TKR Nine weeks out and still limited ROM

[kneeper]

You are pretty early out to be going without any support. You might want to use a cane at least for longer times on your feet--not because you *can't* walk without it but so relieve the strain on the leg.

 

[Gilina]

Well, another odd thing occurred yesterday afternoon. When working on knee bend, of course I had felt the tightness above the knee. Yesterday, I suddenly couldn't even bend my knee enough to feel that tightness. It's as if there is something inside the "hinge" so to speak, that is preventing me from bending my leg even as far as it was bending yesterday morning. I guess I will be calling the doctor on Monday, because the feeling did not go away overnight. Does that sound familiar to anyone?

 

[Josephine]

1. Pain levels change all the time. Right now, a 4 or 5. Forms of pain: All of the above except throbbing.

okay

2. Right now just taking tylenol, 325, one or two every 4 hours or so.

At 3½ weeks, that's wildly inadequate. 325mg of Tylenol is not an effective dose - 1,000mgs is an effective dose which should also be 4 times a day. I understand you cannot take anything else but if you are going to be restricted to Tylenol, at least take enough to be useful. You can take up to 4,000mg per 24hrs.

3-4. Icing whenever sitting down, or using my foam triangle thing to elevate my leg (2x a day for 1 to 1.5 hour--I tend to fall asleep when I lie down). Heating pad on my backside/hip and/or calf when having muscle spasms.

Okay

5. Don't know what my ROM is--it is still less than 90 degrees, but also changes from day to day. Is that weird? Extension--I haven't had 0 degrees extension for a couple of decades, so I suspect getting there will take awhile. Doc wanted 90 degree ROM at two weeks.

No, it's governed by the amount of swelling you have which also changes from day to day. And your Doc is going to have to learn to be patent, isn't he?!

6. Been walking without support for over a week, showering, doing dishes, some cooking, picking up the house a bit, laundry. No shopping yet.

That's much too much. Did you read the articles that were left for you earlier? The one on Activity Progression is the one I am referring to.

7. Doing PT at home. Does that help?

No. This is the most important question of them all. I really do need you to answer it using these guidelines.

Can you detail it like this
At physio or PT
First description - 5 reps x 2 sets
Second description - 10 reps x 2 sets

At home
First description - 5 reps x 2 sets 3 session a day
Second description - 10 reps x 2 sets 3 sessions a day

 

[Gilina]

@Josephine As I said, all at home (no formal PT since they set me back and created more stiffness and pain):

Heel slides 3x a day 5 reps. Ankle pumps anytime I am sitting.

As for Tylenol--I have to be very careful with that since I have a family member in renal failure due to Tylenol (or so his doc told him). And I am not able to take enteric coated medicines due to the food dyes used.

The shin pain, along with the sensation of "something" blocking my bend have me concerned. I know of one person who had such pain and it was finally determined there was "floating junk" of some sort in his knee that once removed, both the pain and bend were fixed. The lower leg pain is making it hard to sleep, too. Plus now I feel pressure in my knee when I stand, and I didn't before. It changed last Friday. Time to call the OS office I guess.

As for doing too much, well, I don't have help for those chores so if I want to eat and have clean dishes and clothes, I don't have much choice but to do it myself. I sit down a lot and ice in between chores. Such is life.

Can't wait to get yelled at when I see the OS later this week. Should be interesting to see if I can get him to listen to me.

 

[Josephine]

Ah, okay - missed that. As for that 'something in the hinge', your knee doesn't have a hinge - unless I have missed that too! But your issue is far more likely to do with pain and tendinitis than debris and I think it likely your surgeon will say much the same.

I'm sorry you have such problems with medications. It must make life very difficult for you. My sympathies.

 

[Gilina]

Ha ha. I didn't mean hinge literally--just that that is how the knee works "like a hinge" because it bends, so it felt like something had been jammed in there. It is getting better, though I'm not quite back to how it felt before, esp when I walk or do heel slides--different tightness in different muscles. I wasn't feeling any pain or pressure when standing for the last couple of weeks, but now I do--only on the inside of the knee, similar to how the arthritis felt (but not as bad) but it was a new/different feeling that came on suddenly. At least the shin/lower leg pain has gone for now--that was very bad when I was trying to sleep or elevate my legs. Nothing helped except Aspercreme. Maybe things (nerves?) are just waking up. I'll have lots of questions for the doc.

I actually do fairly well with only small doses of pain meds. For years, I have felt that by the time I really want/need something for pain, there isn't much of anything that will work anyway. I didn't think the oxy (or Vicodin) really did much once I was out of the hospital. Maybe the generic stuff isn't as good.

This forum is really a lifesaver/confidence builder in so many ways. So glad I found you guys. Thanks.

Gilina

 

[Gilina]

I forgot I wanted to post one thing that might give some of you a laugh. When I did go to my one OP PT session, she measured the ankle, calves and knees of both legs for comparison of swelling I assume. Anyway, she told me my ankle on the none operative leg was the smallest she had ever measured. I got a good chuckle out of that--unfortunately, the rest of me hasn't matched since my thyroid gave up years ago. It was probably the only nice thing she had to say to me--she even criticized me for wearing Birkenstocks. Sheesh.

 

[Josephine]

Ha ha. I didn't mean hinge literally--just that that is how the knee works "like a hinge" because it bends,

LOL! That was what I thought you meant but just wanted to be sure as there are knee replacements that have a hinge with a bolt through the middle! True!

For years, I have felt that by the time I really want/need something for pain, there isn't much of anything that will work anyway.

Ah but that's the wrong way round. Of course if you leave it too long, then the pain grows to the point were no pain meds will work. But, if you take them early on, then they will work very well. Just check out the chart in this article Pain management: importance of managing pain after a TKR and the pain chart.

This forum is really a lifesaver/confidence builder in so many ways. So glad I found you guys. Thanks.

You have no idea how desperately I need to hear something like that right now. Thank you and God bless you.

 

[Gilina]

You have no idea how desperately I need to hear something like that right now. Thank you and God bless you.

You are welcome! That makes me happy. This forum has made all the difference for me.

And good news! My OS (who I liked from the start) is a sensible guy. I guess it was just his PA (physician's assistant) and the PT people who were--well--not my cup of tea.

My OS is happy with my progress. Some of my weird symptoms were things he hadn't heard before, but most have dissipated. (I suspect my medical background makes me more "body/symptom-aware" than some folks.) He gave me a few hints on some exercises, warned me not to use my pedaler too much yet, said never do any exercise to the point of pain because that just causes more inflammation--all the things I've read here and realized for myself based on how my leg reacted!! And, I can take my favorite pain reliever again--aspirin (on top of the two a day for blood clot prevention). And he said, yes, it is a long recovery.

And he was happy to get my print-outs of research I did into bone cement and metal allergies, too!

I've had PT many times--this was my first bad experience with it, so I have to remember that. In the past, PT was always very helpful, esp. since I kept doing what they showed me for a long time afterwards. Same will be true for what I have learned here about my TKR recovery.

And, my incision is healing great! I think the scar will be minimal. I should post a photo in that thread. At four weeks and four days out, things seem to be going well right now. Oh, and I can drive! Just not long distances/long time sitting behind the wheel due to the possibility of blood clots. I just have to not get too overzealous and remember there is still a long way to go.

Thank you. I hope I will have valuable insights to contribute to others in the future as well.

Gilina

 

[PolarBear60]

So happy for this good report, @Gilina ! And driving! Yay.

 

[Gilina]

@Josephine Can you please change my post-op thread title to "8 Weeks Out--Scar tissue blocking ROM?"

My "account" doesn't seem to allow me to change the thread title based on the directions I found.

 

[Josephine]

Before I do, where did you get the idea that "scar tissue" is blocking your ROM?

 

[Gilina]

Not my words--the OS's. Said he thinks "scar tissue" is blocking my ability to bend my knee and he is thinking MUA (which is an overnight in the hospital deal the way he does it and gets me back into the whole "no one to help" and "not functional for awhile" and "pain meds make me very ill "issues). At least I am functioning well right now. And he says MUA needs to be done in the first 3 months to be effective.

I remembered reading here, though, that scar tissue and adhesions are not the same thing, so that got me wondering. I was reading a bunch of MUA posts and information here yesterday.

Is there any surefire way to tell if adhesions are present? A CT scan perhaps?

I still have that "something in the way of my bend" feeling. Despite working on it in a variety of ways, I just don't seem to be getting much more bend--only very slow improvement, though much less pain lately.

Needless to say, I am hoping for more information and advice to help me make a decision about what to do--or not do.

Thanks.

 

[Josephine]

Not my words--the OS's. Said he thinks "scar tissue" is blocking my ability to bend my knee

No, no, I didn't think it was your words! I just wondered if it was the doctor or the PT.

he is thinking MUA (which is an overnight in the hospital deal the way he does it and gets me back into the whole "no one to help" and "not functional for awhile" and "pain meds make me very ill "issues).

Well it won't do that because generally the benefits show themselves quite quickly, it's not that painful afterwards and only if, as I suspect, it's not really adhesions. You said your ROM was "it is still less than 90 degrees, but also changes from day to day" and this makes me suspicious that it might not be adhesions at all, just swelling. You're 8 weeks out now which is quite early and very likely to improve more as time goes on.

And he says MUA needs to be done in the first 3 months to be effective.

There are surgeons whom think this but there are a LOT more who don't. Were I in your shoes, I'd ask to wait another 4 weeks and see if there's been any improvement. I'll bet there will be.

 

[Josephine]

Can you please change my post-op thread title to "8 Weeks Out--Scar tissue blocking ROM?"

As for this, I'd rather you had 'problems with ROM at 8 weeks" Is that okay?

 

[Gilina]

@Josephine

Sorry to be so long answering. (My old computer is getting cranky and problematic.)

Maybe change thread title to: Nine weeks out and still limited ROM

Well it won't do that because generally the benefits show themselves quite quickly, it's not that painful afterwards and only if, as I suspect, it's not really adhesions.

I'm confused by this statement. Can you clarify? What does "it" in the first sentence refer to? Also, do you mean if it is scar tissue, it won't be painful after, but if it is really adhesions, then it will be painful after?

I still don't get the "scar tissue" comment by the doc. Doesn't scar tissue resolve on its own after awhile? And, yes there is still some swelling, though not much visible.

I plan to ask (see him again on July 30) if he actually means adhesions. In that case, I guess I would need an MUA, yes?

I am gradually getting more bend--I can tell when I walk--so I do not want to do the MUA unless it is really, really necessary--mostly because they do it with all the same drugs and nerve block, etc. and an overnight hospital stay, instead of an outpatient procedure (that would work so much better for me). And if I get as sick as I was once I got home after surgery, with no help when I start to faint (which happened repeatedly for several weeks after surgery), I might end up on the floor.

In every other way I feel pretty good--certainly way, way better than before surgery. Only taking 2 x per day 1 aspirin and muscle relaxers. And I can do everything I need to do.

Just confused and getting stressed about the thought of MUA and all the arrangements I would have to make and feeling worse again when I am managing fine right now.

Gilina

 

[Josephine]

I'm confused by this statement. Can you clarify? What does "it" in the first sentence refer to?

My comment was in response to this comment of his ...

he is thinking MUA (which is an overnight in the hospital deal the way he does it and gets me back into the whole "no one to help" and "not functional for awhile"

...so 'it' is the MUA.

Also, do you mean if it is scar tissue, it won't be painful after, but if it is really adhesions, then it will be painful after?

"Scar tissue" and "adhesions" are two terms that are regularly misused and mixed up. An awful lot of people (on here) refer to scar tissue when it would be more correct to say adhesions. Scar tissue or scarring is that which occurs where an incision/cut/wound has been made and it seals the wound and closes it up. Adhesions occur where muscles that should normally be free to glide over one another get stuck down/together so they can't move. If this gets too bad, doing an MUA will rip them apart with sounds like Velcro being pulled apart. Obviously this can be painful for the patient when she wakes up. But often, the problem with limited flexion is not adhesions at all but swelling and pain. So in this case, when the MUA is done early, there are no adhesions to be broken and the knee will be taken to a decent flexion with very little effort at all and therefore no pain afterwards. Does that make it clearer?

I still don't get the "scar tissue" comment by the doc. Doesn't scar tissue resolve on its own after awhile?

It depends if you are referring to scar tissue or adhesions. The scar of a surgical wound will reduce over time until it is a very, very fine layer marking wjere the surgeon's knife went in. Adhesions, being caused by a lack of natural tissue fluid which gives muscle bodies 'glideability' may well be dissipated as the tissue fluid gets to its properly levels again. It should be noted that too much exercising and at too aggressive an level, can make muscles hot and dry thereby facilitating the development of adhesions. It should also be noted that true adhesions are actually pretty uncommon, debunking the PT's and doctor's frequent claims that low ROM is due to "scar tissue".

Gosh this has become quite a lecture! I hope you can understand it all.

I plan to ask (see him again on July 30) if he actually means adhesions. In that case, I guess I would need an MUA, yes?

Answered above.

 

[Gilina]

Thanks for all the info. Wow. Very helpful, but I still am uncertain what to decide.

But often, the problem with limited flexion is not adhesions at all but swelling and pain. So in this case, when the MUA is done early, there are no adhesions to be broken and the knee will be taken to a decent flexion with very little effort at all and therefore no pain afterwards. Does that make it clearer?

Yes and no. If the lack of ROM is [still] due to swelling and not adhesions, then wouldn't flexing it much more with the MUA just make the knee swell more and be more painful and make it less bendy afterwards?

I ask for two reasons. A few weeks ago, most of the "searing" (scream-worthy) type pain vanished. I would call it more "discomfort" now when I do bending exercises. And when I go for walks, I feel a "pulling" across my knee as I bend it that is not really painful.

But, the first 3-4 weeks after I got home after surgery, a few things happened. I was very, very ill, at least 4 times, in a manner that would have left me extremely dehydrated repeatedly for 3-4 days at a time when I could barely drink and couldn't eat. And, my knee/leg was very hot (except, strangely, when I was really sick, then it cooled and got more bendy all on its own--until I started to feel better GI-wise. Then it got stiff and hot again.). My 2-3 PT experiences (the bouncing and pushing, etc.) made the pain and stiffness and muscle spasms much worse. So, those two things make me wonder if maybe it really is adhesions. Do they not have a way to tell for sure? Or does it not matter and MUA would be their solution either way?

BTW, I do feel it getting more loose/less tight and more bendy as time goes by. It is just very slow--which bothers me not in the least, but sure seems to be important to the docs. And I can do stairs! Up at least, down not quite yet.

I think for now, I'd like to see how things progress without any further radical intervention. And ask if he really is talking about adhesions or not.

Glad I have this forum and its helpful members or would be completely lost and wondering if what is going on is "normal" or not. Knowing that every knee is different helps. Thanks.

Gilina

 

[Celle]

But, the first 3-4 weeks after I got home after surgery, a few things happened. I was very, very ill, at least 4 times, in a manner that would have left me extremely dehydrated repeatedly for 3-4 days at a time when I could barely drink and couldn't eat. And, my knee/leg was very hot (except, strangely, when I was really sick, then it cooled and got more bendy all on its own--until I started to feel better GI-wise.

I wonder if the fact that you were dehydrated caused your body to take some fluid from your swollen knee, which then was able to bend more easily? Then, when you were rehydrated, your knee swelled again. If that was so, then it seems to me that the cause of your difficulty with ROM is swelling, not adhesions.

 

[sabbath]

@Gilina, l believe the same as you on the p.t making the knee worse,,its been my feeling right along in my case,,l started outside p.t at 7 weeks my OS dropped the ball on me,, they finally gave me 12 sessions only 2 remain,,the therapist wanted me to put in for more, l went back to see my OS at 12 weeks? To find out he no longer there? See another surgeon. He wrote me a prescription for 12 more sessions ,two days later the VA deny the new sessions which now l feel was a God send,,every time l went to p.t feeling good only to be set back for days from knee now hurting,,My ROM was 85 last week when l was there,,l am not going back for the last 2 sessions,,Some family members think l am being foolish,l am the one with the knee not them is my take