TKR Knee tightness and lack of sleep<

[KarriB]

I couldn't have sat with my leg down for 4 hours at 7 weeks after surgery. Anytime I went out I made sure I could elevate my leg. At church I took up several seats and propped my leg up, restaurants, even when I went back to work for parent/teacher conferences my leg was up on a chair.
Pain will keep you from being able to bend your knee also. Be sure you're not chasing the pain and take your meds on schedule. It's ok to still be taking pain meds at 2-3 months.

 

[Gigi32]

7 weeks is much to early to sit with your leg bent for any length of time much less 4 hours! It was at least 4 months with my first knee before I could go to a movie without having a empty seat next to me to prop up my leg on. That's also why people who return to a desk job earlier than 12 weeks because they think since they can sit all day it will be easy find it is much more difficult than they expected. This is a slow recovery and you need to pace yourself or you'll pay with pain and swelling as I'm sure you've discovered.

 

[Josephine]

I have been told if you do not get to 0 extension your gait will never be normal and a manipulation cannot assist with extension only flexion.

But you know that's not true. It really isn't - remember these articles?
Myth busting: the "window of opportunity" in TKR
Myth busting: the "window of opportunity" JBJS

Please understand where I am coming from I have a surgeon who has already mentioned a manipulation and that was at 5 weeks.

We understand - we totally understand. Have no fear of that.

I at this point do not know what to do.

You don't have to do anything! There's no time line on having an MUA even if it was appropriate, which it's not as MUAs are for flexion, not extension. Besides which, it's not at all uncommon to have a lag in extension at 7 weeks. Remember what I said earlier? Your ROM is there right from the start, just waiting for the swelling and pain to go down 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.

I got up as often as I could and stretched but by the time will left I felt like my knee was stuck in a bent position while trying to walk. It is better now after elevation and icing the past 3 hours but that scares me.

Don't be scared. You're making things worse by being scared of not moving when that's the one thing your knee needs above everything. I have this cute graphic to explain

 

[Bullet]

Went for follow up with ortho surgeon today and again he mentioned that I can have much better results with having a manipulation done. Current flex 103, extension -3. Makes me feel like by refusing I am turning down an opportunity for better quality if life. I stood firm and refused but am conflicted at this point. He has ordered continued aggressive therapy and now a dynasplint which will be started by the end of this week. I follow up with him again in 3 weeks. I am literally sick to my stomach as I just am not sure what to do at this point. I have worked so hard to be told it is just not good enough over and over. My left knee has advanced osteoarthritis and not sure I would ever do this again. People have diagnosis that are life threatening so I should be happy with what I got and just move on.

 

[Celle]

Current flex 103, extension -3. Makes me feel like by refusing I am turning down an opportunity for better quality if life. I stood firm and refused but am conflicted at this point. He has ordered continued aggressive therapy and now a dynasplint which will be started by the end of this week. I follow up with him again in 3 weeks. I am literally sick to my stomach as I just am not sure what to do at this point. I have worked so hard to be told it is just not good enough over and over.

Most surgeons won't even contemplate doing a MUA once your ROM is above 90 degrees. You don't need one and I'm proud of you for resisting.

What's the rush with your surgeon? There's no "window of opportunity" within which time you have to get ROM, or all is lost. Myth busting: the "window of opportunity" in TKR
You can continue to get an increase in ROM for a year, or even longer, after a TKR.

Aggressive therapy at this stage won't increase your ROM faster. In fact, it could even slow it down. Just keep dong a little, gentle exercise. For a recovery from a TKR, Less is More - less hard therapy equals more progress.

You truly don't have to work hard to rehab your knee. Working too hard is counter-productive.
TKR: work “smarter” and not “harder”
Life in the slow lane
You've done your best. Don't try to do more - do less.

I wouldn't use the dynasplint either. It's uncomfortable and I think its value is over-rated. You could try it and see what you think, as long as you cut back on a lot of the other exercise you're doing.

It sounds as if your surgeon and your OS were both taught that you need to work hard to rehab a knee. Some refresher courses are now teaching a gentler approach.

 

[Timetolive]

I am sorry you are having to go through this. it is confusing when the surgeon that you researched, hired, and trusted with your surgery, is now telling you something that seems counterintuitive and disagrees with what Bonesmart tells you. I understand. I will say this, there are many, many people on this site that are in the healthcare field and thousands that have had this surgery. They have "been there, done that" and fully understand what they are talking about. You will have to decide what is best for you and what you will be comfortable with. I also had aggressive therapy. I now have what I believe to be an injury from that PT that I am trying to heal. I have a hard time speaking up for myself, although if I had only spoken up and followed the advice here on BS, I would be better than I am. What would it hurt if you wait on the MUA? You can always tell your OS that you want to give your knee a little time to heal and set a date with him. That way, you are not dismissing his advice, you can slow down and let your knee heal, and in the meantime - you can think about it when you are not under so much pressure. You are in my prayers for comfort and clarity in your decision.

 

[Clipless]

My OS won't consider an MUA unless you're under 100°. I actually approached him and ASKED for an MUA when I was about 4 months post op first TKR. But I was just over 100° and he said "No way!". That knee came along quite slowly, but I can do almost everything with it now- hike, mountain bike, horseback riding, etc. I still cannot literally sit on my feet- that would be nice, but not necessary. Here on Bonesmart I remember a member who had a PKR and her flexion was really good (>110°) early on, but she wanted MORE because she is a yoga enthusiast. She had the MUA and was pleased with the outcome. On the other hand some patients have had multiple MUA's without noticeable improvement. And of course there is risk.

I wish you all the best, whatever you decide.

 

[KarriB]

An infection in my TKR reared its ugly head at the 4 week mark. Part of my treatment was NO bending the knee for 2 weeks, which grew to a little over a month. I wore an imbolizer because my OS wanted my soft tissue to heal after being compromised by the infection. He said he'd be happy if I reached 90. Once I was allowed to bend it was a slow process but I was bending my knee enough to get full rotations about 3 weeks after the infection surgery. I believ that was possible because my knee wasn't swollen. I had spent that month elevating and icing my straight knee. Eight months after surgery I was swimming 15-20 laps a day and riding 4 miles on my bike. Then this last summer I realized I could do squats in the water! There is no time frame for gaining ROM.

 

[Josephine]

I stood firm and refused but am conflicted at this point. He has ordered continued aggressive therapy and now a dynasplint which will be started by the end of this week. I am literally sick to my stomach as I just am not sure what to do at this point. I have worked so hard to be told it is just not good enough over and over.

He's making you feel guilty with all this, but I can promise you that 'aggressive' therapy will only be a self-fulfilling prophecy and regress your ROM by making your knee swell more and obstruct your ROM more. I urge you to cut him adrift and do your own thing. You don't need him unloading on you like this when it's all so unnecessary.

 

[sleepilu]

Your surgeon sounds like a scalpel happy bully! The words "second opinion" come to mind ....


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[Jackieray]

Our surgeons must be brothers! At the end of 6 weeks I was 90 flexion and 0 extension and my doctor said the exact same thing to me. "That's not enough! You could go home and take chance you might get more but I want you to have the most you can get." Something like that. But then he tells me I would be a high risk patient for a MUA because I have soft bones. I'm assuming he meant my leg could fracture during the MUA. I'm just grateful I had already found this website. But I did check with my regular doctor who had referred me to my OS since he knew my history and he told me no, he didn't want me to do it. I wasn't going to do it anyway. I would trust the people on this site. I wish you the best. These decisions are difficult to make.

Whatever you decide to do, please don't ever, ever let anyone push on your leg!!

 

[shrdlu]

First, I am sorry how bad your surgeon is making you feel. I think my surgeon would be perfectly happy with those numbers at this point. (I know, because he told me before surgery-- twice!-- to slow down with this second knee.)

I am not a medical professional, but I will tell you what has worked for me with my first knee (7 months ago) and what is helping me progress with my 2nd knee (4 weeks ago). I am 54, so we are close in age, and I considered myself in moderate shape and reasonably flexible. I had a regular exercise routine prior to the knees going out , but waiting to get the knees done meant that I wasn't in good shape anymore. Mine are partial replacements (Makoplasty--less bone removed in surgery), and in PT, I've noticed that TKR tend to move slower with PT. So don't get discouraged.

Last week , my numbers were -3 and 103 at physical therapy (the numbers have stayed the same for about 3 weeks). But since I had been on my feet too much for a few days, my knee was swollen and kept stiffening up and didn't want to bend, so at home I was more like barely 90 degrees bend, and that took work. Since my numbers would be bad, they didn't even bother to measure me last Friday, since my knee was so stiff. So I elevated all weekend and started my "bend trick" on Monday, and as of yesterday (two days later), I was 106 and 109 flexion (two consecutive measurements). So I increased 3 to 6 degrees bend. I am telling you this to give you hope. For background, I absolutely hate the strap stretch, so I figured out how to gently stretch my knee at home, and that is how I got my bend back with the 1st knee (and I am now doing the same thing for the 2nd knee). (I cheat horribly on the strap stretch, as I had a PT push me once, so I now tense up every time I do that exercise...so I don't do it. And my current PT isn't allowed to touch my leg at all when I am doing bending exercises.) I do these exercises (see below) at home and have PT three times per week. So that is the background. My guess is that the same thing will probably work for you, but clear it with your PT.

1) Stay off of your feet when possible. Do not sit with your knee bent. A bent knee (when you are early in the healing process) means a swollen knee (I once drove 4 hours when I was at your stage, and it took 2 days to undo the swelling.) A swollen knee has trouble bending and straightening. Keep the swelling down and you will heal faster and you will feel better. Swelling = pain. Swelling = slow PT progress. If you can't elevate, then sit with your leg propped up. (For example, if we stop somewhere to eat, I sit in a booth with my leg stretched out on the booth's bench seat or hanging from a chair next to me. I do NOT sit the regular way, with the knee bent.) If you need a pillow, then bring a pillow for your leg. The leg makes the rules right now.

2) Elevate all night long. I have a foam wedge (purchased from my PT place) that I put under my leg while I sleep in the recliner (fully reclined). There is an article on this site that shows how to stack pillows for elevating. By elevating all night long, I undo a lot of the swelling that I did the day before, so my leg starts off the best possible condition for the next day. I often wrap slushy bags in towels (I don't have an ice machine), so that I have gentle cooling, and place that on the knee while I fall asleep. Use pillows and cushions to stuff around you to make yourself comfortable and so that the elevated leg doesn't roll to the side while you are sleeping. Keep doing this until your leg no longer swells. I did this from day one post op.

3) For straightening, roll up 2 or 3 towels tightly. Put larger rubber bands around them, so that they form a fat roll (they will squish down after a few uses). Now lay down flat on your back on the bed, and place the roll under your heel. Let the knee hang in this position for about 3 minutes. Do this frequently, as you can tolerate it. This exercise can be done anytime post op.

4) You might need to separate your straightening exercises from your bending exercises. Knees don't like going from one to the other, so you can put a break in between them. Once the knee loosens up, this won't be as important.

5) For bending, I do two stretches 4 or 5 weeks post op. (I do these during commercial breaks while watching TV.) None of these should cause pain-- if it does, then don't do it. For the first one, lay down on the bed on your side (if left leg, lay on left side/ if right leg, lay on right side). Now bend your knee. GENTLY take your good leg and hook it over the foot of the other leg. Now place a slight pressure on your surgery leg, gently pulling your leg towards your body and increasing the bend. Hold for a bit, then relax and straighten the leg. Only do this to tightness, not to pain. For the 2nd bend exercise, you need to have good control of your leg and adequate leg strength. Lay on your back. Raise your leg so that it is pointing toward the ceiling. Now gently bend your knee, so that your foot lowers toward the bed. Relax the knee, and let gravity pull your foot downward. Relax and hold it for about 5 seconds, and then repeat. If it hurts, raise your leg back toward the ceiling. Only do a few reps (I do maybe 5) at a time. You can repeat these on and off throughout the day.

With my first knee, I did get it down to 0 extension and to 135 flexion. Once I started doing the bending exercises described above, I got about 5 degrees per week without any pain and without a lot of work. As I said, my doctor told me to slow down getting bend once I started doing those exercises because they worked so well. Hopefully some of my suggestions will help you-- the 5 things above are all I am doing at home at this point and what I did with my last knee. And your numbers don't sound bad to me. Let us know how it goes.

 

[Josephine]

A bent knee means a swollen knee (I once drove 4 hours when I was at your stage, and it took 2 days to undo the swelling.)

Nice post, @iamshrdlu but actually bending on it's own doesn't cause swelling - but bending with long periods of inactivity (as in your 4hr drive) will. Big difference.

 

[Bullet]

Thanks Jamshrdlu for taking the time and sharing all your great information. I have done the Two bending exercises you note but not consistently as I have tried to be more in line with my PT routine but I have been changing it up at home. Another bending exercise I have been doing is lying down with my head slightly raised and actively bending my right knee keeping my foot flat on the bed I do this until I cannot actively bend it any more and then with a robe tie around my foot I pull it a little more past my active bend. I noticed for me I get the best possible bend. I agree doing this bent lying on my stomach and pulling on my foot with tie is uncomfortable but the one they had me doing at PT.

I have been told by many different disciplines now that my surgeon is a "numbers" guy and this have caused me a lot of stress when ever I follow up. He has now ordered Dynasplints for my extension as well as my bend. I started the splints on Tuesday of this week and was pretty out of sorts yesterday. The splint for extension is to be worn for 3 hours daily. I wear it while relaxing or watching TV in the evenings. I tolerate this one well. The splint for bend not so nice as it makes me miserable about 30 minutes into it. I am suppose to wear it for 1 hour 3 times a day. I have yet to make it the full hour. Once I am tolerating current setting I will then turn tension up. I feel like this whole process is like a slow torture. I am now medicating more frequently again to tolerate this new treatment. I am still attending outpatient PT "Aggressive" as wrote by my doctor however my therapist is very good and never pushes me past uncomfortable pain levels. I also cut PT to 2 X week down from 3. I forgot to note my surgeon has consistently recommended manipulation which I have declined on each visit. The splints were ordered as second line of treatment.

 

[snowdrop]

I do the second bending exercise that Jamshrdlu describes in my PT sessions. Since I am only 15 days post-op, my therapist places a towel under my thigh and I use the ends to help hold my leg up while letting it bend with gravity. Just thought that might help you to know...

 

[shrdlu]

Another bending exercise I have been doing is lying down with my head slightly raised and actively bending my right knee keeping my foot flat on the bed I do this until I cannot actively bend it any more and then with a robe tie around my foot I pull it a little more past my active bend.

That is the one my PT calls the strap stretch, which I detest. Thus, the other two exercises. My PT today took the foam wedge and turned it on its side so that it made a tall triangle, and I put my knees over it and then relaxed and let gravity do the work. He did this because he knows (after my having repeatedly telling him...lol) that I am going to go easy on the strap stretch, as I tense up every time I do it. Thus, he did the foam wedge thing. I am trying to figure out how to get a firm foam triangle for home...I am already imagining 2 pieces of plywood with a hinge between the two; some sort of mechanism to lock the pieces at a specific angle; 2" foam covering the top, upholstered in a soft plush fabric. (But by the time my leg is well enough for me to begin construction, then I won't need it anymore...oh well. On the other hand, if I cut the 2 pieces of plywood, then I could do the rest of the contruction...sort of...sitting on the bed... Hmmm. I think I am about to get in trouble...again... )

As for laying on your stomach and pulling your foot up with a tie , my PT has never had me do this (not with either knee) -- and I just saw them do it for the first time on a young teenage athlete who had a torn ACL. When I asked about it, they said it was because she was a young athlete, and they don't do it on knee replacement patients. It is interesting what different PTs consider appropriate for knee replacement patients.

Do you have an exercise bike at home? After 105 to 110 bend, my PT allows this, and the bike really helps loosen up the knee. Your splints don't sound nice. I couldn't stand being locked into a bending position for an hour. Part of what I do at home is to release the tension on the knee and then relax into the exercise again, as that works best for me. For me the key is gravity and being relaxed. When those two work together, then the bend comes.

The take away from all of this is that you can figure out what exercises you like best, then do those while laying on the bed while watching tv. (The tv is a distraction-- I find that when my mind is occupied and distracted, then the exercises are easier to do.) Then you will find out that bend will come (unless you are one of the unlucky ones-- but you are pretty early in the game to say that yet). So don't be afraid to figure out what exercises that you like best, because those are the ones you won't mind doing at home. There are a lot of PT exercises that I don't do at home, because I am trying to keep the swelling down so that the ones that I choose to do are more effective. For example, going up and down on tip toes is easy for me, so there isn't any need to repeat those at home. I have quad weakness (but not hamstring problems), so I do quad contractions at home (laying down with at towel under the knee, pushing the knee into the towel for a count of 3, repeat), but I don't do standing leg lefts at home (those are also easy for me). I also get up and down out of the chair plenty of times when at home, so I don't do the squats at home. So you get the idea-- figure out what works best for you, and then you won't mind doing those exercises.

I do the second bending exercise that Iamshrdlu describes in my PT sessions. Since I am only 15 days post-op, my therapist places a towel under my thigh and I use the ends to help hold my leg up while letting it bend with gravity.

@snowdrop I wish I had thought of that. (Slaps head...."duh!" ) My therapist didn't show me those 2 exercises, I just wanted to figure out how to get bend without doing their exercises that I hated. The towel trick would have been nice to know. Thanks for that tip.

 

[shrdlu]

One more word of encouragement. When I left PT for my 1st (right) knee, I was -3 active (on my own) and 0 passive (if the therapist pushed on the knee). But I couldn't seem to get the leg straight by my own. My intentions were good, but of course I didn't keep up the exercises, especially after the other knee popped (at 3 months post op), as then I limped everywhere and had trouble walking again. Now fast forward 6 months. I have had the 2nd (left) knee done, and when I came back to PT, my right knee was at 0. I have no clue when this happened, but just from walking around and occasionally stretching (leaning into a door frame), my knee finished straightening out on its own. (And yes, with my right knee, since it is at 5 weeks and -3, I keep reminding myself that it will straighten out, as it is frustrating to see it stuck at -3 for several weeks. So you do have our understanding.)

 

[newlybionic]

Those dynasplints do sound like some type of torture that was used in medieval times. Your doctor sounds like he has never learned the definition of empathy and has also not kept up with some new thinking about aggressive PT being harmful.

 

[Sbow3111]

I am at the same place as you in recovery ... my TKR was 12/4/15. Try Benadryl at bedtime; this, along with 800 mg Advil has been the answer for me when it comes to getting a good night's sleep.
Also, it sounds as though maybe you're feeling some of the all too common "post-op blues". Check in to this site every day ... you'll be amazed at what an uplifting, awesome place it is to find information proving that you are not alone, and experiencing what so many of us have.


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