TKR One year later and all is well

[Minstrel]

Some questions for the forum moderators

After the news yesterday about my progress, I am relieved. I am, however, not finished. And I have some questions for the professionals here.

If the goal for me was to improve my ROM from the measly 70 degrees that it was, why was I not told the same?

Is it so that patients generally lose 10 degrees of ROM after TKR (another thing I learned for the first time yesterday)?

My surgeon told me that I may not improve much from the 96 degrees flexion that I have achieved and he challenged me to prove him wrong. Why then was I told outright weeks ago that 0 degrees extension and 100 degrees flexion was the goal at the 6 week mark, if this was never really realistic for me?

Do the physiotherapists and the doctors not talk to each other? Or is this a matter of giving all TKR patients the same information? I suffered a lot of grief thinking that there was something wrong with me and that I might never bend my knee enough again. Could I have been spared all that anguish?

How usual is my circumstance? That is, for someone who had their meniscus completely removed at age 18 and then lived for the next 41 years with a knee that was getting progressively more and more degenerative, are my numbers (-6 and 96) usual? Is it feasible that I might improve my ROM another 10 degrees?

These did not occur to me to ask during my appointment yesterday.

 

[sistersinhim]

These are questions you should be asking your OS. But, my opinion is that they say the same basic things to everyone. I think the 10* your doctor was talking about was immediately after the tkr, not the long term loss. We all usually get better ROM after a while. It might take a year or so, but we do gain in ROM and in strength.

I can't answer the question about pt and os talking since I never took pt. I did take it about 3 times, then continued on my own, after my shoulder repair and went to pt at the same place that my os's group was. But, he never mentioned my pt visits.

I was 32 when I had my first knee repair, so I can't relate to have the meniscus completely removed. I just had to have scopes every 3-4 years on both knees as they progressively got worse. Back in the 80s I was told I would have to have tkr, but I couldn't get them until I was in my mid-50s. Things have changed for the better now. Much younger patients are getting them when their quality of life goes down.

 

[kneeper]

My OS said the best predictor of post op ROM was pre-op ROM. He never said anything about losing ROM. Due to my RA I had about 110 before surgery (for many years) and got about 115 in the end. But it is a comfortable/functional 115 that allows me to do most of what I want to. (I had no extension issues.)

For me, what really helped was to just do more day to day activities that required using the bend. (Always listening to the knee, though).

I think you're doing great. Congrats! I would not be surprised if you gain a few more degrees.
I think for those of us with long term ROM restrictions it is harder to get to "normal" because our tendons, ligaments etc. have adjusted to to the low ROM.

I don't think the 100 degree "goal" would have made sense for anyone, much less you. The knee doesn't heal on "schedule," so much depends on your swelling, preop circumstances, etc.

The other thing you'll likely find yourself working on is walking "normal" which may feel weird at first. We spend so many years compensating for our knees that that becomes our "normal" walk.

 

[sistersinhim]

Kneeper is right. We have to learn a new right way to walk now. I limped for over 25 years and find myself limping unnecessarily now. It doesn't hurt to walk. I just start limping for no reason! We have to learn we can do it!

 

[liam2015]

that is a very encouraging check up you received from your surgeon. fantastic that you can do a total revolution on the bike. i was wondering if you still have pain and what you use, if anything, to alleviate it?

 

[KarriB]

@Minstrel my first OS who did my TKR did not communicate with the PTs I used. They were not connected at all, however after my infection I switched to a PT group in the same offices as my OS and revision specialist. The PT sent notes to my revisionist. So there was communication and I was pleased with that because of my complication.

My revisionist said he'd be happy if I reached 90 degrees after being in an imbolizer for a month. Upon being released from PT at month 5-6 my ROM was 109 and it continued to to improve for over a year. At 18 months I realized I could squat in the pool.

Even now I'm very careful of not getting myself into a position I can't get out of, but today I sat on a curb. A curb! And was able to get up just fine! I don't want you to feel that what your OS said is going to limit you. As Kneeper said, move on with your recovery, living your life. Just like age, ROM is just a number. What counts is how we live our lives.

 

[Celle]

If the goal for me was to improve my ROM from the measly 70 degrees that it was, why was I not told the same?

Is it so that patients generally lose 10 degrees of ROM after TKR (another thing I learned for the first time yesterday)?

I should think that the goal of surgery was to give you a fully functioning, painless knee. That would have included increasing ROM, but not been the main reason for the surgery.

I've had 3 knee replacements myself and I've been on BoneSmart for almost 6 years and I've never heard that people lose 10 degrees of ROM. Most people increase ROM, or achieve something similar to their pre-op ROM.

My surgeon told me that I may not improve much from the 96 degrees flexion that I have achieved and he challenged me to prove him wrong. Why then was I told outright weeks ago that 0 degrees extension and 100 degrees flexion was the goal at the 6 week mark, if this was never really realistic for me?

It's only 3 months since your surgery and ROM can continue to improve for a year or more after a TKR, so I think there's every chance that you will continue to increase your ROM.
We can't really say why you were told that, but it was probably just a stock comment, the sort that everyone is given.

Do the physiotherapists and the doctors not talk to each other? Or is this a matter of giving all TKR patients the same information? I suffered a lot of grief thinking that there was something wrong with me and that I might never bend my knee enough again. Could I have been spared all that anguish?

Often they don't communicate and the PTs follow their own agenda, with the same artificial goals set for everyone. Unfortunately, because of this, we read many times here on BoneSmart that PTs have made their clients feel inadequate or that they are failing.

 

[Minstrel]

@liam2015 - to answer your question about pain - I don't feel pain as a matter of course. I sometimes take 2 Tylenol Extra Strength (1000 mg total) as a premptive measure before exercise. I also take Ibuprofen (400 mg total) two to three times daily with meals (the bottle is on the table) to help with swelling.

After the surgical pain subsided, I really did not feel pain, except that which accompanied the exertion with exercises while trying to bend my knee. Perhaps I have been lucky that way.

 

[Minstrel]

About the questions not asked at my 3 month check-up

My surgeon works as a member of a multidisciplinary medical team that includes nurses, physiotherapists, occupational therapists, internists, lab techs, case managers. After a preliminary consultation with the surgeon where you are placed on a waiting list, the next time you see him/her is in the operating room, and after that, at 6 weeks post-op and then at 3 months post-op. It's an approach to joint replacement that has been adopted here as a means of streamlining the process and enabling the health care system to operate on as many patients as the increasing demand requires, in as quickly a time frame as possible (my wait was 6 months).

So, access to the surgeon is quite limited. But the physiotherapists work in the same clinic and I can confirm that they have access to my file (I asked to see my x-rays and they were readily available). So why the discrepancies between what the PTs tell me and what is seemingly successful according to the surgeon? Prior to my 6 week check-up the PT said the expectation for ROM was 100 degrees. The other day, my surgeon was pretty happy with my 90 degree range (up from 71 pre-TKR) at 3 months post-op.

The next time I might see my surgeon is in 8 weeks, if I feel that I am not ready to return to work - a job that requires that I walk 15 to 20 kilometres every day. Past efforts to see the doctor outside of the prescribed time frames were not successful.

And so it was that my questions came to mind after my appointment as a result of the information conveyed at that same appointment.

There is little to be gained by continuing to belabor how much anguish I experienced unnecessarily - except to the degree that it might be helpful for some other patient to know about.

But i would like to learn more about the experience of any other patients who lived for several years (in my case, 41 years) with a leg that became progressively more and more crooked as a result of having had complete cartilage removal. I am happy that I have increased my ROM almost 20 degrees, but I remain very concerned that 96 degrees flexion may be it for me.

Any comparable cases out there?

 

[kmak81230]

Minstrel: Your post could have been written by me; Left TKR five weeks ago (5/9/17) and dreading my 6 wk post-op with surgeon as I can't get past 90 degrees of flexion. I'm 59, was very active pre-surgery and am desperate to be able to get a full revolution on the stationary bike (only about 75% around at this point with lots of swelling and discomfort afterwards). My PT experience is different however and they are not pushing the flexion but focusing on functional movement which I am doing well. Maybe I've been overdoing it . . . and I know everyone is different but I'm concerned with no flexion improvement in three weeks.

 

[sistersinhim]

Wkmak81230, these new knees do that. It's like they take a break, and then all of a sudden take off bending again. One morning you just might wake up and realize that you are on your side and have your knee bent really well! It happens when you aren't expecting it. Just relax and let it happen.

 

[Minstrel]

@kmak81230 - reassuring to read of another patient who has not had the speediest of recoveries. At 5 weeks I could merely rock the pedals of the bike back and forth. Keep in mind that ROM consists of flexion AND extension - most of my gains, to date, have been in extension - which is important for walking properly. I have barely improved my flexion over my pre-surgery measurement, but I have gained 20 more degrees overall in my ROM.

After seeing my surgeon for my 3 month check-up last week, I was given the go-ahead to use the recumbent bike, the upright bike and the leg press in the gym. And in the pool, an exercise that was recommended was to flutter kick with my (scuba) fins on to help build muscle strength in my quadriceps, in particular.

Today was pretty particular: 15 minutes on the recumbent bike, followed by 3 X 25 reps on the leg press, followed by 10 minutes on the upright bike, followed by 30 lengths in the pool, as well as some striding in the water and some knee bends while afloat. There are small increments in the effort level or duration with every passing day (lowering the seat of the upright bike, increasing the effort level on the recumbent bike from 1 to 2, for instance).

I have been measuring the girth of my operated leg in 4 places on a regular basis and there is no appreciable difference in the same (which I'm interpreting to mean no swelling). The only difference I notice in my ROM is while walking around - it feels like my extension is improving. Short of the stiffness that persists and that prevents me from bending my knee any more, I am not feeling any pain, and I continue to take anti-inflammatories.

I am so looking forward to the day I wake up and all of a sudden . . . my knee bends considerably more than it has in a very long time (as Paula, above, has suggested).

In the meantime, I am using the seasonal facility pass that i purchased for the use of my community's indoor and outdoor pools, and its major recreational facility. As a teenager, I was a competitive swimmer and it feels so good to be active again! I look forward to the day I am cycling on my own bike on the trail system, and I am hiking for a couple of hours at a time.

If nothing else, this daily routine of activity is helping me emotionally as I'm in a much better frame of mind these days.

 

[KarriB]

I believe all that exercise is why you haven't gained flexion. All the leg presses, water resistance and 30 lengths of a pool are causing your knee to swell internally. Much of what you're doing is strength training which shouldn't happen until 4 months post op because it puts such strain on a new knee.

 

[Jamie]

Advised that I can expect swelling and stiffness but to not allow that to dissuade me from exercising.

Swelling and stiffness are signals from your body that you're pushing too hard and they should not be ignored or "worked through" with exercise. To do so will only result in more swelling and pain (stiffness is a form of pain).

Given the go-ahead to slowly add more time on the recumbent bike and exercises like leg presses (no weight to begin with). Also told to try using my flippers to flutter kick in the pool to strengthen my quadriceps. Strict instructions to go slowly and to add only 1, or to add to only 1, exercise per day with lots of rest.

These are really ambitious exercises for someone only 3 months out. Your knee is still healing and it's too early to be doing strength training. That comes AFTER the swelling subsides. It would be especially hard on your knees to wear flippers and kick. That adds a significant amount of resistance and puts a lot of stress on your new knee joint. Please don't do that exercise yet. Good pool exercises are walking in the shallow end or sitting on a pool noodle and move your legs as if riding a bicycle. But even these should be done in moderation for another couple of months.

I sometimes take 2 Tylenol Extra Strength (1000 mg total) as a premptive measure before exercise.

This is not a good idea. If you take pain medication prior to exercise or therapy, you lose the ability to read your body's signals that you are doing too much. This could be contributing to your pain and swelling.

I have been measuring the girth of my operated leg in 4 places on a regular basis and there is no appreciable difference in the same (which I'm interpreting to mean no swelling).

You've made an incorrect assumption. Swelling after knee replacement surgery can be visible and measurable on the outside of your knee and leg. But it also occurs inside the knee capsule itself and this is much more frequently the cause of reduced ROM when trying to flex your knee. The knee capsule is a very small space and it doesn't take much inflammation and swelling at all to cause problems. If you have stiffness, you have internal swelling. And it means you need to rest and ice as well as reduce whatever activity you've been doing until that swelling is under control. This doesn't mean that you sit around doing nothing all day. Activities of daily living are fine as are short walks and gentle bends or stretches throughout the day. Just remember that more exercise is never what gives you ROM.....it's time and gentle treatment of your new knee.

Short of the stiffness that persists and that prevents me from bending my knee any more, I am not feeling any pain, and I continue to take anti-inflammatories.

NSAIDs really aren't very effective for post surgery inflammation. Try taking Tylenol instead for your pain (stiffness), use ice and watch to be sure you're not overdoing the exercise or activity.

Lots of people gain additional ROM in the years following their knee replacement. I think you may be pleasantly surprised at how you're doing this time next year. Just don't try to get there too fast.

 

[sistersinhim]

I agree that you are doing way too much exercising. After the first few weeks, I had little swelling, did no exercises or PT, just ADL. My knee has come back better than it has been in over 20 years!

 

[Pumpkin]

You are doing fine, recovery is a marathon not a sprint.
My ROM was still increasing at a year and a half.
You are still very early in this yearlong or more recovery, slow down and let your knee heal.

 

[kneeper]

My PT said it was ok to be a bit sore after PT or activity, but if that lasted for more than a couple of hours you knew you had done too much and to do less next time.

For my first knee they had me do strength exercises quite early and I developed tendinitis. For my second knee I knew better (and had a better PT) and did not do any real fitness type "exercise" until about week 12, and then started very slowly. I had a much more comfortable recovery with very good results.

Each person and knee is different, but there do seem to be some common guidelines that lead to good success without needless extra pain/stiffness/swelling and a longer recovery.

 

[Josephine]

Sorry I'm a bit late to this thread - been recovering from surgery myself!

My surgeon works as a member of a multidisciplinary medical team that includes nurses, physiotherapists, occupational therapists, internists, lab techs, case managers.

Most surgeons do work in a system like this.

Do the physiotherapists and the doctors not talk to each other? Or is this a matter of giving all TKR patients the same information?

Interestingly they don't! They create a philosophy which is discussed in depth in multi-disciplinary meetings and then adopted as department protocol. This then has a tendency to become carved in tablets of stone!

So why the discrepancies between what the PTs tell me and what is seemingly successful according to the surgeon? Prior to my 6 week check-up the PT said the expectation for ROM was 100 degrees. The other day, my surgeon was pretty happy with my 90 degree range (up from 71 pre-TKR) at 3 months post-op.

In my opinion, what happens is that surgeons still adapt their approaches on a patient by patient basis but the PTs stick the stone carvings!



I'd really like to offer you some structured advice but in order to do that, I also need to ask you some questions. Are you willing for me to do that?

 

[Josephine]

A couple more recent comments I just noticed!

Today was pretty particular: 15 minutes on the recumbent bike, followed by 3 X 25 reps on the leg press, followed by 10 minutes on the upright bike, followed by 30 lengths in the pool, as well as some striding in the water and some knee bends while afloat.

Well, my information has always been that we knee patients should NEVER use a knee press or any similar gym machines until about 6 months post op. Apart from causing pain and similar issues, they can also cause loosening of the tibial implant.
Read this BoneSmart philosophy for sensible post op therapy

I have been measuring the girth of my operated leg in 4 places on a regular basis

This really isn't a good idea. Just eyeball it - that's quite good enough. Swelling can change day by day.

 

[Minstrel]

In answer to your question, Josephine, yes, I would be very willing to answer some questions.

These past two days have been difficult for me. My knee is complaining - probably because of all the exercise I subjected it to earlier this week.

The inability to move without painful repercussions is really getting me down.