Bilateral TKR MUA at 8 weeks

[pedsnurse8]

Josephine,

I am generally only having some mild discomfort/ stiffness, about a 1-2.

During PT my pain level can range from a 4-7 even though I medicate with 1-2 hydrocodone (7.5mg/325 acetaminophen) 1 hour prior to PT. My Friday PT session however resulted in my pain level climbing to about an 8 with any activity for the rest of the day.

The PT had me sit on a table and would push my foot back until I told him he was at the point of discomfort and then have me push against his hand briefly, relax while he pushed back further to a point of discomfort (3 times per 1 rep). This would have me close to tears by the 3rd rep even though the sharp pain would stop almost as soon as he released the pressure.

He then had me doing short arc leg lifts with a 1lb weight which seemed benign at the time since I have been doing the short arc lifts for a while. He also had me laying on my stomach with the 1lb weights on and bending my leg up - this also did not seem bad at the time I was doing it. This was followed by sit-to-stands. All of these were two sets of ten.

Activity level on PT days: I do 14 steps down (at home) to get to PT, do PT, go 3 minutes down the road to Walmart or Fred Meyers to take a 10-20 minute walk out of the Washington weather (except when I feel wiped out from PT) then 14 steps back up at home and then nothing else other than ADLs (no house cleaning).

On non PT days I do short arc lifts, stretch my flexion on the pedal bike (gently) and then pedal for 5 minutes, heel raises, roll a foot massage orb back and forth to flex my knees - all a couple of times a day with some short walks.

I also sort and fold laundry, pick up things as needed in the bedroom and sitting room I am using (my daughter and her wife are doing the cooking and dishes and cleaning the rest of the house). Other than that I am icing and elevating 6-8 hours/day and listening to books on tape or watching the idiot box. I do shopping during my walks following PT.

I also tend to take 2 hydrocodone at bedtime to try and sleep.
I have been approved to start hydrotherapy this next week.

I no longer work as a nurse because of arthritic hands (have had both thumb joints reconstructed but hand strength is not there to start/change IVs, open medications bottles, or do injections) and shoulders, so return to work is not an issue.

 

[Celle]

• At your stage of recovery, those ROMs really are not that bad. I understand that surgery on your right knee was more complex than on your left knee. That, alone, will account for its slightly slower progress - it's too early to say that adhesions are the cause.
• Every knee is different, even if you have them both done at the same time and no matter what you do, they will recover in their own, sweet time. You can't do anything to speed up that process - the knee is in charge - but unduly irritating the healing tissues can slow down progress.
• Your OS wants to do MUA on both knees while you are there, even though it's not indicated for the left? Really? To me, that sounds a bit like "While we're taking out your gall stones, we'll just whip out your appendix and tonsils too. Nobody really needs them!"
• There's no harm in waiting. You might not even need the MUA if you wait a little while. If it must be done, there's nothing to lose by waiting.
• Oh, and as an older person (I'm 72) I, too, appreciate the mobility a good ROM allows me!

As an ex-nurse, I do understand the desire to "do something" and to recover as quickly as possible, but it doesn't work that way with knee replacements. There's nothing you can do to hasten the process. It's a marathon, not a sprint.

Best wishes!

 

[maryo52]

So, yeah, adhesions tend to happen from mid kneecap up. I had to have a second arthroscopy to have the lateral area cleaned up at 2 years post TKR.

So you're, what, 6 weeks out? I knew there was a problem with my knee very early on because I had a "hard stop" in my ROM. A PT doing even one maneuver on you that is painful can be enough to fuel adhesions. I say that based on many reports on this forum and my own experience. It certainly is not in the medical literature.

Ultimately what we each have to do is get to know our knee and understand and take our cues from our knee. If you aren't having much swelling, then I agree, adhesions looks possible or probable. Maybe he wants to do MUA on both since it adds almost nothing to the intervention but may break one or two adhesions on the other knee -- but I can't answer for him.

I think for most people, the thought of another hospital visit, another anesthesia, etc., etc., etc. is mortifying. I had quite a feeling of failure. But so many people on this forum who dread MUA end up with great results. I think the most recent one was sparkie.

 

[maryo52]

One comment on your routine: really should not use weights, or resistance on the bike. Again, more effort will not produce more results. I know counterintuitive, but true.

Are you in Washington as in rainy cloudy weather, or Washington as in helicopters flying between the Pentagon and CIA all day? I was born at GWU.

 

[Jamie]

I'm sorry, but I definitely think your therapist is way too aggressive for you at 5-6 weeks out...especially with a knee that by the surgeon's own admission required a lot of extra work. That translates to a lot of extra pain and swelling in recovery if for no other reason than the fact that he was in there messing around with bones and tender tissues for an extended period. Those exercises you described from your last PT visit did your knee no favors at all. It's too soon for weights. You should not have that kind of pain. Using one leg to push another into a bend is NOT a "routine" exercise. Yes, I know you can see photos of it on the internet. But it's really not needed and it's counterproductive if it creates the kind of pain you describe. Remember....you're feeling THAT much pain under medication! It's no wonder you hurt afterwards. You can get your ROM without doing this!

I think you are suffering from some swelling. Just because you're not seeing it doesn't mean it's not there. The knee compartment is so compact that it doesn't take much internal swelling to cause pain and loss of ROM.

Your activity level still seems a bit much to me for this early in your recovery. You are still in the early stages! If at all possible, I'd do pretty much nothing but gentle bends and stretches on the days you don't have PT. And....it's a pretty big deal to be out shopping right after an exercise session. You'd be better off to try that when you are rested and then ice and elevate immediately upon return. That kind of activity IS physical therapy and you're working yourself very hard.

I edited your post to tag Josephine so that she can come and respond to your latest posts. Please don't be in a hurry. The main goal is to have a SUCCESSFUL recovery....not a QUICK recovery.

 

[leejaa]

Swelling is not always visible on knees but can be more internal so it can be an issue without visible outward swelling. Hard choices for you regarding the MUAs .

I do take exception to the comment that at 53 you are young for a total joint replacement and need or require or deserve more ROM than someone older. I was 58 for first in Jan and 59 in Sept for my second knee replacement. I want more ROM and ability to do things as I have waited 12 yrs to be able to do more and have suffered from losing activities that I wanted to do plus had pain doing basic activities like grocery shopping. On this forum I see people who are older than me and doing more and living a super active life style and I want to be there now and when I am older. Age is not a measure of active life - age is just a number when we could no longer deal with the pain and decided to get our lives back.

It is your decision as to what you do but sometimes less can be more. Read some of the stories here and decide what you want for yourself and not what someone is advising. You have the background to understand more than most having been in the medical field so make sure it is your choice.

 

[kar1963]

Hi.. i had my mua thursday of last week so it is still new .. i did alot of reading on mua on this forum i read things over and over . I asked my therapist questions and my os questions and ultimately i listened to me and my knee and had it done. Your os will get great results while you are under but pt will have lower numbers .. my knee is sore a bit swollen but the bend is better and the feeling of having a boa constrictor wrapped around my knee is about all gone. The work continues and i am sure there will be set backs but they are mine to overcome. I do think doin one knee that really is not showing the need to manipulate is crazy ... all i can advise is take your time, read, ask ton of questions .. good range of motion does not have age limits .. we all need it we all crave it some just take a little longer to get it.. good luck to you my friend in kneedom...

 

[Josephine]

I am generally only having some mild discomfort/ stiffness, about a 1-2. However resulted in my pain level climbing to about an 8 with any activity for the rest of the day.

Then your pain level is not 1-2, it's an 8! No?

I'm also not impressed with what your PT is getting you to do at only 6 weeks out. Honey, your knee is still a itty bitty baby! You (and he) need to be much kinder and gentler to it. I've edited your exercises of the more excessive ones that are much more suited to around 12 weeks out
- the PT had me sit on a table and would push my foot back until I told him he was at the point of discomfort
- then have me push against his hand briefly, relax while he pushed back further to a point of discomfort (3 times per 1 rep).
- he then had me doing short arc leg lifts with a 1lb weight 2x5
- laying on my stomach with the 1lb weights on and bending my leg up 2x5
- this was followed by sit-to-stands 2x5
- non PT days I do
....... short arc lifts 2x5 once a day
....... stretch my flexion on the pedal bike (gently) for 5 mins once a day
....... pedal for 5mins
....... heel raises 2x5 once a day
....... roll a foot massage orb back and forth to flex my knees a couple of times a day
....... some short walks

I think this has about halved your exercises.

I would also say that while you gave a fulsome answer about the PT and ADLs,, you've said nothing about the other questions which were

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how often are you icing your knee and for how long?

4. how often are you elevating your leg, how high and for how long?

 

[pedsnurse8]

Josephine,
I have been prescribed hydrocodone 7.5mg/325 acetaminophen 2 tabs every 4-6 hours. I take 2 at night, 1 in the afternoon. I take mobic in the am and that seems to be enough until afternoon/evening as long as it is not a PT day. My OS did give me 80 tabs the first two times but has reduced that to 60 this last time. I did take the meds, 2 tabs every 4 hours round the clock for the first 2 1/2 weeks but do not have much pain now. I have never gotten any real pain relief from acetaminophen and cannot take ibuprophen or naproxine.

I am tempted to try going back on the tramadol I was on prior to surgery so I don't have to deal with calling in for prescriptions every 8-10 days.

I ice and elevate (above my heart) for 2-4 hours about 3 times during the day and for about the first 3 hours of the night when I feel I can maybe sleep while I am on my back. Lately I have been trying to sleep on my side with pillows even though it can take quite a few repositioning attempts to get semi-comfortable just to get some sleep.

I did wonder about adding ankle weights to my PT as I felt that is what made my last session so painful.

 

[Josephine]

I am tempted to try going back on the tramadol I was on prior to surgery so I don't have to deal with calling in for prescriptions every 8-10 days.

That sounds like a jolly good idea. It's all I had for my knee and it was excellent! 50-100mgs at a time with 1,000mg acetaminophen and at times I even took 150mg Tramadol! I recommend it highly! It's used a lot in the UK and we rarely use hydrocone or oxycodone for straight forward post-op analgesia.

I have never gotten any real pain relief from acetaminophen

But how much did you take at a time? I've observed several times that US folk tend to take 1 tablet at a time which is only 325mg. This is one third of the working dose. In order to get a working dose, 1,000mg need to be take at a time.

cannot take ibuprophen or naproxine.

And jolly good too! It's iniquitous stuff! Do you have reflux or is it because you are on blood thinners (just curious). Actually we have an article in the Library about this NSAIDs, acetaminophen (Tylenol, paracetamol) differences and dangers.

 

[maryo52]

I think we're each wired differently. Go with the drugs that work. Acetaminophen does nothing for my pain but it's true that most people do not understand how to take it effectively.

You really have to be vigilant about PT. Several people on this forum have reported a single incident in PT where they were painfully pushed and their ROM arrested or went backward, and attribute that incident to having MUA.

 

[pedsnurse8]

Well, I had the MUA on the right knee only on Nov. 21st. My ROM for both knees is now at 110. I am having more issues with swelling in the right knee but it is still less than what I had after arthroscopy. I have to admit the MUA has resolved the issue of no progress in ROM for the right knee but I am glad I did not have the left knee done as I did not feel it was necessary.

 

[Jamie]

Good for you!!! I hope you have continued success with the MUA. Be sure you are icing for that swelling....lots of ice. I agree that the left knee doesn't need an MUA.

 

[maryo52]

Right on!

 

[kar1963]

Glad to hear it helped you.. ice ice baby