PKR MUA advice please

[RosieD]

Hi. I am 6 weeks post-op right PKR, medial side. Immediately post op, my surgeon seemed quite quite surprised by the amount of swelling I had. He asked for me to have ice therapy but the machine was being used on another patient and the physio wanted to get me moving safely so that I could go home. So no ice for almost 48 hours after surgery.

My leg then became very bruised - I had a sudden sharp pain in my thigh followed by further bruising which I was told was due to the break down of clot where the tourniquet had been applied during surgery. The whole of my leg from groin to toes was bruised and swollen but I was told that I must continue the daily blood thinning injections for 2 weeks.

I was also referred for weekly physio and was told that I must push in order to improve the bend in my knee even though it was hugely swollen. After the 3rd session , I broke down because despite all my efforts, I wasn't able to get beyond 50 deg. I saw my surgeon again and he told me that the priority was to reduce the swelling and he thought that the blood thinning drugs were responsible for the excessive swelling.

I saw a different physio and I've been given non-loading exercises to do for 10 minutes four times a day. I've also cut down on the distances I try to walk each day. There has been some improvement in the amount of swelling but no improvement in my knee flexion - it's still 50 degrees. So today my surgeon has recommended MUA in 3 weeks time.

I feel hugely let down by the physio. I was previously fit, normal weight and generally healthy. I ski usually 4-5 weeks every winter, ride a bike, hill walk and sail. All this stopped 10 months ago when my knee started to trouble me but I was quite shocked when I was told that I'd need a knee replacement. I hoped that a steroid injection would help, but it gave minimal relief. Talking to others, I was very confident that I'd be back to normal pretty quickly after surgery - and maybe I would have if I'd had the correct management with ice, elevation and gentle rather than forcing exercises.

I want to make sure that I do the right thing in order to recover as quickly as possible now, so I'd appreciate your advice.
Thank you.

 

[benne68]

Welcome to BoneSmart, @RosieD. Please give us the exact date of your surgery so we can create a signature for your posts.

There is a direct link between swelling and lack of flexion: your knee cannot bend if it is swollen inside! And all the exercise you've been doing is adding to the inflammation. I suggest you stop any exercise -- other than normal activities of daily living for a week to give things time to settle down. Additionally, start elevating and icing multiple times a day for at least 40-45 minutes at a time to help reduce the swelling.

I will share I full recovery guidelines below.

 

[benne68]

I'm glad you found us while you are still in the early weeks of this year-long recovery, @RosieD

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

Just keep in mind we are all different, as are the approaches to this recovery and rehab. The key is, “Find what works for you.“ Your doctors, PTs and BoneSmart are available to help, but you are the final judge as to the recovery approach you choose.

KNEE RECOVERY 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.

If you want to use something to assist with healing and scar management, BoneSmart recommends hypochlorous solution. Members in the US can purchase ACTIVE Antimicrobial Hydrogel through BoneSmart at a discount. Similar products should be available in the UK and other countries.

2. Control discomfort:
rest
elevate
ice
take your pain meds by prescription schedule (not when 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 - 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
the BoneSmart view on exercise
BoneSmart philosophy for sensible post op therapy
5. At week 4 and after you should follow this
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

Good nutrition is very important during recovery:
Dietary Tips for Recovery
Nutrition Basics

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.

 

[Jockette]

Hi and Welcome to Bonesmart!

I’m sorry you’ve had such a rough start to your recovery!

Yes, your main efforts should be to help the swelling go down. Your ROM will return after that happens. If it was me, I would not agree to an MUA at this time, or even in 3 weeks time, since you still have so much swelling. An MUA will only further upset your leg and cause more swelling.

I was also referred for weekly physio and was told that I must push in order to improve the bend in my knee even though it was hugely swollen.

As you’ve found, this is very bad advice. There is no “window of opportunity.”

Myth busting: "window of opportunity" in TKR

This "six week window of opportunity" surgeons often speak about is little more than a myth. It presupposes that all patients have the ability to create adhesions which is far from the truth. It also ignores the simple fact that in the first 3-4 weeks after surgery, swelling reactive to the...

bonesmart.org

Myth busting: No pain, no gain

With rather blatant snitching from a couple of other sites, I give you the lie to this saying! Wikipedia No pain, no gain (or "No gain without pain") is an exercise motto that promises greater value rewards for the price of hard and even painful work. Under this concept, competitive...

bonesmart.org

I saw a different physio and I've been given non-loading exercises to do for 10 minutes four times a day.

This is also not a good idea, that’s way too much, especially with all the swelling you have.

As @benne68 said, spend more time icing and elevating, and just do some short walks around the house until you’re feeling better.

Talking to others, I was very confident that I'd be back to normal pretty quickly after surgery

I also have a PKR and the way I understood it, it would be a quick recovery. Mine was not! Once I found Bonesmart, at 4 weeks post op, I learned that even partials take an average of a year, not the 6-8 weeks I thought.

I want to make sure that I do the right thing in order to recover as quickly as possible now, so I'd appreciate your advice.

For most of us, nothing about this recovery happens quickly. Healing takes time, but with proper care, we can avoid making it any longer than it has to be. Overdoing the rehab, and pushing through pain, are some things that do not enhance our healing. I’m sorry that’s the rehab protocol your PTs believe.

 

[RosieD]

My op was on 28th October.
I'm in two minds about the MUA. The swelling in my knee and leg is less than it was 2 weeks ago but the degree of flexion is unchanged. If flexion is being prevented by scar tissue formation, surely it's better to deal with that sooner rather than later. I'm inclined to go ahead with the MUA unless I see some improvement in flexion over the next 2 weeks. I'm going to concentrate on the ice and elevation and avoid being on my feet for any longer than 30 minutes.

 

[Roy Gardiner]

It's not scar tissue as such that's the issue; it's adhesions. That's when soft tissue sticks together. It's quite unusual. It's also rather early in recovery to diagnose it, because there's so much swelling to confuse the issue.

The problem with MUA is that it in effect restarts your recovery from day 1, because it uses brute force to break any adhesions. You and your doctor must decide whether to do it.

Whether you do or not, the BoneSmart view is that recovery needs to be challenging but not painful. You should do stretching exercises not to the point of pain but just discomfort. Pain is your body telling you that you're causing further damage, not helping recovery. Your body needs healing, not training.

I'm going to concentrate on the ice and elevation and avoid being on my feet for any longer than 30 minutes

Good plan. IMO being on your feet 30 minutes is too long. As soon as it starts to hurt just a little bit, that's enough.

 

[Jockette]

Pain is your body telling you that you're causing further damage, not helping recovery. Your body needs healing, not training.

Yes!

 

[Layla]

Great advice from Roy Gardiner. I hope you able to avoid the MUA through making progress over the next couple weeks. Fingers crossed for you, Rosie.
Please stay in touch.
@Rosie

 

[RosieD]

I appreciate what everyone here is saying about it being too soon for MUA, but I also don't want to delay my recovery. My surgeon thinks the heparin at the time of surgery and enoxaprin daily post op resulted in excessive bleeding into the joint and I can understand this - I'm quite a small person so maybe the dose should have been reduced. Then the physio I was advised to do in the first 3 weeks aggravated things.
The swelling is going down now but I'm still stuck at 50 degrees flexion - it's been this since the day after surgery. I'm inclined to think that if this doesn't improve in the next 2 weeks I should have the MUA. If adhesions have formed and are the reason for my stiffness, then it would seem sensible to deal with this. Does that seem reasonable?

 

[Roy Gardiner]

Yes it does, to me. MUA more or less restarts recovery, as has been said, because it's so stressful. So yes, if MUA is needed, delaying it delays your recovery. Only your doctor and you can make the final decision.

The BoneSmart view is that you will know what to expect in recovery, and will know to be extra-gentle. You don't want to let those adhesions re-form! Move, but without pain.

 

[dnkz]

Everyone is different and everyone is going to recover in different ways at different speeds. Having said that, I too was very apprehensive about an MUA. TKR on July 30th this year. I went through with it because ultimately I do trust my surgeons advice and recommendations above all else. The benefit was immediately apparent. It did not cause more swelling or “starting over”. In fact, for me anyway, my swelling went down a bit. My ROM went from stuck at around 87 after 6 weeks to 110 the day after the MUA. I do have to say that the pain in my knee upon regaining consciousness was quite severe but subsided considerably after about 5 hours.

I have zero regrets about my MUA. It was my surgeon’s aid that ultimately put my mind at ease prior. She said that during an MUA, the surgeon is not pushing your knee beyond what is anatomical possible. That made sense to me. Best of luck to you!

 

[benne68]

@RosieD Only you can make this decision. Educate yourself about what the procedure involves, ask questions of your surgeon and read about others' experiences here. I

It's your knee and your recovery. Know that we are here to support you on whichever recovery journey you choose!

Sending hugs

 

[RosieD]

Thank you for the responses, especially to dnkz who has been through the procedure. It would be good to hear from more people who have had it done. Also has anyone else been stuck at 50 degrees flexion? I'm really surprised that this is where I am as I didn't even have a total knee replacement, and I was reasonably fit before surgery.

 

[ukus]

Hello Rosie. I had a LTKR on Sept 24, and then on November 19, I had an MUA. My reason for having the MUA is due to being stuck at 87/90. I felt like I hit a "hard stop" when I was working on trying to increase the flexion. It was frustrating.

It went well I had some pain and took the meds for a week. The swelling I had decreased after the MUA.

The procedure did help my flexion, and I am at around 125. I also used a CPM machine every day for 4 weeks and elevated and iced. I had PT every day for 2 weeks. My PT's were very gentle.

Anyway, that has been my experience.

Anne

 

[Layla]

Hi Rosie,
Below is a link to threads of those that experienced MUA.

I wish you comfort as you make a decision and peace of mind with whatever you decide.

Knee Surgery Recovery Area

For post-operative knee patients, on the "other side"

bonesmart.org

@RosieD

 

[spikesnewknee24]

Hi to my fellow MUA’ers,

I had my second MUA this week, Wednesday. The first was done 11/4 and before it I was stuck at 49 degrees after my Right knee TKR on 9/30. I had some post surgery blood pressure problems and had to be admitted to the hospital so that slowed down my bending ability. Then I had knee spasms once home and my PT sessions were delayed getting started. After the first MUA I was able to get to about 70 but still had severe pain in my left inside knee every time I or my PT bent it up or tried to pass that 70 degree mark.

My surgeon recommended a second MUA and I’m glad I did it; once home on the same day I was at 120 in the CPM (only ever got to 102). And the next day with my PT and then on my own I was at 102. Today I clocked in at 107 by myself. Whew.

The surgeon reported that he broke up scar tissue during the second MUA. The pain in my inner knee experience before the second MUA is no longer there. My bending now feels like a strong tension across the knee and in my thigh muscles rather than a sharp pain isolated to one side of my knee like before.

I hope this is helpful.

 

[Layla]

Happy Two Month Anniversary, Rosie!
Best Wishes for the New Year!
@RosieD

 

[RosieD]

Thank you for the information and supportive messages. It was very helpful to hear other people's experience of MUA.
I had MUA on 20th December, 4 days ago. The surgeon told me afterwards that he achieved 130 degrees flexion while i was under anaesthetic, and that there was a lot of crunching/cracking (I can't remember his exact words) in my medial quad muscle as he stretched it.
Afterwards i was in quite a lot of pain and could only tolerate flexion in the CPM machine to 90 degrees even with 4 doses of IV opiate at 5 minute intervals. Later I had to ask for the flexion to be reduced to 85, but then i had more analgesia and a rest with ice and when I went back on the machine, it was increased gradually to 105 which i tolerated. The pain was only for a few seconds and then it was over a minute for the rest of the cycle so I could take deep breaths and get through it.
I felt quite good at home the next day and did stretching exercises for 10-15 minutes every 2 hours through the day. I applied gentle heat to my thigh for 15 minutes before exercise and iced my knee for 20-30 minutes afterwards. I also tried massaging my quad muscle manually and with a massage gun. I went for a walk and felt more comfortable doing that than I had previously so the next day I walked a bit further which was probably a mistake as my knee became much more swollen. I did feel though that my quad was less tight.
However, yesterday was a disaster. I drove myself to physio so didn't take a full dose of codeine. The physio spent a bit of time with me doing some gentle exercises to warm my muscles and knee up, but then she forcibly flexed my knee in different ways. It hurt but not excessively so, but by the time I got home I was in agony and could hardly walk. I took the full dose of codeine and some oramorph and applied ice with my knee elevated, but nothing seemed to help. I had a fitful night's sleep and I am a bit more comfortable today but I back to having very restricted knee flexion - 80 degrees or less.
My pain is in the quad muscle not so much in my knee, and I wonder whether all the symptoms I have are due to muscle damage. 3 days after my PKR, I had a sudden sharp pain in my thigh while walking followed by the appearance of a large bruise. I phoned the hospital and was told that it was probably due to a clot at the site of tourniquet application bursting. (I was on anticoagulants as is routine.)
My feeling is that i need the muscle to repair before doing anything more with my knee.
Has anyone else experienced this, and what did they do about it?

Thank you for any advice.

 

[sistersinhim]

I think you very much overdid the new MUA trauma to your baby knee. What it needs now is lot of TLC, not aggressive PT or exercises. I suggest you ice and elevate the whole time you are sitting or lying down. Rest that quad muscle so the inflammation can subside. Exercising it will only keep it inflamed. Walking around the house is enough exercise to keep it moving. Having the MUA set back your recovery date to that time. Your knee now has to heal from it, along with its normal PKR healing.

Please treat your knee like a baby, because it is!

 

[benne68]

I'm sorry you are in so much pain, @RosieD, and agree you overdid it for so soon after your procedure.

As sister said, most of what you are experiencing is from the fresh trauma to the knee. The best way to deal with it is to give your muscles, tendons and ligaments the chance to recover by (1) cutting way back on the exercise, and (2) icing and elevating as much as possible.

Wishing you comfort as you recover.