TKR Post op ROM

[markbet]

Hi, I had a TKR on 12/4/19. This is my one and only surgery in my entire life. I have SO many mixed emotions about where I am at on my recovery, and where I should be, I just don’t know.

I have been going to PT three times a week since surgery. She has me doing a routine,

1. I exercise on a total gym contraption on a slight slant for 5 minutes, legs only.
2. Then I work out on an exercise bike for 5 minutes.
3. I then do some pretty simple stretch exercises, 15 times each.
4. She then has me do a single stair step 15 times, usually by this time, I am starting to get swollen and somewhat stiff.
5. Then off to the table, where I do some more stretches and then the dreaded ROM check.
6. So I guess I am close to eight weeks out from surgery, my bend bounces from 110 to 115 depending on how swollen I am that particular day. Last Friday, I was at 115 degrees bend, but still 5 degrees from my leg being straight/extension.

I purchased a recumbent exercise bike back in January. I first tried riding my bike for 30 minutes, big mistake, when I got off the bike, I was almost crippled from the swelling that occurred. Now, I ride for 15 minutes once a day, and trying to increase my speed enough to get to two miles each session, and I maybe pushing that too much, because of the swelling. I have gone as far as starting to wear a full length compression stocking all day, trying to keep my swelling down, along with icing my knee.

I will not permit a MUA, I just can’t bring myself to do that. My PT agrees that MUA’s do more harm than good, because it is basically ripping the soft tissue apart, and in the long run I would have even more scar tissue to deal with?

I find myself being very depressed because my ROM is not where I am told I should be by this time, at least 120 degrees, and not having a straight leg. I was told by my PT to prop my leg up at the heel, and place a ten pound weight on my thigh in an effort to break loose my tendons in the back of my knee/leg. I have tried that, but the pain is all most intolerable. I also do an ACL stretch, but going straight isn’t quite happening yet. So mentally I am not doing so well, and finding this support group can get my confidence built up some, because it is pretty low right now.

 

[sistersinhim]

Hello @markbet. I have moved your post and started a thread for you. If you would like the title changed just let me know.

You are doing way too many exercises for a baby knee. Your swelling and pain is telling you that. Who told you that you should be 120 by now. Every single knee is different and has experienced a different history and trauma during its surgery. There is no set rule of where anyone is supposed to be at a certain time. Each knee is an individual.

The following are our basic guidelines and should help get you started. As you read more on other members recovery threads, you’ll get a better perspective of what to expect and what not to do, especially regarding PT.

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.​

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. Here is a week-by-week guide for Activity progression for TKRs


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 a 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 history before providing advice.

 

[mog]

Hello markbet and welcome.
Firstly can i say CONGRATULATIONS you are doing so well,better than me and everyone is different. It sounds like you have reached the point to relax and listen to your body, yes keep the current ROM but let your body heal it will help with the mental issues so much..less pain = happier brain.
Good luck on this rollercoaster of a marathon not a sprint.

 

[markbet]

My PT has been telling me for five weeks that I'm not where I am supposed to be as far as ROM, which is grinding my self confidence into the ground. I lay awake at nights worrying about it, in fact, during my sleepless nights, I lay in bed and do stretches. Thank you for all of the information to read, I have my homework cut out for me, and that is good.
My PT told me that since I am kind of bow legged, that when the surgeon replaced my knee, that he realigned my leg! And now my leg after 66 years of being bowed, is now trying to get used to being somewhat straightened. I'm not completely convinced about all of that, my next visit to my surgeon is in about four months, and I will ask him about that.

 

[Roy Gardiner]

The cause of pain and swelling is overdoing exercises, the answer is to stop. Do only stretching exercises, not strength building, and do them to the point of discomfort, not pain. Your lack of progress is because of overdoing things.

Now, I ride for 15 minutes once a day, and trying to increase my speed enough to get to two miles each session, and I maybe pushing that too much

I think so.

• 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

my ROM is not where I am told I should be by this time

There is no should be, all recoveries are different.

prop my leg up at the heel, and place a ten pound weight on my thigh in an effort to break loose my tendons in the back of my knee/leg

Not really. See the link to exercises from my signature, below

when the surgeon replaced my knee, that he realigned my leg

Yup. I could shove my fist between my knees with heels together before surgery, straight now!

 

[Celle]

My PT has been telling me for five weeks that I'm not where I am supposed to be as far as ROM, which is grinding my self confidence into the ground. I lay awake at nights worrying about it, in fact, during my sleepless nights, I lay in bed and do stretches.

Your PT is doing you more harm than good,by undermining your confidence like that.

There is no "behind" in ROM development. what your PT Is working from is a one-size -fits-all (or none) theoretical schedule. To have you gain ROM fast makes him/her look good, but it's not what is best for your knee. Your knee is on its own recovery schedule. It knows what it's doing and it's going to do all right.

There's no need to rush to get ROM (Range of Motion) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

In any case, it's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee has the potential to achieve good ROM right from the start, but it's prevented from doing so by swelling and pain. As it heals and the swelling goes down, your ROM (both flexion and extension) will gradually increase.

There really is no need to do the amount of exercising that you're doing. Your knee will regain ROM naturally as it heals and you use it in your normal activities of daily living. INstead fo spending so much time exercising, spend that time icing and elevating your inee, to help disperse the swelling, which is the main thing preventing further ROM development.

Once a week is more than enough for PT. Stop the excessive exercises and just do as Roy suggests, above.

In case you think you can't do that, you can. It's your knee and you are the only one with the right to say what happens to it.
Saying no to therapy - am I allowed to?

 

[markbet]

You guys are immensely helpful! I am so glad I stumbled on your website! Two minutes on the exercise bike it will be. Now I know why my knee would actually be shaking while peddling, I was so over working that poor thing. I have a LOT of reading to do, again, thank you so much!!

 

[Tykey]

With your current ROM, what activity can you NOT do?
I guess I'm at around 115 after 5 months, but I've never measured it, and do everything I choose. I'll be quite relaxed if it doesn't increase over time. But it will.

 

[markbet]

I do quite a bit of work on farm equipment, and need the ability to keel and be on my knees. I purchased some good quality knee pads, I am hopeful they will be enough protection, and my knee will cooperate. My TP got me to 115 degrees, but I thought she was going to snap my leg off to get it there! Can I bend my knee comfortably to 115, the answer is no. I still wear slip on shoes, I don't think I could bend my leg enough to put on a lace up shoe.

On edit, do any of you use full length compression stockings to help control the swelling, and are they recommended?

 

[Summer2020]

I’m at 6 weeks post op and I’m about where you are. -4 extension and 120 flexion. I too endure the heel up on something and a 10 lb weight on my knee and holding it for minimum of 45 seconds. Then if he wants to measure my extension he pushes down on my knee until I’m breathing like I’m giving birth and about to scream. So -4 is not my true extension number it’s only forced. I saw my surgeon today and asked him about the PT saying the best ROM I’m going to get is in the first 6 weeks. He shook his head and said I’ve seen ROM improve the most from 6 to to 16 weeks but every knee is different.

so long story short.I think you’re doing great. Lot more exercising than I can tolerate so maybe your swelling is being caused by that. But boy you’ve worked hard so far! As I’ve read all over this forum it takes time to get the ROM to where you want it. No rush.

And yes I’ve been wearing the full length Ted hose since my surgery. My dr today said I didn’t need to wear them anymore. But I said I get a lot of swelling after PT and he said. ‘Oh that makes sense, well then wear them the day of and day after PT. Other than that you don’t really need to anymore .’

 

[Jockette]

My TP got me to 115 degrees, but I thought she was going to snap my leg off to get it there! Can I bend my knee comfortably to 115, the answer is no.

Stop allowing your PT to do this, not only is it unnecessary, it’s casing more pain and swelling, which is counterproductive. I will never allow that to happen to me again.

I was told by my PT to prop my leg up at the heel, and place a ten pound weight on my thigh in an effort to break loose my tendons in the back of my knee/leg.

Stop doing this also, not only is it also unnecessary, it’s barbaric!

I don’t even know how long my extension took, but it came along fine and no one ever pushed down like that on my leg to straighten it.

I had good numbers for flexion, but like you they were all forced. I found Bonesmart at 4 weeks post op and learned I shouldn’t let them do that, but I’m not confrontational and I just didn’t have the nerve to tell them no. As a result, I now literally have some PTSD from my experience and now I know for sure, I won’t let this happen if there’s a next time.

My ROM continued to improve after my one year anniversary, and even after my second anniversary, so that is proof that there is no “window of opportunity”. I honestly don’t understand how the medical profession can continue believe this.

 

[markbet]

I am fast approaching my 25% recovery milestone, my RTKR was 12/4/2019.
I keep reading all of our different concerns, swelling, ROM, pain, etc. The one concern that keeps popping up that seems to be a main concern is, adhesions. My question about adhesions are, at what point do you develop adhesions? Is this something that would more than likely show up at our six week exam? Do adhesions show up on the x-rays that are taken?
I have read that adhesions are not common, but in fact are rare, is this true? I would think this problem would rear its head early on. I ride a recumbent bike daily, and the last time my ROM was checked, I was around 115 degrees. If adhesions are present, would that not make it almost impossible to bend my knee enough to ride a bike? Will riding a bike prevent adhesions? I tried and succeeded walking up and down my stairs that lead to the basement, 14 steps down, and 14 up, it was just a little uncomfortable, but it was with no pain. I mean I swell some, but it seems I look at my knee wrong, and it will swell up on me. Back to the adhesions, at this point, I would know if I had an adhesion problem, correct?

 

[sistersinhim]

Yes, the number-obsessed PTs will rattle on about it as if the big. bad "scar tissue" is just sitting there, waiting to pounce if you don't do enough exercise.

Actually, it's quite the reverse. The infamous scar tissue (which is more correctly called adhesions) is very rare, and one of the easiest ways to develop it is to work your knee too hard. Over-worked knees get inflamed and hot, and hot tissues become drier than normal and more likely to stick together and form adhesions.

This article explains the difference between scar tissue and adhesions:
MUA (Manipulation under Anaesthetic) and Adhesions

You need normal scar tissue. That's what holds your incision together, and it's part of the normal healing process. Without it, you'd always have an open wound.

 

[markbet]

I just wish between the OS and PT, that they would ease up on the scare tactics. I can see with myself and others, this major procedure is extremely mentally challenging anyway. Do they not realize how negatively this affects our mental health? I do read all the positive replies Bone Smart puts out, but this being my only surgery, I am truly scared, and the negative thoughts seep back into my head especially with a PT that actually has a doctorate in PT is pounding in my head, "you better do this or you are going to be a cripple for the rest of your life!" This has be the most horrible thing I have ever experienced, both physically and mentally, it is flat out exhausting.

 

[sistersinhim]

and the negative thoughts seep back into my head especially with a PT that actually has a doctorate in PT is pounding in my head, "you better do this or you are going to be a cripple for the rest of your life!"

He might have a doctorate, but he hasn't had a tkr. Tens of thousands of us have. All through the years this information has been gathered and Bonesmart has found that the majority of people rehab better with an easy, less aggressive PT.

We aren't trying to sell anything. We aren't making money off of our suggestions. We just care and want to help as many people as we can.

 

[markbet]

We aren't trying to sell anything. We aren't making money off of our suggestions. We just care and want to help as many people as we can.

I hope you didn't think I was insinuating you are taking advantage of anyone. That was the furthest thing from my thoughts. To the contrary, I have read many helpful threads that are helping me get through this ordeal.

 

[Tykey]

Hi Markbet, if you Google the AAOS (American Association of Orthopaedic Surgeons) sites referring to Knee Transplants, you'll find their approach to rehab is very similar to Bonesmart's, and I couldn't find any reference to adhesions, MUAs, knees setting like concrete. Just gentle exercises.
Being a Brit, I can't vouch that the AAOS is a bona fide organisation, someone else might comment.

 

[Jaycey]

I can't vouch that the AAOS is a bona fide organisation, someone else might comment.

AAOS is indeed a bona fide organisation. And it has very strong ties with it's British counterpart - the BOA (British Orthopaedic Association).

 

[markbet]

I guess my question was, at what point after surgery does adhesions occur? If I was going to get adhesions, would I already have them at this point?

And riding my recumbent bike basically insure I will not get adhesions.

 

[Celle]

Adhesions can occur at any time during the healing process, but they are less likely to occur in the early days of recovery.

With a flexion of 115, it's most unlikely that you have them, or will develop them.

And you don't have to listen to your PT who has a doctorate. Just tell him you don't want to hear anything more about adhesions. If he persists in talking about them, walk out of the room. He'll see that you mean what you say.

You are in charge of your knee's recovery, not anyone else. It's your knee and you are the only one with the right to say what happens to it.

There's no need to rush to get ROM (Range of Motion) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

It's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee has the potential to achieve good ROM right from the start, but it's prevented from doing so by swelling and pain. As it heals and the swelling goes down, your ROM (both flexion and extension) will gradually increase.