PKR My recovery begins<

[Celle]

I think you might be working too hard at trying to improve your ROM. Doing too much inflames your soft tissues and increases swelling. That decreases your ROM, so it's counter-productive.
TKR: work “smarter” and not “harder”
Myth busting: no pain, no gain

In addition, doing too much in any day - like going out to lunch and then going to PT - has the same effect.
If you keep doing that, you run the risk of setting up a chronic inflammation, so try to do only one extra thing each day, either lunch or PT, but not both.

Keep on resting, icing and elevating as much as you can. When you're in the recliner, how much are you elevating your leg? It's all too easy to not elevate it enough. You may need to use some pillows as well as the foot rest. Have another look at this article, for some examples of how to elevate:
Pain and swelling control: elevation is the key

I'm also going to ask @Josephine for her advice for you. She'll probably ask you a lot of questions. Do try to answer them as fully as possible, so she can advise you appropriately.

 

[kneeper]

I see you're icing in your recliner. Depending on how high the footrest goes, you may want to use an extra pillow to get that leg really elevated. I always did that.
Also, with such a busy day that angered the knee you should give it a day off. The knee has spoken!

 

[Josephine]

I'm getting nervous that I'm not making much progress. Wondering if this is normal at 5 weeks or if I have reason for concern

At 5 weeks? Give yourself a chance, my dear!

So I can give you some structured advice, I'd like to ask you some questions if you don't mind, and it would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. And don't compare this with the bone-on-bone pain you had before surgery! ) Also don't forget to include other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness but only within the overall pain score!

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

5. What is your ROM - that's flexion (bend) and extension (straightness)

6. how swollen is your leg?

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

8. what kind of PT exercises and exercises at home are you doing? How much and how often?
This is the most crucial question so please help me by using the format I have left as an example

Exercises done at home: 3 sessions a day
Heel slides x10 (reps)
Straight leg raises x10
Steps x10

At PT
Squats x5 (reps) x2 (sets)
Wall slides x5 x2
Clamshells X5 x2

 

[tdawgs]

@Josephine Okay here goes with answering all your questions:

1. Pain level right now (after PT today) is 4. I don't really have pain unless I've over done it. Also, I think because the pain is less than the bone on bone pain that sometimes I don't realize I'm actually in pain until it's really bad.

2. I was prescribed Percocet 5/325 mg. I am averaging 1-2 per day as needed. So far today I had to take it twice 4 hours apart.

3. I've backed off on icing quite a bit. I've really only been doing it after PT sessions. Typically for about 30 min and then replace the pack and go for another 30 min later in the evening. Otherwise I'm not icing.

4. I elevate when I sit and at bedtime (until I end up moving around and I come off the pillows). If I'm on the couch I have one pillow under the leg. If I'm in the recliner I have a small pillow under the knee and use the recliner to lay back to get some good elevation. At this point I'm spending more time sitting than moving around. I feel like I sit too much actually.

5. My current ROM was measured at 69 today. My best thus far was 72 about 1 week ago before I was given the okay to start bearing full weight on my leg. Extension last measured at 2 but they haven't measured that in about 2 weeks.

6. Swelling is moderate

7. Activity level has been pretty active. My husband has been away for 2 weeks (he's home now!) and I had to do it all on my own with the help of my 9yr old son. So every morning I get up and assist getting him ready for school, make a light breakfast/pack a lunch/clean up a bit. I usually shower every other day. During the day I might do a load or 2 of laundry or unload/load the dishwasher and wash up pans in the sink. I have a little dog that needs to be let out a few times during the day. I get myself to PT twice a week and since I work in the same building I will go upstairs and visit with coworkers for about an hour (so total time out is about 2 hours). I make an easy dinner each night for me and my son and clean up with his help. A few times I've attempted to vacuum a small area (that's too much for me right now). I've only been out shopping a few times with help and I've had to use the scooter in the store but I used crutches from the parking lot to the store.

8. PT exercises: The therapist starts with passive ROM movements (I lay on the table and he lifts the leg and then he flexes it some and gently pushes the bend. He has never done anything to the point of it being painful. I use a machine called a Nu Step. I sit in it and there are pedals that I put my feet on and then I use the hand grips to move the legs back and forth to work on bending and straightening. That is done for 5-7 minutes. I do heel slides using a strap to help pull up towards me, usually about 25 of them. Today we did about 10 "squats" where I stood holding a bar and bent like I was going to sit in a chair. Next I did heel lifts (like standing on my tip toes) set of 20. Calf stretches for a few minutes. Sitting on the side of the table I was lifting my leg straight out did about 20 of those (I still can't lay flat and do a straight leg lift on my own). And finally he put me on the bike and I just rocked back and forth trying to gain some ROM for about 5 min.

At home, this is where I kind of fall down. Because I've worked so hard at PT the following day is useless. When I sit in a chair I try to do some bending and stretching. I will do it until I feel like I've done enough to be effective without causing swelling. I also stand and lift my leg straight out, trying to get that quad to strengthen. When I'm sitting in the recliner I bend and straighten to just move it so it's not stiff. I've started trying to take a few steps without crutches when I'm working in the kitchen (I have counter top and island on both sides to hold onto).

Hope this was enough information! Thank you for your help

 

[Josephine]

1. Pain level right now (after PT today) is 4. I don't really have pain unless I've over done it. Also, I think because the pain is less than the bone on bone pain that sometimes I don't realize I'm actually in pain until it's really bad.

Well, you have to be careful about that.

2. I was prescribed Percocet 5/325 mg. I am averaging 1-2 per day as needed. So far today I had to take it twice 4 hours apart.

Okay

3. I've backed off on icing quite a bit. I've really only been doing it after PT sessions. Typically for about 30 min and then replace the pack and go for another 30 min later in the evening. Otherwise I'm not icing. Swelling is moderate

You should be icing more as you have swelling. Did you not see that swelling is a form of pain? Swelling is caused by pain? You accomplish little or nothing in 30 minutes. Ice for at least 40-60mins and more than 4 times a day.

4. I elevate when I sit and at bedtime

Elevate when you ice. You've got to get that swelling down

5. My current ROM was measured at 69 today. My best thus far was 72 about 1 week ago before I was given the okay to start bearing full weight on my leg. Extension last measured at 2 but they haven't measured that in about 2 weeks.

The principle reason for your poor flexion can be summed up in one word - swelling! Did you read this article? Swollen and stiff knee: what causes it? Swelling is primarily caused by the exercises.

7. getting him ready for school, make a light breakfast/pack a lunch/clean up a bit, a load or 2 of laundry, unload/load the dishwasher, wash up pans in the sink. dog needs to be let out a few times during the day. I get myself to PT twice a week and since I work in the same building I will go upstairs and visit with coworkers for about an hour (so total time out is about 2 hours). I make an easy dinner each night for me and my son and clean up with his help. A few times I've attempted to vacuum a small area (that's too much for me right now). I've only been out shopping a few times with help and I've had to use the scooter in the store but I used crutches from the parking lot to the store.

Since you're 5 weeks out, this is quite a lot for you to be doing. You shouldn't be walking that much either. Did you read this article?

I also cannot fathom what you've said about your exercises. I asked if you would be so kind as to list them according to the example I left. Instead you've made an essay about it!

Here is the example again - can you please help me to help you by giving me your list of exercises again?
Thank you so much!

Exercises done at home: 3 sessions a day
Heel slides x10 (reps)
Straight leg raises x10
Steps x10

At PT
Squats x5 (reps) x2 (sets)
Wall slides x5 x2
Clamshells X5 x2

 

[tdawgs]

While I would like to give you a straight forward list for my exercises, I don't have a set routine. The therapist changes things every time I go in. So I'll do my best. I don't even have "names" for the exercises. They've never formally handed me papers that say "do this" with how many of each.

At therapy:
Nu Step x 5 min
Heel slides x 20 reps
Modified straight leg raises x 20 reps
Squats x 20 reps
Toe raises x 20 reps
heel raises x 20 reps
calf stretches x 20 reps
Quad sets x 20 reps

At home: I don't have a routine that I follow. I don't do them every day and I don't count a number of reps. Here's my best guess at what I do:

Heel slides x 10 when I think about it maybe a couple times per week
Quad sets x 20 when I'm sitting in the recliner (maybe 2-3 times/day)
Modified straight leg raises x 10 a couple times a day
Ankle pumps 3-4 times per day x 20

 

[kneeper]

IMHO you'd be better off skipping the NuStep for now and using an exercise bike for a few minutes instead. NuStep is more for strengthening rather than bend. And just say no to the squats for now. They are hard on the knee and sensitive tissue.

 

[referee54]

IMHO you'd be better off skipping the NuStep for now and using an exercise bike for a few minutes instead. NuStep is more for strengthening rather than bend. And just say no to the squats for now. They are hard on the knee and sensitive tissue.

I agree---stay away from the NuStep and stick to a simple stationary exercise bike set on "0." No need for squats now, just take it easy and cut back on what you are doing. Let the inflammation die down.

 

[Josephine]

A recent site glitch has erased my reply so I'll try and post it again.

My comments in bold
Nu Step x 5 min - not the best thing to use at 6 weeks
Heel slides x 20 reps - heels slides are very easy to do badly and doing these in such intense sessions is badly! You need to read this Heel slides and how to do them.
Squats x 20 reps - squats are the worst thing you can do for a newly operated upon knee. Stop doing them
Modified straight leg raises x 20 reps - a tip about SLRs: once you can do them, you don't need to do them any more!
Toe raises x 20 reps, heel raises x 20 reps - these are particularly hard on a new knee so please stop them. Besides which, you are fully mobile so they are actually unnecessary.
calf stretches x 20 reps - stretches are okay but you'd be better doing about 5 3-4 times a day
Quad sets x 20 reps - the same here. 20 reps is too intense. You'd be better doing just 5 at a time

Ankle pumps 3-4 times per day x 20 - these are just anti-clot exercises and don't need to be used once you are ambulant.

 

[tdawgs]

The Nu Step has no resistance at this time. We are using it to help with bending. I'm in control of the whole thing. The screen doesn't even light up while I'm using it. Honestly, I had a pretty bad experience using the bike after my last arthoscopy. One of my feet slipped off the pedal causing it to jerk forward quickly and my surgical leg bent hard and fast. I cried for 15 min after it was so painful. Since I don't have enough ROM to pedal, I'm really leary about using the bike again. I've told the therapist this and he still encouraged me to try it. I was very conservative in what I did while I was on it.

I'm afraid to stop PT all together because of the insurance/short term disability. According to them, I should be able to return to work next week! So they've requested PT reports and Drs notes to prove that I'm not ready to work. It's such a shame that Insurance companies that don't want to pay are so in control of MY recovery!

I cancelled todays appointment because I was in a lot of pain (7/10) and felt it wouldn't be productive. I have an appointment on Thursday that I will keep. I figure once a week should be enough to keep tabs on my progress. And I promise I will quit the squats! I asked to stop them not only because it didn't feel good on the operative knee but also because my poor right knee is getting sore taking on all the work. I've never had a problem with my right knee and I don't want to start now! Honestly I never want to go through this ever again!

 

[Celle]

We usually recommend not returning to work until about 12 weeks, and then starting with part time. Recovery from a partial replacement (PKR) can take just as long as from a full knee replacement(TKR).
Phased return to work
I hope your doctor and PT can support your need to recuperate for longer.

 

[Josephine]

Gosh yes! Given your issues, I would suggest that 12 weeks is an absolute minimum for you to return to work - what ever it is you do.

 

[kneeper]

Sorry you had a bad experience with an exercise bike. Before I could pedal all the way around I just rocked back and forth for a few minutes.

 

[tdawgs]

Gosh yes! Given your issues, I would suggest that 12 weeks is an absolute minimum for you to return to work - what ever it is you do.

The 12 weeks have been requested by my OS. I am a Medical Assistant who works in Pediatrics. So I do a lot of getting down to the pint sized patients level. Not to mention a wee bit of pediatric wrestling! LOL The NP who basically does all the dirty work for my OS, knows full well the scope of my job and won't allow me to over do it. She's already told me that I will be starting back on light duty when I go back. I'm in no hurry!

As a side note, with today's increased pain I've also noticed that I've gained more ROM. I feel like I have increased pain right before I gain more function. Just an observation :D



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[tdawgs]

Is it reasonable to still need about 2 Percocet for pain daily at 6 weeks post op? I suppose I should ask if I can take Ibuprofen at this point. They didn't want me to take it for awhile because of my bruising issue. The last few days I've had more pain than usual. I've been able to get by with 2 Percocet in a 24 hr period plus icing. Yes, I've probably been doing too much. I made Easter dinner on Sunday including making Hot Cross Buns the night before, and a pie the day of plus the ham and a couple of side dishes. The husband did help but I'm sure I did more than he did.

 

[Celle]

Is it reasonable to still need about 2 Percocet for pain daily at 6 weeks post op?

Yes, it's very reasonable. Some people still need to take pain relieving medications for about 4 months. Don't stint on the pain meds. They are better for you than the anti-inflammatories, like Ibuprofen.

Yes, I've probably been doing too much. I made Easter dinner on Sunday including making Hot Cross Buns the night before, and a pie the day of plus the ham and a couple of side dishes. The husband did help but I'm sure I did more than he did.

Yes, you are doing too much. Back at work, still doing PT, and doing housework - all that adds up to much more activity than your knee is really ready for.
Perhaps you need to read this article again?
Activity progression for TKRs

 

[tdawgs]

Yes, you are doing too much. Back at work, still doing PT, and doing housework - all that adds up to much more activity than your knee is really ready for.

Thankfully out of all those activities I am not "back to work" yet. Only "back to work" at home. Did I mention I cut back PT to once a week

So outside the U.S. the Doctors don't have a problem continuing to prescribe something like Percocet over a 4 month period? I feel that after about 2 months they think your pain should be done and you can exist on Ibuprofen. I "think" my primary care doctor would extend the prescription a couple more months. All narcotic rx's in the state of Ohio are tracked in a database. I'm sure that the physicians are watched regarding how many narcotic prescriptions they write.

 

[charmed-life]

Not sure of US or state laws but I know my OS said they usually do 3 months or so - main thing is they want to see you are decreasing and following the amounts they suggest - like "every six hours" - they know how long it should last. Our clinic has signs up in every room saying they do not prescribe narcotics for chronic pain.


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[JLP]

My OS had a very reasonable approach to pain meds and expected me to start tapering off at the 12 week point. I am having a colonoscopy next week so had to stop them at about 9 weeks. I am having trouble with night time pain and Tylenol helps some but not enough. If I feel a need to take something stronger after my procedure, it will be hydrocodone instead of Percocet. I manage very well during the day, it is just nighttime that I have uncontrolled pain. Drug addiction is certainly having an impact on those with severe pain after surgery who have a legitimate need for these drugs.

 

[Josephine]

Is it reasonable to still need about 2 Percocet for pain daily at 6 weeks post op?
The last few days I've had more pain than usual.

Those two comments are contradictory!

Did I mention I cut back PT to once a week

Try cutting it out completely!

you can exist on Ibuprofen

Actually no you can't. It would be about as much good as taking vitamins! Gram for gram, the pain killing power of ibuprofen or any NSAID versus Tylenol is about 40% at best. Don't believe all the advertising that claims it's the best thing since sliced bread - it's not. It's okay for the occasional headache or something but this post-op pain is a different kettle of fish altogether. And don't forget that inadequately managed pain causes more swelling and pain so it's not just 'pain' you need to be concerned about. But when the time does come to reduce it, use Tylenol (1,000mg 4 times a day) as an alternative, not NSAIDs.

Medications: acetaminophen (Tylenol, paracetamol) and NSAIDs, differences and dangers