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PKR Manipulate or not?

GrassValleyMe

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Just had my 6wk post-op for partial knee. Surgeon wasn't happy (95deg), and wants to schedule manipulation under sedation to break up scar tissue. I live alone in a rural area. Hospital is a tough 135 miles away (takes from 3 to 5.5 hours in the car excluding breaks). I didn't tolerate oxy so used only Ibuprofen from day 3. Paid an agency caregiver 4hrs/day for first week, then 4hrs/wk thereafter. So have to do everything myself - 3 cats, bring in firewood during power outages (#4 is coming up tomorrow), get myself to appointments (had to pay my handyman to take me to the grocery store and bank to pay him!). Don't have a ton of spare income. Most of my friends are elderly, or live several miles away ( my church is 15 miles away), family are all 6,000 miles away, husband died 10 yrs ago. I've worked hard at PT, and overdone it in the garden a couple of times, pulling weeds. Swelling is gone, and incision healing is beautiful (I heal well).

Here's the question. It's mid November. On New years Eve I'm booked on a trip with my friend and former travel agent. My surgeon is on vacation from Dec 16 till Jan, so gave me 2 weeks to decide about him breaking up scar tissue. He wants me to take handfuls of pain meds before each PT session (including oxy and anti-vomit stuff), and have them push me hard. But "surgery" anyway. Says it will "only" put me back a week in rehab. I'm hesitant to do this, especially if I have to drive there in snow, or ask friends to give up a day to take me. Can I break up this internal scar tissue myself? Is it too late if I delay surgical intervention till mid January? (Uggh). Wish I hadn't had surgery.... Already battled with depression for years.
 

Jockette

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Hi and Welcome to Bonesmart.

95 degrees at 6 weeks is fine. I think your surgeon is being very impatient for your recovery. We are each individuals with individual time frames for our recoveries. We should not be made to adhere to a specific ROM number by a certain date.

Lack of appropriate pain medication in the early days/weeks, and overdoing it can produce and/or maintain swelling, which is the primary reason for a low ROM at times.

Recovery from either a partial or a total, takes an average of a full year. At 6 weeks it is way to early to even consider worrying about ROM.
. So have to do everything myself - 3 cats, bring in firewood during power outages (#4 is coming up tomorrow),
This, and everything else you do in the course of your day is really all the “PT” that you need. It gives your new, healing knee plenty of natural mobility movements. If you are also doing a list of PT type exercises, you don’t need them, and they may be a source of overdoing, as you have all those other duties that must be done.

At this early stage you do still want to spend time resting, as much as you are able, and elevating yourknee while icing it. Try to balance this out with your activities.

There is also no rush to have an MUA, they can be done any time. However, with a ROM of 95 I seriously doubt that you need one. What you need is just Time for your knee to sort itself out and heal. Tell your doctor you want to wait, or just say no to the MUA, period. He can’t do it without your consent.
Saying no to therapy - am I allowed to?


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.
 

Jockette

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Please tell us the date of your surgery and we’ll make a signature for you. It will help us advise you appropriately.

Which partial did you get, Medial, Patellofemoral or Latetal? And which knee, left or right?

I have a Patellofemoral partial, so I understand partials.
 

Jockette

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I will leave you our Recovery Guidelines. Each article is short but very informative. Following these guidelines will help you have a less painful recovery.

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. At week 4 and after you should 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.
 

Rockgirl4

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Welcome to Bonesmart, and I'm glad you found us.

Personally, I think your surgeon is rushing you. There is no "window of opportunity" in which to get your range of motion back, and some of us just take longer than others. In addition, an MUA can be done at any time, though surgeons tand to have their own preference for when they want to do it.

As for your progress, I think you're doing great. Many surgeons have a goal of getting to 90 degrees flexion (bending) by 6 wks, which means you're already there!!!! :) My surgeon "hopes" for his patients to get there by 4 wks instead, but he was okay with me taking longer. I hit 89 degrees at the 4 wk mark, and he called that "sluggish, but not worrisome yet." I made it to 94 degrees at 6 wks, along with a forward rotation on the stationary bike. That was the #1 goal he set for me for 6 wks post-op--not a number!!! I was at 104 degrees by 9 wks when I saw the surgeon again. I went in worried, but he was thrilled and said there's definitely NO NEED for an MUA if someone is bending >100 degrees on their own---meaning no PT is pushing it to that number. He reminded me you will continue to gain more range of motion as the weeks/months go by.

So I would ask you if YOU are bending the knee to 95 degrees or is that number coming when a PT forces your knee to bend???? If I was managing it on my own, I'd wait on the MUA and give my knee more time to heal. We simply do not all heal in the same amount of time, and I ALWAYS take longer than most (11 knee surgeries in total). An MUA can be done at any time, though MY surgeon prefers to do it by 8 wks post-op. He didn't say why. My old surgeon preferred to do it at 11-12 wks post-op, so there is some variability. We've had some members here who had it performed at 5-6 months post-op. Keep in mind it is your decision on when or if you do it.

As for the recovery from MUA----it CAN and DOES set a person back. Your soft tissues are traumatized and pulled apart again. Every person is different in how long it takes to recover, but my experience was bad. Very bad!!! I needed a good 3-4 wks for my knee and quadriceps muscle to calm down, but I had also had 4 knee procedures within 5 months, so my quad was basically fed up anyway. I was told to take a "2 Percocet and a Valium" cocktail before each 2-3 hr PT session. My old surgeon ordered this, and I had to go 5 days in a row after the MUA, with my PT forcing the bend over, and over, and over----while I screamed, cried, and begged him to stop. I was told to deal with it or never walk normally again. Now I know that was just wrong :hissy:!!! It was brutal and something I will never allow again. I still believe (and my TKR surgeon swears by it!!!) that it caused even more inflammation/swelling, and my TKR surgeon told me to never let a therapist do this to you---EVER!!!! He was adamant that my PT after this TKR would be slow, controlled, managed and not rushed.

That's just my 2 cents and experience, and I wish you the best in whatever you decide. :)

--Lisa
 
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Celle

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Hello @GrassValleyMe - and :welome:

Please will you tell us the full date of your knee replacement and which knee it is, so we can make a signature for you? Thank you.:flwrysmile:

Your surgeon is one of the impatient ones! Most surgeons are happy with a bend of 90 degrees or more at 6 weeks and you've achieved that.

At only 6 weeks post-op, it's most unlikely that you have internal bad scar tissue (adhesions). They don't usually form as quickly as that.
It's far more likely that it's swelling that is preventing your knee from bending more. You've had to be rather more active in these early weeks than we advise, so that will have increased the swelling.

My advice is to tell your surgeon that you want to wait a while longer before having a manipulation (MUA). There's no time limit on when an MUA can be done and you have the right to decide to do that, because it's your knee.
Saying no to therapy - am I allowed to?
CONSENT: what it means and how it can be used

I've worked hard at PT, and overdone it in the garden a couple of times, pulling weeds. Swelling is gone, and incision healing is beautiful (I heal well).
Although your external swelling seems to be gone, you will still have some internal swelling and it only takes a little bit to prevent that knee from bending more.

Your daily activities have given your knee plenty of exercise. You've been doing more in those early weeks than we recommend. (Check this article to see our suggestion for progression of activity -
Activity progression for TKRs )

You don't need to work hard at PT on top of your daily chores. In fact, often it's working too hard at PT that can hold up progress.

I suggest you cut back your exercise as much as possible and, instead, increase the amount of time you spend resting, and icing and elevating your knee, to help reduce that residual swelling.

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. Your knee is capable of achieving good ROM right from the start. Its ROM will gradually increase as your knee heals and the internal and external swelling decrease.

In spite of what you've probably been told, there's no need to rush to get ROM (Range of Motion) 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
 

lovetocookandsew

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IMHO, 95 degrees is fine at your point of time. I agree with the advice given by Jockette and Celle. I also want to add that you don't have to do anything your OS wants; just because he operated on your knee does not mean he now owns said knee. It's your knee and your body-and only you can decide the recovery path you want to take.

My suggestion is to back off the PT altogether-all you're doing with your daily living is more than enough, and I would argue that it may be too much so early on. Our knees, and our bodies, all recover at different paces; having a set number required by an arbitrary date is counter-productive, IMO. It causes patients to overwork their recovering knees to achieve what the OS wishes, instead of what your knee will do at any given point. Instead of stressing over ROM, I encourage you to allow your knee to recover at it's own pace. That doesn't mean you should sit around all day waiting for it to heal; rather that you should live your life as your knee allows without overdoing. If you do something that causes more pain or swelling, back off a bit and try that activity a little later.

Spend some time elevating and icing your knee still; it really helps with the swelling and pain. I'd also suggest skipping the MUA and just waiting for a few months and see where you are then. Remember, this is an average year long recovery, but most people start feeling much better around three months post-op. Give your knee permission to recover at it's own pace, while gradually increasing your activities as it allows. Our post-op knees are very good at letting us know what they like, and what they hate, if only we listen and observe. Good luck, and please keep us posted as you recover!
 
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GrassValleyMe

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Many thanks for the input and encouragement. My partial KR was Oct 2, L knee (yay, for driving!). Today I was at scheduled PT and they confirmed that I was, and am, easily at 105deg. And they got me to 111. They too feel it's early days, and can wait to see if MUA is needed. I certainly didn't take the "handful of pills" recommended yesterday by the OS, namely first an antinausea, then 600-800mg Ibuprofen plus two Tylenol plus one oxycodone. I value my body and internal organs too much to take all that every time I go to PT . Like the advice to live normally, and add everything else in moderation. Thanks.
 
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GrassValleyMe

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Thank you ALL. Not sure if I should acknowledge Rockgirl4, Celle, and Lovetocookandsew separately. ( I too am a senior, and not on social media.) Can do 95+ on my own; if I use a strap round my foot to assist, without pain but just feeling stiffness, I'm at 105. After massage and working and with PT assist I was at 109. Then, with my teeth gritted and white knuckles, she took me to 111. I can do full rotations no problem on my little pedal "cycle" at home, and on the big bike at PT I can slowly do full with minor discomfort, after a couple of partial warmups. Need crazy glue to stick my left rump to their seat .
 

Celle

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Thank you for your surgery date. I've put it in your signature for you.

Can do 95+ on my own; if I use a strap round my foot to assist, without pain but just feeling stiffness, I'm at 105. After massage and working and with PT assist I was at 109. Then, with my teeth gritted and white knuckles, she took me to 111.
Please don't force your knee to bend, or allow anyone else to do it - that's bad for it. The number that counts is the one you can achieve without any assistance, by using your own muscles. At least the other numbers show that your knee has the potential to bend further, as time passes.

Remember our advice - "If it hurts, don't do it." Pain is your knee's way of telling you that it isn't ready for that activity yet.

Try not to get hooked into your PT's drive to achieve good flexion quickly. You have all the time in the world and there's no need to rush.
 
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GrassValleyMe

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Sorry, I have no idea what type of PKR it was. The inner (medial?) part of the knee had been bone on bone for almost 2 years. OS wanted to do TKR, but when I saw the X-rays and the plastic model, I requested partial, as the ACL doesn't get cut. He said he'd have a full on the cart if there was more damage than seen on the X-rays. But the home health nurse had paperwork which said "bi-compartmental partial", and Monday's post-op pics showed the upper bone capped, and the inner lower one. Still have my own patella.

PS after physio today, and the 25min drive home, I finished making a moussaka, and roast butternut squash, while my electric stove still works. (PSPS tomorrow). Realised it was getting late, so grabbed the empty propane tank from the BBQ, and a 5gal gas can (for my little generator), got them filled in town, went to hardware store for thick plastic for my woodpile, got some easy-to-eat-cold groceries (bananas, potato salad, brownies, cheese, bread), got soaked in a rain/hailstorm in the parking lot, came home, got a coat, dragged trash and recycle down the driveway, brought groceries in, crammed almost everything into the one fridge I can run on my generator, loaded a cooler with stuff in case I can't start the generator without help, called in my cats, put a pie and some potatoes in the oven, strapped on my ice brace, and put my feet up on the sofa while I ate my delicious moussaka with a cat purring at my side. Yep, guess I do a lot of physio.
 

Cjackso21

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Hello. I had a MUA and was injured in the process so it set me back. But it was after my 2 revision, which was a complete second knee (first was cementless and fell off). My left was done years before and I struggled with flexion extension and still cannot bend it as my right that had the MUA but my extension is now fine and this left knee works great! I was told that extension is more important for walking. Flexion only bothers me getting in and out of the back seat of a car. Can live with that. Good luck!
 

Celle

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I requested partial, as the ACL doesn't get cut. He said he'd have a full on the cart if there was more damage than seen on the X-rays. But the home health nurse had paperwork which said "bi-compartmental partial", and Monday's post-op pics showed the upper bone capped, and the inner lower one. Still have my own patella.
It sounds as if you had a medial compartment PKR, with a plastic button placed on the back of your patella, to replace damaged cartilage there. The kneecap itself is never removed entirely, just re-surfaced.

Even in a TKR, the ACL and PCL can be preserved. The femoral component of the prosthesis has a notch to accommodate them. They are only removed if they're in bad condition.
IF the cruciate ligaments are removed, a slightly different type of prosthesis is used that has the ability to stabilise the knee, as the cruciate ligaments used to do.
 
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GrassValleyMe

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Thanks. After your great advice, I gave myself permission to take it easy - doing puzzles with leg elevated, and a few gentle heel slides and pedalling and walking round the house tidying up. My knee feels much better, and is happy with me doing stuff. Only one Ibuprofen 14 hrs ago. At 7 wks post-op ( I labelled my scar shot incorrectly as 10 wks) I'm proud of my knee, and told her so !!
 
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GrassValleyMe

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BTW, I love crystallized ginger and read that it's an anti-inflammatory, so I ordered 3lbs and snack on it. And while I was under Home Health Care, they had a great diet sheet for wound healing: more calories, more protein, more fluids. Meat, eggs, nuts, legumes, dairy. Whole milk instead of skim. Butter & cheese & milk powder/ protein powder in everything. Yowza - porkchop sauteed in butter, with lots of potatoes and Brussels sprouts sauteed with it ... Told the visiting nurse it's the best diet I've ever seen.
 

sistersinhim

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You are doing great! You don't even need to go to PT will all the activities you are doing at home. That is more than enough exercise for a new knee.

I was also alone during my tkr recovery. I didn't take any PT or do exercises at home. I just let my daily activities be my PT.

Using your knee as it was intended to be used is the best recovery, not doing the same repetitive movements over and over. We don't do that in our normal living. Why do it to try to rehabilitate a new knee? You are doing more than needed to get back to a normal knee!
 

Steelergal

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I agree, you're doing very well! I had an MUA at about 14 weeks, but I was stuck at just under 80 degrees flexion for quite a long time (and it turns out had a lot of adhesions). While my MUA was successful and I'm glad I did it (my flexion the following day was 94 and I'm just now at 100 degrees), I'm still improving very slowly. There was a lot of discussion with my OS and we did not make the decision lightly. And now that it's done, I feel like I'm finally starting to truly recover from this surgery. Walking is easier, I'm using my cane less, I'm not as stiff and sore, etc. My OS told me that if I could get to the point of a full rotation on the bike, that would help stretch everything to continue to improve flexion. You can already do that, so you're in great shape!
 
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GrassValleyMe

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Yay! Progress report: cooked a Thanksgiving feast; able to get in and out of car normally (my arms thank me); set up and powered my outdoor fake Xmas trees on uneven soft ground (the lights are so pretty at night); and today at PT did 117degrees unaided, along with 1.8 miles on the stationary bike in 10 minutes. I'm feeling normal. And my PT said "No, you weren't MUA-worthy". Glad you all said don't do it. I'm now at 2 months post-op.
 

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