hubby is very good on the cleanup crew afterwards. Yes I putter around the house probably more than I realize.

8. exercises done at home - ankle pumps, extension push, heal slides, to the side slides, leg raises - all while laying on the bed. I do 2 sets of 10.
sitting - making leg go forward - 2 sets of 10
standing - tippy toes, heal to toe stretch, to the side, backward curl and front bent knee life - 2 sets of 10.
balancing along the kitchen counter - walking sideways front direction then backwards - 2 sets of 10

I do them mostly daily - I do heal slides and extensions daily several times. The rest I do as I've listed.

I make several loops around the house several times daily walking heal toe and try to sit out in the sun daily.

Curious what you think of all of this. Thanks in advance for the help.

 

[Josephine]

1. pain - around a 4 or 5. That seems to be where I am most of the time. I go down to a 3 occasionally.

Okay

2. medication -
hydrocodone/acrtaminophen 10-325 mg every 4 to 6 hr. I'm taking 2 per day - one prior to doing my PT and the other at bedtime.
flexeril 10 mg - up to 3 daily - I'm taking 2 - pre PT and bedtime
I have some Tramadol 50 mg - 1 every 4 hr. as needed. I'm usually taking 1 about midday.

Well first thing is that you should never take pain meds before PT. In this situation, pain has a very important role which is to warn you when you are doing too muc.

3. swollen - moderate.

Swelling is a manifestation of pain you know - did you factor that into your pain score?

4. ROM - extension just shy of 100 at last measurement, probably past 100 now.

think you meant that flexion is 100! Which actually isn't bad. But what is your extension. Here's a graphic to explain how this system works and instructions on assessing extension Extension: how to estimate it

5. icing - I use the ice machine from the hospital at least 1x daily, usually 2x's. I leave it on a couple of hours - it isn't directly on my skin. (It feels so good when I am icing, but I find I'm incredibly stiff afterwards)

I think 2 hours is probably too much to keep your knee immobile. I suggest you at least bend it up a few times every 30 minutes or so. Just a gentle bend to move it, nothing aggressive.

6. elevation. I'm an epic fail here and admit it. I elevate, but not to the level in which I should. I can't get comfy when elevated more than one pillow high.

There is no such thing as 'fail' in this book! First thing is never to have your leg totally straight. Yes, I know hospital people rant about it being 'dangerous' but I would argue with that. I've certainly never done that myself as it's extremely painful. Here are examples of good and bad ways to elevate your leg. I would suggest that you cannot get comfy because your leg isn't in a good position.

7. activity level - I make the bed, pick up the kitchen and prepare 2 meals daily. Lunch isn't much - usually reheating something. Dinner I'm making daily - I find I sit a lot while doing so. Hubby is very good on the clean up crew afterwards. Yes I putter around the house probably more than I realize.

A teeny bit too much, especially if you are back at work. You need to re-read this Activity progression for TKRs, assuming you read it before! (in post 2#)

My comments in bold
8. exercises done at home mostly daily - but none at the weekends
ankle pumps 2 sets of 10 - actually you don't need to do these. They are only intended to be for when you were not very mobile to ward off blood clots. That is long past now as you are so very active
extension push 2 sets of 10 - I don't recommend these, extension will come on it's own eventually
extensions daily several times - ditto
heel slides 2 sets of 10 - these are very easy to do badly and this is badly! But a) they're not going to give you an increase in flexion anyway so stop doing them!
to the side slides 2 sets of 10 - don't see the point of these at all
leg raises 2 sets of 10 - a little tip about SLRs, once you can do them, you don't need to do them any more!
sitting - making leg go forward - 2 sets of 10 - never heard of these and so they're pretty pointless
standing tippy toes -nooo! these are very bad for your hamstrings
heel to toe stretch - don't see the point of these either
to the side - or these
backward curl and front bent knee life 2 sets of 10 - no point to these either
balancing along the kitchen counter - walking sideways front direction then backwards - 2 sets of 10 - at 8 weeks, no point!

I make several loops around the house several times daily walking heel toe - those are the kind of things that will improve everything but don't obsess over the 'heel toe' thing. Just walk casually.

In summary, you're doing rather too much of things that are unnecessary. It's not the exercising that gets you your ROM, it's time. Time to recover, time for swelling and pain to settle and time to heal. One thing that seems to be missing from all the PT's protocols is that all your ROM is there right from the start, just waiting for all that to happen so it can show itself. In the general run of things, it doesn't need to be fought for, worked hard for or worried about. It will happen. Exercise as in strength training is counter-productive and in the early weeks does more harm than good. Normal activity is the key to success.

So stop doing the exercises and just get on with your life! And if you feel reticent about going against PT advice, remember that you are a sentient human being and allowed to choose for yourself!
BoneSmart philosophy for sensible post op therapy
Saying no to therapy - am I allowed to?

 

[eaglemom]

Thank you thank you thank you. I've thought some of what I was doing wasn't really doing anything. This afternoon (before I saw this) I discussed with the hubby about out patient PT. I really don't even feel I have the energy to go somewhere and give it my best effort - my effort is tired!! I can't see going to a program if I can't give it my best effort. I don't know how the surgeon will respond tomorrow, but for now, I'll say I'm going to give myself several more weeks without a formal PT person.

Equally I've not been cleared to drive - & no matter what is said tomorrow, I'm not doing it. I don't feel as though it would be safe. I'll slowly ease into it in a couple of weeks. Our friends are great about helping us get whatever we need. I do know I need to begin to make an effort to at least want to leave the house - I'll have someone pop by to get us & we'll do lunch out. That's probably the extent to which I can do now anyway.

You guys are wonderful.............thank you from the bottom of my heart. I'll report what the surgeon says tomorrow.

 

[Josephine]

If you have to make an effort to do something or even leave the house, then you're not ready for it!

And when you are talking to your surgeon about this, do remember this all the time - you have a right to say no and to decide what you want to do and when. Read this Saying no to therapy - am I allowed to?.

Obviously I don't know your surgeon but I do know surgeons and they do tend to huff and puff if patients aren't compliant. So take care what you say. Better yet, don't say anything! I never did!

 

[sistersinhim]

I didn't say anything about PT to my surgeon either. I never took it, and my OS didn't know, but was still very happy with my knee. If you aren't ready to take it, then don't. It's your knee and you have all the time in the world to take PT if you want to, or to not to do it at all. It's your decision.

 

[Celle]

I never mentioned PT to my surgeon until my 6-month check up, when my ROM was great. I told him than that I had not gone to PT at all and his response was "Well, you obviously didn't need it."

He's not very hot on PT anyway, and doesn't allow any formal PT for the first month after a knee replacement. After that month, his patients usually go to PT once every 2 weeks and are shown new exercises at each session.
His patients all do well and he hasn't had to do a MUA to help with ROM for the past 4 years.

 

[eaglemom]

Very interesting........... thanks for sharing your stories.

 

[eaglemom]

Thought I'd bring you guys up to date after my last appointment. I left the office kind of shaking my head.

Of course the incision has healed nicely, it really looks good. I still have bruising but its fading. They were fine with my ROM it needs to be better but is fine for now. However, they were not happy with my extension, at all. They again went over the reasons the extension has to get better (like I didn't know that) and asked about PT. I voiced that I didn't think I wanted outpatient PT because I can't give it 100% - so home health was extended. Not what I wanted but oh well. I tried again about not having PT and I clearly got the picture that they wanted out patient PT. I'll admit I wasn't as forceful as I could have been about it - and equally they weren't listening to what I was saying.

I have another appointment in 3 weeks where it very casually was said "that is when we'll schedule a manipulation if your extension isn't better." That is nothing that I want - and frankly I quit listening at that point.

I need to work harder on extension but rest as I'm not recovered. I should be up & about but only do bare minimum, listen to my body when its tired but push myself, don't just take pain meds but take pain med's when you need to......... you understand.

I guess I'm just frustrated with everything. Which is to be expected. The more I do around the house the more tired I become and swelling increases which means more pain. I'm going to do what I can and that is it - I don't have the energy to push much harder. My IT band and hamstring are what I've got to work on.

There you have it - my update. Thoughts?

 

[sistersinhim]

Nothing can be done to your knee that you don't approve of. Extension coming slowly is a common complaint. But, it will come. You can not force it, it will improve as your knee improves. If you don't want to take PT, then don't. If he gives you a prescription for it, take it, but don't call and make an appointment. I didn't, and my doctor never said a word about it.

It is your knee and you are paying for the services to it. You have the last say so! If you don't want to go back in 3 weeks and listen to his MUA push, then just cancel your appointment unless you have another problem beside extension. Remember, extension does come eventually! The more you use your knee in your daily living, the more it'll come.

 

[KarriB]

The only thing I did for extention was letting my leg bridge between my chair and the ottoman a few times a day. Try doing this and there should be improvement in 3 weeks. You don't have to work hard, just let gravity do all the work. My TKR is actually - extention, so much better than my natural knee. Take a look at this link to see what I mean.

https://bonesmart.org/forum/threads/extension-how-to-estimate-it-and-ways-to-improve-it.9529/

 

[Josephine]

Me too! But in my first knee, my extension was a bit laggard but I chose not to worry about it and though it took a little longer, about 5-6 weeks more, it did eventually come good. One lesson I learned from this is that nothing we do will affect extension. But it will come in its own good time. Just have faith and stick with it.

And oh yes - extension, however bad it is, will not ever be sorted by an MUA. Just not - ever! So that's a jolly good reason for you to tell him you're not prepared to accept the MUA and that's that!