TKR LTKR nearly 6 weeks out- Questions and concerns about PT

[tweetybird]

Hello everyone! First time posting, but I’ve been scouring this site for a few weeks for answers and advice. Had my LTKR on May 25, 2022 - so I’m almost 6 weeks post op. What a crazy ride this has been so far! I have cried nearly everyday since surgery! It has been a blessing to have found this site and read about others who are going through the same journey as me and comforting to read the reassuring words of those who have already been through the journey. I have a couple of concerns that I hope someone may address on this forum:

1. My incision has healed well, but gosh it is sore to the touch! I can’t stand to have sheets or blankets on top of it. Is it normal for it to be this tender at 6 weeks? Any of you do massage on your incision to help break up any adhesion formation. PT advised me to do it.

2. I’m so confused as to what approach to take towards recovery. I love the Bonesmart philosophy of being gentle and allowing knees to heal- but on the flip side I hear from PT and other individuals that I need to be more aggressive with my therapy or I’ll miss the window. This scares me and causes me so much confusion and anxiety!

My Rom is poor for 6 weeks-I’m only bending usually somewhere in the 70’s. My extension is much better. My last PT visit was miserable-PT bent my knee as much as I told him I could tolerate (and then some). Then he held it for 40 seconds in that position 5 times over. My sweet husband was by my side and I was squeezing his hand so hard and tears were streaming down my face! He said it reminded him of when I was in labor with our children! Right after that was done the PT sent me to some machine that bent my knee back with a 5 lb weight on it for 10 minutes. Although I didn’t feel the effects that day-the following two days I was miserable with a very stiff and swollen knee. Felt like I had lost any progress I had made in the last few weeks. I am nervous for the next PT appt as I know I will have to have an uncomfortable conversation with the PT about his approach.

Bonesmart posts have advised gentle stretches as an alternative to therapy. Where can I find examples of these stretches? Currently I am doing knee slides and extension exercises at home. Any other exercises I should be doing?

3. Sometimes I feel like for every step forward-I take two steps backward the next day. Is that normal for 6 weeks out? People keep telling me “oh, wait for 2 weeks or 4 weeks or 6 weeks or 8 weeks and then you will notice such a difference in how you feel.” Truthfully, neither the 2 week or 4 week mark and it doesn’t look like the 6 week mark will bring much of a difference in how I feel. I can see I have made small steps forward but, my progress has been slow and simple. I really wish there was more transparency on doctor’s parts to clue you in to what to expect. Guess you don’t really know till you walk that road yourself. I try to remind myself that I’m only on week 6 of what will likely be a 52 week journey! It certainly tries my patience! Grateful for all the dedicated people on this site who so willingly share their experience and expertise with all of us newcomers! Thank you!

 

[ski_bum]

Hello everyone! First time posting, but I’ve been scouring this site for a few weeks for answers and advice. Had my LTKR on May 25, 2022 - so I’m almost 6 weeks post op. What a crazy ride this has been so far!

I found putting a large pillow at the end of the bed under blankets making a tunnel and stopped irritating the leg. Plus able to turn leg without toes catching sheet causing knee pain.
PT told me to massage the lump above my knee working it into the back of my knee. The surgeon explained that was muscle they cut and raised lumpy means it is healing. If it was flat it was not healing.
I don't remember if my incision was sensitive or not. I massaged incision with O'Keeffe's hand healing cream. Can hardly see incisions.
As for ROM, trust Bonesmart. I quit both times after 2 visits. Second time PT cause my first 10 month old knee to hurt going backwards.
My favorite place is the Hot Tub twice a day, stationary bike and of course Ice.
Wishing you the best and trust Bonesmart about Aggressive PT.

 

[sistersinhim]

@tweetybird, welcome to Bonesmart! Your PT has not been trained in joint replacement rehab. You need to find another one that has had up-to-date training. There is no time limit on gaining ROM. We've had members whose bend improved even into the second year.

Each person is different as is their recovery. Most find that the Bonesmart approach works best for them, but others find that a more aggressive therapy helps them more. It's your recovery and your choice on how you recover. As you read more on other members' recovery threads, you’ll get a better perspective of what to expect. The following are our basic guidelines and should help get you started.

Knee Recovery: The Guidelines

1. Don’t worry: Your body will heal all by itself. Relax and let it. Don't try and hurry it, don’t worry about any symptoms now; they are almost certainly only temporary.
2. Control discomfort:

rest​

elevate​

ice​

take your pain meds by prescription schedule (not when the pain starts!)​

don't overwork.​

3. Do what you want to do BUT...
a. If it hurts, don't do it, and don't allow anyone to hurt you.
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again for a few weeks.
4. PT or exercise can be useful BUT take note of these

the BoneSmart view on exercise​

BoneSmart philosophy for sensible post op therapy​

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.

Try out our great new opportunity to improve your gait. It's OneStep. It's free and you will find it to be a huge help to you. Click here: OneStep

 

[Jockette]

My incision has healed well, but gosh it is sore to the touch! I can’t stand to have sheets or blankets on top of it. Is it normal for it to be this tender at 6 weeks?

Yes, this is normal and may feel like this for quite a while.

 

[Jockette]

Any of you do massage on your incision to help break up any adhesion formation. PT advised me to do it.

Many of us are told to do this, but it’s not necessary. I didn’t, and I didn’t get any adhesions.

My last PT visit was miserable-PT bent my knee as much as I told him I could tolerate (and then some). Then he held it for 40 seconds in that position 5 times over. My sweet husband was by my side and I was squeezing his hand so hard and tears were streaming down my face!

I can’t tell you how upset this “rehab” approach makes me. It is inappropriate and is one of the reasons your ROM “is so poor.” This forceful bending is keeping your knee upset and inflamed and is increasing your swelling, which prevents ROM from improving. My PT did something similar. I gripped the sides of the table I was laying on so tightly that I pulled a muscle in my left shoulder, which by the next day was a pain level of a 100, and the dilaudid I was taking for the knee didn’t touch it. I will never let a PT do this to me again.

I understand how you feel about it being an uncomfortable conversation, but you must tell them they do not have your consent to do that again. It is absolutely not necessary, and it is doing harm to your knee. I seriously don’t understand why they think this will help us heal. It won’t!

Right after that was done the PT sent me to some machine that bent my knee back with a 5 lb weight on it for 10 minutes.

This is also inappropriate for your new knee.

If your conversation doesn’t go well, dont go back to them. Find another office who will agree with your choice of rehab, or do your own at home.

Bonesmart posts have advised gentle stretches as an alternative to therapy. Where can I find examples of these stretches? Currently I am doing knee slides and extension exercises at home. Any other exercises I should be doing?

The stretches I personally recommend are just very gentle bending motions. You just need to give your knee mobility. These stretches happen as you go about the house doing your daily activities.

Here is our article about heel slides, if you want to do them, but a “ formal exercise” is not required.

Heel slides and how to do them properly

NEVER cause yourself pain doing this, only mild discomfort Do these every couple of hours during the day so you don't overstress your leg which is very easy to do. This is what happens when you do 10-30 reps in 3 lots 3 times a day. That much intensity is unwise. You get a much better effect...

bonesmart.org

 

[Jockette]

BoneSmart philosophy for sensible post op therapy

You will have noticed there is a significant opinion here about the potential hazards of PT. You may feel that your therapists are experts and know what you should be doing. However, over the last several years I've been here, I have observed that the more intensive the regimen of exercising...

bonesmart.org

Regaining our ROM is more about Time than repetitions of a list of exercises.

Time to recover.
Time for pain and swelling to settle.
Time to heal.

Our range of motion is right there all
along just waiting for 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. Normal activity is the key to success.

 

[tweetybird]

Thanks everyone for your advice! I really appreciate you taking the time to respond. I will definitely talk to my PTA about what happened and see if we can find a more suitable therapy for my knee.

One more question - can anyone guide me to any studies or info that supports the Bonesmart approach to therapy? Gentle therapy makes SO much sense to me- why aggravate an already inflamed joint with intense therapy that creates more inflammation? But - I think that traditional PT is geared toward an aggressive approach to TKR rehab. I’ve found it difficult to find any studies/opinions supporting a more “hands off” approach.

My first PT appt was with the PT doctor. I brought up the subject of a the idea of less aggressive therapy and he immediately started with window of opportunity talk and how he would hate for me to have MUA and ended with a joke about how PT actually meant physical torturer. Was very off- putting to me! Would love to have some info to support my position. Thanks!

 

[Jaycey]

Read these articles again:
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR

There is no "window of opportunity". Everyone recovers at their own pace.

As for studies regarding the BoneSmart approach - we base our recommendations on thousands of members who have come to us with the same concerns you are sharing. Pushing through and aggressive PT just is not right for most. Members who have changed their approach and adopted the gentle recovery are usually delighted with the result.

In the end the decision is yours.

 

[Jockette]

We don’t find much information out there about a gentle approach other than here at Bonesmart. I don’t understand why, because like you, the Bonesmart approach makes so much more sense.

Many of our articles are written by Josephine, who worked almost exclusively with joint replacement, both in the operating room, and also seeing patients in recovery. Josephine has over 60 years experience. (She has since retired) So, she is quite experienced and has seen this gentle approach to be very effective.

I’m sure, for your own peace of mind, it would be great to find other sources like Bonesmart. But, it really doesn’t matter if you have other proof or not. What matters is that, this is your knee, your recovery, and your rehab. Not your surgeon’s, or your PT’s, or even your family’s. It’s yours. Your opinion on how you want things to go is the only opinion that matters. And if you want to do a gentle rehab, then do a gentle rehab.

As one of our staff members likes to say, this recovery is a long journey but if you stick with the BoneSmart approach the journey will be less painful and you will still reach the same final destination. Ultimately you get to choose the path, the tough rocky road through painful PT, or the BoneSmart path through the meadow with the pretty wild flowers.

You won’t convince your current PT that a gentle approach is effective. He has been trained a certain way and many patients are compliant, even though they don’t like all the painful rehab. This doesn’t mean we all have to comply.
Saying no to therapy - am I allowed to?

we base our recommendations on thousands of members who have come to us with the same concerns you are sharing. Pushing through and aggressive PT just is not right for most.

This is what one of our members, TortiTabby, experienced:

(Just so you know, ADL means Activities of Daily Living.)

“At my six week appointment this is what my OS wrote in my visit summary: "She reads an online website called Bone Smart which states to not push through pain following knee replacement. If she were to follow this direction, she will have to learn to live with a knee that only reaches to 85 degrees of flexion. I believe this website is very misleading."
It has now been 20 weeks and all I do is ADL and this is what my ROM has done:
3.5 wks: 75
6 wks: 85
7 wks: 90
10.5 wks: 95
14 wks: 100
17 wks: 105
20 weeks (where I am today): 110
I am so thrilled it keeps improving and improving and I know now that I will get to my goal of 120 (or even better, dare I say!)
So, if a OS or PT bullies you into thinking your ROM will not improve over time they are wrong. By the way, I haven't been back to see the OS since that horrible appointment at 6 weeks, but I sure am going back when I reach 120 just to say, "Ha! You were wrong, BoneSmart was right!" “

And,

“Just an update for those who are apprehensive about gaining ROM:
It has now been 26 weeks and all I do is ADL and this is what my ROM has done:
3.5 wks: 75
6 wks: 85
7 wks: 90
10.5 wks: 95
14 wks: 100
17 wks: 105
20 weeks: 110
26 weeks (where I am today): 120!!!
I did it! My goal of 120! No "pushing through pain", no PT after the first 3 visits, and most importantly to me: No MUA! My surgeon who said I would never get beyond 85 ROM without pushing through pain was wrong, wrong, wrong. I'm excited to see if it gets even better. “

 

[Claire56]

@tweetybird My OS's office seems to follow the BoneSmart philosophy. They don't prescribe PT unless there seems to be a problem or I'm sure they would if requested. The PT/OT that I saw at the hospital took me through the exercises in their handout. All the exercises in the handout were at least similar to ones described on this forum.

 

[sistersinhim]

Not all therapists are using aggressive PT to rehab a joint replacement. Call around and find one that uses the gentle approach. The younger therapists and OSs are using gentle rehab. Through years of experience, it has been discovered that the gentle way is best.

I'm one of those who never took formal PT. I've 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 along with the necessary house and yard work. 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. Just use it naturally.

 

[NewRightie]

My Rom is poor for 6 weeks-I’m only bending usually somewhere in the 70’s. My extension is much better. My last PT visit was miserable-PT bent my knee as much as I told him I could tolerate (and then some). Then he held it for 40 seconds in that position 5 times over. My sweet husband was by my side and I was squeezing his hand so hard and tears were streaming down my face! He said it reminded him of when I was in labor with our children! Right after that was done the PT sent me to some machine that bent my knee back with a 5 lb weight on it for 10 minutes. Although I didn’t feel the effects that day-the following two days I was miserable with a very stiff and swollen knee. Felt like I had lost any progress I had made in the last few weeks. I am nervous for the next PT appt as I know I will have to have an uncomfortable conversation with the PT about his approach.

Wow I’m so sorry your PT was so aggressive with your baby knee! Please switch if you can.

Yes, the incision can be super sensitive! In the beginning, I wore a light compression sleeve (“tubigrip they called it at PT) and that would keep my sheets from irritating the incision. The shape of my leg would make it roll and feel tight so that didn’t last. I laid on my side and that helped. After giving up on the sleeve, it’d hurt but then if I stayed still, it would calm down until I rolled over. I’ve heard that rubbing textured fabric over the incision can calm it down eventually, too. Trial and error led me to icing right before bed which helped it calm down for the initial contact with the sheets. Perhaps we develop a tolerance at some point.

Second knee, I started acupuncture the week after the bandage was removed and that knocked the sensitivity way down and I slept so much better, as well. I wish I’d have tried that with the first knee!!

 

[Tower6brkrs]

I was aggressive with pt. Manual manipulation from a therapist familiar with tkr was key, for me. Heat before therapy and ice, ice; ice. At 6 weeks I was full extension and beyond 90 flexion. Rehab started day one of surgery. Everyone is different but it worked for me. Nerves still haven't come fully back on top of knee so kind of numb still, the whole process was stressful for me. Good luck

 

[Jockette]

I was aggressive with pt.

Everyone is different but it worked for me.

It’s important to recover the way that we want to recover, and we each have the right to choose which approach we want. As my uncle has always said, that’s why there’s chocolate and vanilla!

Welcome to BoneSmart!

Why don't you start your own thread and tell us a bit about your situation. Our members are here to support you. Here's a link to Starting a new thread and posting .

 

[kneeper]

You asked about stretches. Mostly I just did the heel slides. My PT gave me a few others on a sheet for gentle stretching of the calf, hamstring and quads. Nothing so vigorous as what you see for athletic stretching.

My scar was a little sensitive but not bad. It took a while before I could wear long pants (luckily my surgery was in the summer) but otherwise not bad. My PT had me massage it (once it was completely closed), but I don't know that it particularly affected the final result in terms of sensitivity and flattening out. The scar will just take what time it takes to flatten down.
Nothing too intense as far as massaging but it did feel good. I just used some lotion that was easy on the skin. The lotion makes it a more gliding motion when you massage.

 

[Samsrf]

@tweetybird I started with aggressive PT after seeing 3 of them I quit at 7.5 weeks!!! It didn’t make sense to me to not be able to walk normal for 2 days after “therapy” - it should make you better not worse right? OS said at 12 weeks I was doing just fine. Finally surfed yesterday and a little muscle sore today- but the knee is rad. Still working on flexion - been at 0 extension, which doc reminds me is “most “ important since week 3. I wish I hadn’t stressed so much. The key for me is to just keep gentle moving.

 

[Annie5]

Hello everyone! First time posting, but I’ve been scouring this site for a few weeks for answers and advice. Had my LTKR on May 25, 2022 - so I’m almost 6 weeks post op. What a crazy ride this has been so far! I have cried nearly everyday since surgery! It has been a blessing to have found this site and read about others who are going through the same journey as me and comforting to read the reassuring words of those who have already been through the journey. I have a couple of concerns that I hope someone may address on this forum:

Hi thanks for sharing your fears. I’m 5 weeks in and from reading people’s experiences on here I know that it’s going to be a long road and it’s going to be painful for a lot longer. I hope you feel better soon xx

 

[possum_here]

Hi, I had my first RTKR 9 yrs ago and my LTKR is in a few wks.

I have only just rejoined Bone-smart because I believe in their principles.

I have worked in rehab for many years and have had hundred of patients go through this journey.

Some of the PTs were aggressive in their programs and I would have patients approach me in tears. I followed the principle that every one is different and one size does not fit all. I was able to get better progress by a gentle approach.

Our bodies are unique and just because someone is able to do something in the therapy room and someone is unable to get the same results. Does not mean they are not putting in the same effort, it just shows their bodies are different.

I remember attending my first therapy session which was a group program and the PT put a 10kg weight on one of the patients and they were screaming in pain. I called the PT over and said a 10kg weight would cause uncalled for damage and he said but they will benefit long term.

At the next session the patient did not come back, they had been admitted back to hosp for revision due to the PT hard push.

So you should never suffer in silence because a PT is pushing you too hard. Yes, it does hurt but there is a limit and you have to be prepared to speak up.

I expect to attend a few PT appts and I have already met him. So he has already been told regardless of my recovery, if I feel he is being too heavy handed in my rehabilitation sessions I will go it alone.

So I hope you are able to get treatment which assists your recovery, not hinders it further.

Good luck

 

[Cathyjbeck]

I am currently at 6 weeks and I too struggle with the best way to do PT.

It’s been a few weeks since you originally posted so how are you doing now?

 

[kneeper]

My PT told me if you hurt for more than an hour after doing exercises, you're doing too much. Do less the next day. Also, this early imho you don't need weights--your body weight is plenty when you do exercises.