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TKR One Year Out

Yes it seems to support that slow gains are possible…but with an average gain of only 11 degrees with MUA at any time, I would still question the risk:benefit ratio of MUA (vs bonesmart gentle stretching). That said, I personally would rather regain ROM early in recovery before tissues heal too much and get too tight for more rapid gains.
 
marmarmish said:
But if I am having trouble wrapping my head around this issue, you can bet many others are too!
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We have this question come up on Bonesmart all the time. In my 6+ years on Bonesmart I’ve seen many members worried about their ROM, and then report after the 3 month timeframe, and even later, of increased ROM. I am one of them. After a tough first year, (I had decent ROM in the beginning, but had a huge setback at four months, and again at 5 months, which reduced my ROM quite a bit)
my ROM continued to improve throughout my second year, as my whole leg continued to relax and heal, and I even noticed a bit more in my third year. Personally, I never needed any formal studies to prove what our members said was true, and what I experienced myself.

As far as getting the most rapid increase the first 3 months, most of our medical teams don‘t specify that. If they did, I think we’d relax more about our ROM. But, many of us are threatened (yes, threatened) with the Window of Opportunity . It’s sad, because we are so vulnerable in the early weeks, and even months, as well as recovering from major surgery, the last thing we need is threats and stress over something that I believe will heal and take care of itself, and that timeframe is different for each of us.
 
Jockette said:
marmarmish said:
As far as getting the most rapid increase the first 3 months, most of our medical teams don‘t specify that. If they did, I think we’d relax more about our ROM. But, many of us are threatened (yes, threatened) with the Window of Opportunity . It’s sad, because we are so vulnerable in the early weeks, and even months, as well as recovering from major surgery, the last thing we need is threats and stress over something that I believe will heal and take care of itself, and that timeframe is different for each of us.
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I agree. I think time pressures result in these abrupt explanations coming across as threats. My surgeon did the right thing IMO in educating me about my options. I chose to push flexion so I could have hope to get on skis this winter and get back to my job that requires a lot of kneeling and squatting, and try to not overstress my other equally arthritic knee.
 
Jamie said:
With a quick search of Knee Replacement ROM after 3 months, I found:

pubmed.ncbi.nlm.nih.gov

Knee Kinematic and Clinical Outcomes Evolution Before, 3 Months, and 1 Year After Total Knee Arthroplasty - PubMed

This study showed that 1 year after TKA, patients exhibited improved gait velocity and ROM and experienced a significant decrease in the level of pain and an increased clinical score (although different from CG).
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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Maybe I’m reading the abstract wrong, but it suggests the difference from 3 months to a year in ROM is about 5 degrees.
Eta: This study was a gait analysis that looked at ROM during walking. Basically the degrees of ROM during walking improved a bit from pre-op (44) to 1 year (47) but was only 42 at 3 months. I didn’t read the full study to see if it measured full ROM. But it suggests that it takes well over 3 months before walking is better than pre-op.
 
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I’m not seeing what you describe. I did not pay to read the full study.
 
@dotski I see the same - the study was about gait kinematics, and it concluded that walking speed and ROM improved over the course of the year. The normal walking ROM is 60 degrees.

I'd be interested in a similar study but one showing full ROM!

FYI - my current gait ROM is 55 - 59 degrees (per my "Smart Knee Implant").
But my full flexion is about 95 - 100.
 
Thank you both for your analysis of the link. You did a better job than I did and I appreciate it.

I'm sorry that I could not find more studies on this topic. I do know that it's not one that's covered much for some reason. That's sad.
 
@Jamie Thank you for the kind words. It's surprising there isn't more info on what I think is an important topic.
Maybe this could be addressed at the 2023 Joint Replacement Awareness Day???

Hope you are having a nice day! :xmas-wave-smiley-emoticon:
 
I would think it’s nearly an impossible thing to research in a way that would meet medical research standards. For ethical reasons it could be difficult to recruit and randomize patients between no stretching/just ADL’s vs standard PT stretching….since it is so well accepted in the medical field that regaining ROM, the earlier the better, leads to better outcomes. I strongly believe that the more mobility (barring no hyper mobility) a joint has…the less strain on adjacent joints. When one body part is restricted it has a ripple effect on all others. Eg if an ankle gets broken (or fused) and the opposite leg has limited knee bend, it will be impossible to sit on a toilet without extensive help from the arms. Almost everyone develops worsening joint function in hands and shoulders, etc as we age. And this surgical recovery can accelerate issues in other body parts due to the ripple effect on one joint (knee) being dysfunctional. So even though there may or may not be good evidence to support a 6 week ROM window (although so far I can only find evidence to support it)….there are many other good reasons IMO and IME to try to restore normal knee motion …the sooner the better.

I’m not saying it has to involve excruciating pain though. My OS was clear from day one that I could not do damage by passive stretching keeping muscles relaxed. When I hear and read of injury to quads and patella tendon, it seems to have involved a mechanism of also activating the powerful quad muscles, which adds further force onto the stretch. A therapist passively pushing on my knee can also do this, and hence create a muscle guarding/contraction pain response. So I avoided this as it is ultimately counterproductive IME. I got the best results when I was able to set aside lots of time for prolonged relaxed stretching, me 100% in control, gradually increasing my tolerance and trust that I wasn’t going to tear something (which in turn kept quads more relaxed and not fighting against it).
 
Ha! I just stumbled across this!
bonesmart.org

MUA (Manipulation under Anaesthetic) and adhesions

First let me first put your mind at rest - this is quite probably nothing to do with not having done enough PT or been 'good enough' in following orders. Here is my standard mini-lecture on the subject so read and absorb ... All the structures in the body, muscles, tendons, ligaments, even gut...
bonesmart.org bonesmart.org

Look at the end of the July 18 2009 article - a study done in the UK in 2006.
Very interesting, tho it's unclear if the 3 examples where just the lucky few, or typical of what he saw...
 
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dotski said:
therapist passively pushing on my knee can also do this, and hence create a muscle guarding/contraction pain response. So I avoided this as it is ultimately counterproductive IME. I got the best results when I was able to set aside lots of time for prolonged relaxed stretching, me 100% in control, gradually increasing my tolerance and trust that I wasn’t going to tear something (which in turn kept quads more relaxed and not fighting against it).
Click to expand...
I agree. In my experience, relaxation with gentle movement and gentle slow stretching in tandem with slow deep breathing helped me achieve extension without pain or rebound swelling. Keeping the quads relaxed was key to this.
 
marmarmish said:
Ha! I just stumbled across this!
bonesmart.org

MUA (Manipulation under Anaesthetic) and adhesions

First let me first put your mind at rest - this is quite probably nothing to do with not having done enough PT or been 'good enough' in following orders. Here is my standard mini-lecture on the subject so read and absorb ... All the structures in the body, muscles, tendons, ligaments, even gut...
bonesmart.org bonesmart.org

Look at the end of the July 18 2009 article - a study done in the UK in 2006.
Very interesting, tho it's unclear if the 3 examples where just the lucky few, or typical of what he saw...
Click to expand...
I remember reading that also, very interesting 1 surgeon’s perspective. There can also be some bias in that those people who are comfortable enough to do their rehab without PT may have a different level of knowledge, experience and body awareness. No randomization but definitely good food for thought! When I first started having knee issues, PT was very helpful. Over time I’ve come to better understand knee anatomy/kinematics and I use PT more to help with problem solving various little issues (as I already know all the standard knee exercises).

I also find it interesting the lack of difference between MUA vs no MUA (compared to your earlier cited study that indicated only 11 degrees of ROM gained with MUA (if I recall correctly!). It seems to perhaps boil down to the question of “do I want the faster track or the slower track to ROM?” Either way it will improve from the looks of it.

The study mentioning that MUA is most effective prior to 8 weeks, does lend support to the 6-8 week ROM window for most rapid flexion gains. I gained 2 degrees per day weeks 1-6 and then gained a further 10-15 degrees of flexion between weeks 6 and 10. At 12 weeks seem to have gotten a bit more extension (still can’t get to zero :(). My PT said 16 weeks window for extension. Our regional health authority has 12 weeks as the goal for full extension. There is so much inconsistency between all info sources, so it’s no wonder we get confused trying to figure out where to most direct our efforts.
 
That said, if it were me with ongoing inflammation issues and IT band irritation, I personally would not opt for MUA if I already had 100…especially when the studies have also seemed to indicate it is more effective when ROM is less than 90.
 
@dotski "I gained 2 degrees per day weeks 1-6 and then gained a further 10-15 degrees of flexion between weeks 6 and 10."

Nobody like a bragger! :loll:
 
Oh my gosh I’m so sorry I didn’t mean to sound like that! As much as I am pleased with the flexion, I just finally got my X-ray film file to open and think I have found answers as to why I’m struggling with patellofemoral pain and crepitus much worse than my worst OA flare. The joint space has decreased quite significantly in my patellofemoral joint. Comparing the pre op vs the immediate post op and 6 week post op patella views (lateral and skyline). I still have loose bodies in back of knee joint also. I’m wondering if I should have gotten a button (patella wasn’t resurfaced),
I suppose if I didn’t have the ROM, surgeon might blame my pain on that. :chinstroke: I see him in the new year and and may have some challenging questions for him…if time is not the healer it should be. Definitely not overdoing it (my step count is only 1000-1500 on average). Anyway, sorry I didn’t mean to hijack your thread with my woes. You ask really great questions!

I really hope taking it easy helps settle your pain.
 
@dotski No! I was only joking!! And you are not hijacking anything! I think we are having a great conversation!

I'm sorry to hear of your setback! I hope you are able to get it resolved soon! :praying: It sounds awful....
 
My tendonitis has really calmed down so I started up with my exercises yesterday. I could have sworn I was able to bend my knee further than previously. So today I was excited to see how my ROM had progressed. It was a kick to the gut to see I was only getting 70 degrees!! :hairpulling: Down from 95 degrees when I last measured over a month ago. So bummed.
 
It's great to read that your tendonitis is better! Could you be guarding your knee, afraid of hurting that tendon again? That would explain your lower bend. I bet you will see that bend improve as you realize you are not going to hurt that tendon again.
 
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