TKR My new knee 12-27-2023

InjuredAgain

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Hello. I found this forum while researching quad weakness after TKR, and have questions about advice on recovery from the surgery that is regularly posted here.

I had a left TKR on 12-27-2023 so I am 5 1/2 weeks post op. I’m a highly active person and in my last year without a knee injury was ranked top 100 in the nation in singles tennis in my age group (I’m 62 years old and weigh 200 pounds). My knee problems started with a persistent clicking with walking and especially hiking. My wife and I did a three week hiking vacation in Colorado where we submitted two 14000 foot peaks. After that, the knee was sore on the inside/medial side where the click was. Early next year, during physical activity, I sustained a full thickness, non-displaced medial meniscus tear. This coincided with my knee just plain wearing out, and MRI showed multiple spots of bone-on-bone and degenerative bone changes. I tried to manage that and the meniscus injury eventually became much more minor than the cartilage surfaces wearing out.

Late last summer, I did a one-day 21 mile long hike with my son that involved 5000 feet of elevation gain and 7500 feet of elevation loss. My knee was uncomfortable with every step but I made it. Unfortunately, I could not walk for a week after because of knee pain. Not long after that, I scheduled my TKR surgery.

I made it clear to my ortho and my PT that I wanted to resume the tennis and hiking at the same levels and was told there was no reason why I could not do so, maybe at a slightly but not significantly reduced level, after TKR. I told them I wanted to rehab aggressively and they were both on board. My surgery was scheduled four months out. Because I was no longer trying to preserve my knee, figuring that if I hurt it badly, it was going to get replaced anyway, I went full bore into strengthening exercises beforehand, pushing well into the discomfort zone doing resistance training. Just prior to my surgery, I was doing sets of squats to 90 degree knee bend with body weight plus 185 pounds.

My surgery started at 3 pm and I was awake by 5:30 pm. By 6 pm, I had walked around the floor using a walker, climbed up and down some steps, eaten, and had emptied my bladder so they sent me home. My implant was cemented.

I got a recumbent stationary bike and was making full revolutions on day 2, and I‘ve ridden it every day since. I was off the walker on day 4 and off hiking poles by day 7. I stopped oxycodone on day 5, which was also my first PT day. I was up to two miles of walking by week two, and started resistance training on week three. I hit my first tennis balls on day 19. I was walking down stairs one leg after the other with almost no limp by week four.

I have pushed the recovery hard and have been fortunate to not have any significant setbacks. I had 135 bending and 0 straightening at week four and have slightly more flexion now. I am doing one and two legged leg presses, hamstring curls, and leg extensions in the gym, about ten sets of each exercise on a two-day on, one-day off schedule, along with all of my other full body resistance training. I started doing athletic type movements, mostly involving one legged lunges in various directions ending with a knee lift, calf raise, and a one legged hop.

I have minimal knee pain and minimal swelling, but the knee does feel warm all the time. I sometimes get some mild pain in the tendons behind the knee that goes away after a few minutes of stretching, and occasionally in the front of the knee if I go down some extra tall steps. My knee does get stiff after just a few minutes of sitting still, though it also loosens up with just a few minutes of stretching. Sitting still in a chair for an hour is pretty uncomfortable.

I wanted to give a fairly complete picture of where I am and what I’ve done. I’m always looking for more sources of information to give myself the best chance of fully recovering. So right now, what seems to be hampering progress is quad weakness. I still am unable to fully actively straighten my leg, though if I fully straighten it and do a leg raise, I have only a minor droop. But despite all of the leg presses and leg extensions, strength has been very slow to recover. Reading up on quad weakness brought me here, where I have seen much advice on taking it slow during the recovery process. I’ve been doing anything but taking it slow, so I‘m wondering what downsides there may be to pushing the rehab as hard as I have been doing. My surgeon and PT have said to use pain and swelling as my guide and I have minimal amounts of both. Is there a possibility of long term damage by what I’m doing? And if so, what might that damage be?

Thanks!
 
Welcome to the forum! I can't answer your questions as you can consider me your complete opposite - I could barely walk before having right TKR and still need the left one done as soon as this one gets strong enough. I think it just goes to show how different we all are in our recovery. I hope you can find some answers to help you get back that strength. My guess is that it takes time since you are about 5 weeks post-surgery.
 
I was told to absolutely avoid extensions with weight. The reason for being careful with weights is not that muscles are weak, it’s that you have internal incisions that need to heal before you put pressure on them. At PT they have me doing leg press but much lower weight on the operated leg, but not curls with weight yet. Remember that most of your recovery comes from healing, not from pushing your knee. I would try stopping the weights for a week and see if it makes a difference. You might be reinjuring your muscles even though you aren’t having pain and swelling.
 
Welcome to BoneSmart. Everyone has their own baseline fitness, priorities, and goals. We do have a "slow is better" philosophy, but we're here to offer support.

My background, and the original source of my knee problems, stems from a severe knee injury sustained doing martial arts (which I returned to, with adaptations, for many years after surgery and one year rehab). One thing I learned in over 20 years of martial arts, seeing and advising scores of injuries, is that even minor sprains and strains need 6-8 weeks to heal at the cellular level. It's built into the physiological process.

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That's why personally I chose to do zero strengthening besides walking and quad sets during that initial post op period with both knees.

As to what damage you might be doing? Theoretically muscle micro tears or major tears, tendinitis, etc; however, if you're not having pain or troublesome symptoms it's unlikely.

Problems with range of motion and stiffness are general indicators of internal swelling. Stiffness, especially with prolonged sitting or standing, is a long term issue pretty much regardless of one's rehab approach; it slowly improves.

You may already know this but just in case: the current body of research shows we seniors who want to gain muscle need more protein than usual, and we need it spread throughout the day. 25 grams per meal, three meals daily, is the number I find quoted on reputable studies.
 
Thanks to everyone who has replied, and best to all of your recovery efforts.

@mendogal The chart you posted was the one that I had seen elsewhere on this forum. I have my first visit with my surgeon in eight days, at the seven week mark, so I’ll get further clarification then. I did have a PT session today and was told that with no pain and no swelling, I am fine to continue progressing in the exercises I am doing, and have gotten some additional exercises to help with dynamic balance.

Thanks for all the information, and best of luck to everyone in their recovery journeys!
 
Happy Two Month Anniversary, Injured Again.
I hope your visit with the surgeon went well and you're happy with the progress you're making.
All the best as you continue healing!
@InjuredAgain
 
Happy Two Month Anniversary, Injured Again.
I hope your visit with the surgeon went well and you're happy with the progress you're making.
All the best as you continue healing!
@InjuredAgain
Thank you! I’ll provide an update.

I hit 140 degrees of flexion in week six. I met with my ortho for my first post-op at week 7 and was told no more post-op appointments would be necessary as I was doing well enough.

I’m currently in Sedona in the middle of a 10 day hiking trip. I’ve been doing up to seven mile hikes that involve rock scrambling while carrying a 25 pound pack. It is the first time in years that I have been able to hike with no knee pain. The rock scrambling involves going up and down with my knee bent at least to 130 degrees, and then using muscular strength to step up with just one leg, or to bend the knee that much so I can drop down off a ledge.

I started playing singles tennis at week six. I’ve continued resistance training in the gym and have about 80% of my quad strength back at 90 degrees of flexion, but probably only about 60% strength at 10 degrees of bending. The hiking has really helped with the nerve activation and coordination when my leg is almost straight.

I get home in five days and will start run training at that time, along with initiating sharp directional change movements on the tennis court. I’ve been extremely fortunate to be able to push hard and not have setbacks.

I do get zingers every so often, and the numb skin in my outside knee sometimes has phantom itching which can’t be relieved by scratching or rubbing. Because the TKA corrected bowl-leggedness but only in my left leg, I am having to re-learn how to walk with my legs closer together, and I suspect I will need to be very conscious of this when I start running. My knee is stiff, especially in the morning but pretty much after any time when I don’t move it for 15 minutes or more, though that’s slowly getting better.

Again, I’m very fortunate that I’ve been able to push hard (and I have pushed super hard) to recover and not have setbacks. I’ve really enjoyed the process of rehab and intend to continue the three to five hours a day of hard rehab work as long as I can. I’m 62 years old and it feels like the new knee has been a fountain of youth not only physically but mentally.

The very best to everyone, and I hope you all have success in your knee recovery journey!
 
Thanks for taking the time to share such a great update while on vacay. You certainly are progressing nicely in your recovery. Stay safe and enjoy your time in Sedona. Happy travels!
@InjuredAgain
 
@InjuredAgain

What an amazing recovery and so inspiring! Whenever I have had PT I have told my doctor and pt that I am used to pushing through pain so if that is a signal to stop, they need to be very direct with me.
Found your posts looking for info on ROM and Flexion.

I really hope I can get back to hiking with my son in Idaho.

P.S. I am originally from Arizona and Sedona is one of my favorite places on the planet.
 
@InjuredAgain

What an amazing recovery and so inspiring! Whenever I have had PT I have told my doctor and pt that I am used to pushing through pain so if that is a signal to stop, they need to be very direct with me.
Found your posts looking for info on ROM and Flexion.

I really hope I can get back to hiking with my son in Idaho.

P.S. I am originally from Arizona and Sedona is one of my favorite places on the planet.

I also made it clear that I was willing to push hard into to discomfort and pain so long as that didn’t cause any symptoms that prevented me from doing my exercises afterwards. As someone who has been active all my life, I went in thinking I could trust myself to know what was that dividing line of good pain and bad pain. But also knowing that pushing to the limit means exceeding it on occasion - otherwise there’s a bit more left on the table that could be done.

We had this hiking trip planned in advance of my decision to have the surgery, but we didn’t think there would be a four plus month wait for a surgical opening. I convinced my wife to keep the vacation on the books until I knew that I couldn’t do it. That way it would be that carrot dangling in front of me to work harder.

One thing I found that really helped with gaining flexion was to stretch while lying in bed. I had surgery on my left knee and I found that if I lay on my left side, that by extending my left knee forward and then bending my lower leg backwards, I could use my right heel on my left instep to help increase the bend. I found this bending to be almost pain free, whereas when I lay on my back and used a stretching strap around my ankles, that it hurt a lot more. By doing this when I woke up, it seemed to help that my leg was warm from the blanket and everything was loose, and the stretching seemed to jumpstart my ability to function throughout the day.

At nine weeks, I still don’t have active 0 degree straightening. I can maybe get it to two or three degrees from straight. There’s still much more weakness when my leg is nearing straight. My PT says this will come and it has gotten better with time.

As far as hiking, I had kind of a circuitous route to being able to do it. I was doing sets of body weight squats by the second week and was in the gym doing leg presses by week three. I graduated to doing single leg presses with my surgical knee shortly afterwards. So I built back some of the strength loss but was still walking stiffly. That’s when my PT said I needed to walk more to relearn how to do it with my new knee. I started mall walking and pretty quickly got up to four miles but I still suffered from an uncoordinated gait. A lot of that was due to my quad not being strong enough nearing full extension, which along with a tight calf, led me to lift my surgical leg off the ground sooner than my other leg, and also lifting my heel off the ground sooner. I got a series of exercises doing one legged lunges and stretches for my hamstring and calf.

I had been able to walk up and down stairs one leg after the other by week four, but it was these exercises and stretching that finally let me walk so that you couldn’t tell I had a TKR - this was probably at week five.

In my experience, I had to get to this point of being able to walk normally, go up and down stairs one leg after the other, and be able to walk down a fair steep grade, before hiking felt safe and the exercise of hiking led to improvements. I had tried hiking earlier and all it did was make me feel unable to cope with the balance needed for uneven surfaces. At about week 6 1/2, I started hiking some flat trails and was able to get to five miles with no pain and no swelling afterwards. That’s really when we knew this trip would be possible.

We’ve done four hikes spread out over eight days. Every hike has been an improvement. I had a feeling of slight quad weakness with every step on the first hike around Bell Rock and Courthouse butte. Two days later, that sensation was much less doing seven sacred pools, the cave, and soldier pass. Two days ago, that weakness was almost non-existent hiking Boynton Canyon, subway cave, and the cuchina woman vista, though the 8.5 miles was a little too much for my knee and it swelled up a bit. This morning, it felt fine and we hiked to devil’s bridge, and for the first time I didn’t notice any weakness except once or twice scrambling up and down from the bridge. Today, my new knee feels like a normal part of me now.

The very best of luck in getting back to hiking! Work on flexion first, so you feel safe bending your knee as much as you need when hiking, then build up that leg strength and balance. I think (and hope) that it comes back to you quickly!
 
Happy Three Month Anniversary!
Your recovery has been amazing. Thanks for sharing and enjoy!
@InjuredAgain
 
Thank you!

I feel incredibly fortunate to have been able to push my rehab hard without encountering any setbacks. I can jump, run and sprint, change directions sharply, hike or ride a bicycle for hours, and I’ve resumed heavy resistance training. I only have a little bit of knee soreness after consecutive multi-hour days of hard activity.

I‘m still unable to fully straighten my leg by doing a leg extension or a long arc quad. I‘m stuck at 2-3 degrees of bend though if I turn my leg 90 degrees so it is sideways, I can easily fully straighten it. I’m told this will come with time and that it just takes as long as it takes. I also still am having itching where the skin is numb and some zingers that happen mostly at night.

Everything else is good! I’m now helping a couple of guys at my tennis club, one who just had a TKR and one who is getting one next month.

The very best to everyone!
 
feel incredibly fortunate to have been able to push my rehab hard without encountering any setbacks. I can jump, run and sprint, change directions sharply, hike or ride a bicycle for hours, and I’ve resumed heavy resistance training. I
This is a very remarkable recovery and I wish you well. You are obviously very fit and also very lucky.
Many of us will not be able to run or jump following TKR or PKR surgery due to the nature of our previous damage and our implant type. I was advised by my surgeon not to run or jump indefinitely after my PKR. I can walk any distance I like and use my leg freely for all normal activities- including getting down on the floor with my grandkids. I can run short distances, for say catching a bus- but I wouldn't try to jog or run any distance.
I would also be worried about sharp twisting movements like changing directions suddenly. Twisting on a fixed foot is a potential cause of knee damage I have been advised.
 

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