MUA Post MUA Question on Adhesions

[Mustski]

Hello, so happy to find this forum. I had TKR on May 31st and started PT three days later. At about day seven, I began experiencing significant swelling, to the point of being unable to stand without extreme pain from the rush of fluid down into the knee. My PT was great and recommended we respect the knee and let it calm down. When it finally calmed down at about three weeks post TKR we began to again work on ROM. I was getting nowhere on range of motion (sitting at 75/80 for two weeks) so at seven weeks (July 17th), I had an MUA. Surgeon was able to get 140 degrees of flex at the time of MUA. Back to PT I went, the day after MUA, with an immediate 110 degrees of flex at PT. Within three days, I started going backward, and when I hit 80 degrees - we (me and my PT) decided to "go slow to go fast" and are now not doing more than slight to moderate stretching and using the recumbent bike. We gained 20 degrees last week and I'm now at 100 degrees of flex. Here's my question: Since there is no exposure of the interior of the knee during an MUA, can new adhesions form?

 

[Jockette]

Here's my question: Since there is no exposure of the interior of the knee during an MUA, can new adhesions form?

Hi and Welcome!

Technically, the answer is yes, BUT, it would take time and you would probably have to be very aggressive with your exercise, for that to happen.

Your PT sounds very wise, backing off and respecting your knee, and giving it time to heal. This is the best way to avoid adhesions, and why Bonesmart recommends a gentle rehab after joint replacement.

Healing does take an average of a full year, and many of us had low ROM numbers for quite a while, and still came out with a great outcome. Patience with this recovery is extremely important.

I will leave you our Recovery Guidelines. Each article is short but very informative. Following these guidelines will help you have a less painful recovery.

Just keep in mind all people are different, as are the approaches to this recovery and rehab. The key is, “Find what works for you.“ Your doctors, PTs and BoneSmart are available to help, but you are the final judge as to the recovery approach you choose.

Knee Recovery: The Guidelines

1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary

2. Control discomfort:

rest​

elevate​

ice​

take your pain meds by prescription schedule (not when pain starts!)​

don't overwork.​

​

If you want to use something to help heal the incision, ​

BoneSmart recommends hypochlorous solution. Members in the US can purchase ACTIVE Antimicrobial Hydrogel through BoneSmart at a discount. Similar products should be available in the UK and other countries.​

3. Do what you want to do BUT

​

a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​

b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

​

​

4. PT or exercise can be useful BUT take note of these

​

the BoneSmart view on exercise​

BoneSmart philosophy for sensible post op therapy​

5. At week 4 and after you should follow this

Activity Progression for TKRs​

6. Access to these pages on the website

​

Oral And Intravenous Pain Medications​

Wound Closure​

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly
Chart representation of TKR recovery
Healing: how long does it take?

Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds

We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

While members may create as many threads as they like in the majority of BoneSmart’s forums, we ask that each member have only One Recovery Thread. This policy makes it easier to go back and review the member’s history before providing advice, so please post any updates or questions you have right here in this thread.

 

[Jockette]

Here are a couple of important articles for you:

Myth busting: "window of opportunity" in TKR

This "six week window of opportunity" surgeons often speak about is little more than a myth. It presupposes that all patients have the ability to create adhesions which is far from the truth. It also ignores the simple fact that in the first 3-4 weeks after surgery, swelling reactive to the...

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

This is an important paragraph in the MUA article:

”I would however, put in this warning about too much PT/physio done too aggressively and especially that causing excessive pain. What this does very effectively is cause the tissues to become over warm and even hot. (though a warm knee during recovery is normal and a sign of healing). This I am referring to is excessive heat. This means that the structures are becoming dry within and dry structures (muscles and ligaments) will get stuck together, resulting in the dreaded adhesions (image below)! So when you find yourself questioning the BoneSmart suggestions of rest and gentle exercising, remember that this is what we are trying to protect you from!”

 

[Layla]

Hello and Welcome to BoneSmart. Thanks for. joining us!
Sorry for the pain you had to deal with and any accompanying discouragement over the entire process.
I like your PT's idea of "go slow, to go fast" thankfully you're not being pushed. With your patience, the PT's guidance and walking to promote blood flow and prevent blood clots, your mobility will gradually increase as you work toward the desired outcome.
Please stay in touch so we can follow your progress and support you along the way.
All the best to you!
@Mustski

 

[mendogal]

I would like to add to the above wise counsel... In my experience with both athletic injuries and multiple knee surgeries, stretching my knee (and especially having PT stretch it!) early in recovery has been counterproductive, while gently and slowly repeatedly moving it - both actively and passively - through its current range of motion has been tremendously helpful; I do active range of motion with my 6 month old knee before and after walking, and a combination of active and passive with my newer knee at the same time plus after sitting a while and after icing.

 

[sistersinhim]

In this recovery, the slow tortoise wins the race! The thing that limits ROM is swelling. Think of a water hose that is full of water with the nozzle cut off so it can't come out. Now, roll up that hose. Can you easily do it? Of course not! Open up the nozzle and let the water come out then it will bend and roll up just fine. Your knee is the same way. Getting that fluid, (swelling), out will allow it to have a better ROM. To get that out you need to lower the inflammation. To lower the inflammation you need to ice and elevate, (above your heart), as often as possible. Your movements should be gentle movements, which will be enough by doing just your daily activities. Many of us never took formal PT, just used our knees normally, and had great outcomes. I am one of those who didn't suffer the pain and swelling of PT, never did exercises, and I recovered just fine after numerous knee surgeries.

It sounds like you have a great PT, but still need to cut back on your exercises and let that poor knee heal.

 

[Roy Gardiner]

using the recumbent bike

Using a bike to gain ROM is pretty simple:

• Set the bike to zero resistance
• Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
• Gently turn the pedals, through discomfort but without pain.
• Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
• Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
• Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
• And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't

Here is a bit more chat and some pix and how 'healing' and 'training' are different

 

[Layla]

Forgot to mention....Happy Anniversary to your two month old knee!
May it heal perfectly and serve you for many years to come!
@Mustski

 

[Mustski]

"Slow" is starting to win this race. Last Monday, when we decided to shift our approach and go slow, I was at 80 degrees flexion. By the end of the week, I was at 100; after two days off from PT, I was at 103 yesterday, and today I am at 105! Such a relief; this is working!

 

[Layla]

Yippie Skippie!
Keep it up and have a great rest of the week!
@Mustski

 

[sistersinhim]

Yay, it's working for you!

 

[Mustski]

Saw my OS today and informed him of our slow approach; he's supportive and warned me not to be disappointed if we hit plateaus that sit for a week, maybe even two, before we work through. Happily, my husband heard this message as well. It feels like the whole team is now pulling in the same direction with the same expectations. Phew!!

 

[Layla]

Wonderful news! I'll bet that feels much more relaxing for you.
A peaceful Friday and weekend to you!
@Mustski

 

[Mustski]

OK, knowledgeable people... it feels like I'm starting over every morning. I roll between 110 and 113 degrees on a good day, but that's after massaging, riding the bike, stretching, etc. Before I do those things, I'm usually right around 90 degrees. It is so disheartening... Is this normal? When will I just be able to bend my knee?

We can also add patella realignment surgery in 1978 to the list of abuses to my right knee.

 

[sistersinhim]

When you have a MUA that sets your recovery way back and we begin to count that as your new date. You had that less than a month ago, so your knee is still healing from the MUA and TKR, that's double work. What you should be doing are very few exercises and increased resting, icing, and elevating. You can not force the knee to heal any quicker than it will heal but you can set it back by doing too much too soon. Adhesions are formed with the tissues get hot and dry. Overworking those tissues will become hot and dry. This is why we stress the importance of not overworking the knees.

 

[Mustski]

Got it; thank you. That's what I was thinking but was a little surprised flex (said "extension" in error in the earlier version of this post) isn't sticking once achieved. Trying very hard to not overdo things.

 

[sistersinhim]

Swelling affects not only your bend but your extension, too. The MUA didn't do anything for your extension, but the whole knee is now inflamed even more and that causes swelling and stiffness, which affects the ROM, both bend and extension.

My extension was slow coming in, too. The best way I helped mine was to walk with a long stride, walking with a heel-to-toe gait. This helps to stretch out those large muscles and tendons in the back of the knee. But, this takes time. Those soft tissues are very slow to stretch out, but they do stretch out!

Try not to worry so much. Worrying is stressful and that is bad for healing. Just relax and know that your knee will be fine in its timeframe!

 

[mendogal]

Got it; thank you. That's what I was thinking but was a little surprised extension isn't sticking once achieved. Trying very hard to not overdo things.

The achieving of extension and then seeming to lose it over the course of the day is 100% my experience with both knees. I believe it's just as Bonesmart says: we don't normally gain or lose it; it's there waiting to be accessed as the swelling goes down.
My advice? Stop measuring! Focus on a sane balance of activity and rest, and guage your progress by your walking, biking, and activities of daily living.

 

[Mustski]

OK, oh wise ones... next question. The swelling is definitely going down (yay!) and I'm able to bend my knee (not measuring ;) in the course of my normal day and I'm sleeping better.

Today I am experiencing a sharp electric shock type of pain, that comes and goes, in the area to the inside of my knee, about level with the middle of my patella... I think this is the MCL?? What the heck is this, and is it normal?

 

[Jockette]

I am experiencing a sharp electric shock type of pain, that comes and goes

I’m guessing what you’ve described is what we call “zingers.” They are quick pains that do come and go and are your nerves healing, so technically it’s a good thing!