TKR Powerhouse's Recovery

[Jamie]

Your emails were professional and to the point. Unfortunately, you received canned responses from both your therapist and your surgeon. As you've witnessed, every recovery is different so this knee is not happy with the level of exercise and activity you are getting when you do both formal PT and your activities around home. If the extreme pain you're experiencing goes away once again when you have stopped the therapy sessions for a week or so, I think you have your answer about what is causing it.

It is normal for pain (if it's going to occur from overdoing therapy) to come 24-48 hours after the session. The same is true if you overdo activity on your own as well. It's not always immediate.

What we see with our members is not what your surgeon and therapist are telling you. Our members do just fine overall when they limit activity and therapy movements to what their knee will tolerate at the time with only minimal pain or swelling afterwards. What is critical is to find that level so that you are moving the knee consistently with challenging bends and stretches, but not so much as to put yourself in agony that results in the healing soft tissues becoming inflamed.

Recover from a TKR is an individual process. No one can put timetables on it. There is no "window of opportunity" after which you will never gain any more flexion or extension. Some people and their joints just take longer than others.

I'm glad you're taking an active role in your recovery. You're going to do just fine. Take all the information from your medical team on board plus what you read here on BoneSmart. Try the options on for size and figure out what works best for you and your body.

 

[Powerhouse]

My final email to them last night:

I guess I will have to do my own research and find something or someone that will help me since it seems you two don't have definitive answers to these terrifying nighttime episodes, nor how I am to deal with the shin splint & charleyhorse pains in my calf that lasts for hours after it happens.

I glean you assume I am wanting to avoid PT and that could not be further from the truth.

Instead I am trying to avoid having to go to the emergency room when these pains feel like someone's got my knee in a vise & is cutting my knee in half.

I don't know any other way to explain it so you can understand.

Tina
-----

Dr S called me, said he was on vacation but for me to be at his office first thing Thursday morning.. he will take x-rays and do full exam.

 

[kneeper]

I'm glad to see they are at least going to look at it. At least in person you'll have a fighting chance of explaining the overnight situation.

 

[Powerhouse]

It's been a bit of time since I posted... Tomorrow marks 5 weeks since surgery. I have not gone to PT since 6/20 because of the after-effects of it - horrible spasms and lack of ROM. When I had my TKR in 2015, it was rough, but I was up and doing a whole lot more at 5 weeks than I am doing now & doing PT 2-3x week.

I saw my surgeon last week and his only answer to the extreme spasms is inflammation. We had a talk about PT and BoneSmart. I told him that if I have inflammation, the only way to rid it is rest, ice, elevation and ADL.....which has so far worked since I haven't had the spasms since 6/23, since PT on 6/20.

He wholeheartedly disagreed....his wife is a physical therapist. He said that if I do what BoneSmart says, I will be left with a knee that doesn't function right and will never get optimal ROM.

Even though my flexion was 90, he pushed my leg back and got me to 95...didn't hurt too much.

Then he had me lie on my back....he pushed down twice on my knee so hard to try to get more extension - I was in tears.

He had me turn over on my stomach and he pushed my foot up toward my butt to get even more flexion - more tears (I told him I was gonna start cussing him out).

He said that if I go to PT and it doesn't hurt then I didn't do it right.

Since that visit 4 days ago, my leg has been basically frozen in place ...about 70 is all the flexion I could get. Finally, in the middle of the night last night, I felt it beginning to not be so stiff - I could flex it more and extend it better. I was praising God!!!! I did a few stretches and a couple light exercises, went down the stairs (which I have been doing with no problem) and took the dog out and came back up the stairs - that's it, hardly anything. Now, a few hours later, even with 3 rounds of icing, I can barely move my leg again.

It is so frustrating trying to find the right balance of what to do to prevent not healing, but also to prevent 3 days or more of basically being in bed because of pain & stiffness.

It's also frustrating to hear the diametrically opposed PT advice. Which one is really correct?

He wants me back in PT ASAP - how do you go to PT when you can hardly move? How do you go when you know pain & stiffness is going to happen for days later?

Tears flowing here.....feel so behind.

PS... I sent him link to BoneSmart.org as well as the TKR post-op recommendations. He had said he would be interested to see any research to prove that PT in the first weeks is incorrect.

 

[Jockette]

Oh my, I am so sorry to read about this appointment with your surgeon. What he did was unnecessary, and look at the harm he did.

People are all 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.

This is what one of our members, TortiTabby, experienced:

(Just so you know, ADL means Activities of Daily Living.)

“At my six week appointment this is what my OS wrote in my visit summary: "She reads an online website called Bone Smart which states to not push through pain following knee replacement. If she were to follow this direction, she will have to learn to live with a knee that only reaches to 85 degrees of flexion. I believe this website is very misleading."
It has now been 20 weeks and all I do is ADL and this is what my ROM has done:
3.5 wks: 75
6 wks: 85
7 wks: 90
10.5 wks: 95
14 wks: 100
17 wks: 105
20 weeks (where I am today): 110
I am so thrilled it keeps improving and improving and I know now that I will get to my goal of 120 (or even better, dare I say!)
So, if a OS or PT bullies you into thinking your ROM will not improve over time they are wrong. By the way, I haven't been back to see the OS since that horrible appointment at 6 weeks, but I sure am going back when I reach 120 just to say, "Ha! You were wrong, BoneSmart was right!" “

And,

“Just an update for those who are apprehensive about gaining ROM:
It has now been 26 weeks and all I do is ADL and this is what my ROM has done:
3.5 wks: 75
6 wks: 85
7 wks: 90
10.5 wks: 95
14 wks: 100
17 wks: 105
20 weeks: 110
26 weeks (where I am today): 120!!!
I did it! My goal of 120! No "pushing through pain", no PT after the first 3 visits, and most importantly to me: No MUA! My surgeon who said I would never get beyond 85 ROM without pushing through pain was wrong, wrong, wrong. I'm excited to see if it gets even better. “

 

[beesknee]

Sorry you are having a tough time. I would listen to your doctor and start doing some PT. Maybe request your PT be as gentle as possible.

The only actual research I found that points toward PT not making much of a difference after 3 months was a very small study done by splitting 45 PKR patients into two groups.

What is the effect of supervised rehabilitation regime vs. self-management instruction following unicompartmental knee arthroplasty? – a pilot study in two cohorts - Journal of Experimental Orthopaedics

Purpose The optimal rehabilitation strategy after a unicompartmental knee arthroplasty (UKA) is unclear. This study aims to compare the effect of transitioning from a supervised to a self-management rehabilitation regime by pilot study of patient outcomes subsequent to UKA surgery. Methods Fifty...

jeo-esska.springeropen.com

 

[Jockette]

Tears flowing here.....feel so behind.

You are not “behind” at all. We are all different. While specific PT does work for some, for others, it is not the best option. Each surgery is different, even on the same person, so what worked for your other knee is no guarantee that the same protocol will work for this one. This is why we say listen to your body. Your body has clearly told you that the PT you had in June did not work for you. By taking charge of your recovery the way you did when you stopped going, your body improved.

And now, you have a huge setback to recover from, since your surgeon did what he did to you.

Some of us do better allowing our knee to heal first, before adding “exercises.” There are no rules for this, how we cover is our own decision. It’s your knee, not your surgeon’s, not your PT’s.

My surgeon and PTs did a similar thing with me at my checkups and appointments, and I will never allow that again, there is no need for them to force our ROM like that.

. He had said he would be interested to see any research to prove that PT in the first weeks is incorrect.

It’s not a matter of being correct or not. It’s a matter of personal opinion of how to rehab your knee. There are many opinions, and your opinion about your recovery is the most important. Do what you feel is right for you.

I will repeat:
People are all 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.

 

[Jockette]

Here is another example of a different opinion about this rehab:

Busy day to start week 10 of recovery back at work after Covid isolation started at 7:00 am. Physio appointment at 11: 00 am my physio nurse is just like Bonesmart didn't even do any physio just talked and discussed my knee. She was pleased with my progress and asked me to continue with gentle physio or just going to work is enough for my young knee. I explained how much this forum has helped me so much physically and emotionally and she was fascinated and agreed that the advice given makes a lot of sense. Her parting words were listen to your knee it will tell you when it is not happy.

There is no right or wrong, choose what works for you. We all get to the end of this recovery, one way or another.

 

[Powerhouse]

That is what is working for me....doing it on my own. But the pressure to do aggressive PT is intense....makes me feel like a wimp or lazy if I don't do what they say.

 

[Moone]

Lots of good advice here and fully understand feeling conflicted. One of my physio said I was 'way behind' and should be up walking already. Which made me feel horrible, push too hard and am now anxious and worse off. My surgeon is great. His advice was to give it time, all people are different, do what you can and above all be kind to yourself. I think am thinking a little may go a long way and we are all different. I am horrified to think of someone else forcing you to move!!! That sounds wrong(and painful) on so many levels! Do what you can, and you should set the limit and push when you can - I would not go back to them. I feel you could do better on your own. Best of luck

 

[Powerhouse]

Thank you all...for your support......means so much to me, gets my head on straight!!

 

[Jockette]

makes me feel like a wimp or lazy if I don't do what they say.

I felt like this, too, until they hurt me too many times. Now I‘ll do it my way.

 

[Jamie]

@Powerhouse .... good for you for listening to your own body and going with what works for you. Some people can recover with aggressive therapy, but in my 13 years of working with patients here on BoneSmart, I can tell you that a majority of the people we've seen do much better by exercising just to the point of mild discomfort and not tear-inducing pain. I talk with many surgeons and therapists, all of whom support this BoneSmart philosophy. You just happen to have one of the surgeons who doesn't. Unfortunately there are a lot of them still.

I know people would like to think medicine is a science with definitive answers for everything, but it's not. Especially with joint replacements, there is no "one size fits all" recovery plan. Each person is unique going into surgery and unique in recovery on the other side. A good surgeon or therapist will listen to their patient's feedback and respond appropriately for what they are experiencing. No one is claiming that therapy won't hurt. But, as you well know, there is a huge difference between that point during movement where you just begin to experience pain and pushing way past it.

PS... I sent him link to BoneSmart.org as well as the TKR post-op recommendations. He had said he would be interested to see any research to prove that PT in the first weeks is incorrect.

I take issue with this comment from your surgeon. BoneSmart does not tell people to never do any PT in the early days following surgery. What we tell people is just what I've written above. Start activity and therapy slowly and never push beyond mild discomfort as you're bending and stretching your new knee. Very gradually increase any activity or exercise so that you are not experiencing any pain or swelling in the 24-48 hours afterwards. If you do get increased pain or swelling, back off because your knee is not ready for that level of activity quite yet. Your knee does need motion frequently each day to stay mobile. But that can be walking about your home for 5-10 minutes every couple of hours along with gentle bends and stretches. There is plenty of time to advance slowly to more exercise such as an exercise bike or walking outdoors or physical therapy exercises.

Please don't feel guilty about following the path in recovery that is working best for you. We read a lot of medical studies and frankly, you can find material that supports aggressive therapy and also studies than don't. Patients must trust their own judgement when dealing with pain. You have found a definite cause and effect situation and you're going with what is working best for you. That is good.

I'm always a bit aggravated at medical professionals who are quick to assume when a patient questions therapy that involves excruciating pain that they are trying to get out of therapy and exercising their new knee. My experience with people is just the opposite. No one wants to just lie around all the time after surgery. They are eager to get their lives back, but they want to do so in a reasonable way that doesn't involve increased pain and swelling.

Hang in there and keep doing what is working. We're here to support you in your choices and to address any concerns you may have. Don't hesitate to post whenever you need a boost.

 

[Powerhouse]

Hang in there and keep doing what is working. We're here to support you in your choices and to address any concerns you may have. Don't hesitate to post whenever you need a boost.

Thank you so much for this informative, detailed & caring reply..... I'm just ready to turn off the light to to sleep and saw this. I will sleep with greater peace in my heart as to "doing it my way"...like Frank Sinatra says.

 

[Jamie]

I'm glad you feel more confident and relaxed now. Sweet dreams!

 

[BBCG]

Hi Powerhouse, I’ve been reading through your journey and am also applauding your efforts to do what’s right for YOUR new baby knee, as others here are as well! I am so sorry to hear your doctor is a bully and pushed your leg like he did! My doctor would never have done such a thing! Ever!

So, I just want you to know that your intuition to be gentler to your new baby knee is something another 2-TKR Bonesmartie agrees with. My two surgeries ended up being very different, and I was so fortunate to find Bonesmart when I was having so much pain after TKR #1! This time (#2 TKR was 13.5 weeks ago) I did it the Bonesmart way and the entire process has been light-years better! I have greater ROM with this knee than the last one, better extension too. The Bonesmart way does work, beautifully, and with far less pain, maybe just merely at the discomfort stage now.

 

[Ginger1210]

Hi Powerhouse this forum may not be medically proven but i wholeheartedly believe in, experience and empathy the people and advisors on here have basically been there and done that and have the T shirt to prove it. Surgeons and physio`s are great and very skilled and educated but i wonder if they would advocate the recommendations they suggest if they have had a similar operation??
Your body heals at a different rate to anybody else every recovery is unique. Having a source of experience on this forum helps you make educated and sensible decisions regarding your unique knee. My neighbor has had two new knees over the last ten years both done by the same surgeon. The right knee took 4 months to recover the left took a full year, doing the same physio. This is the beautiful but frustrating thing about the human body.

 

[kneeper]

That is what is working for me....doing it on my own. But the pressure to do aggressive PT is intense....makes me feel like a wimp or lazy if I don't do what they say.

That's how I gave myself tendonitis with my first knee when one PT pressured me to do squats (against my better judgment .) It took a long time to settle down.
With knee #2 I resisted squats but did do other exercises they suggested (while also using my judgment). Maybe they wanted me to do x number of repetitions of an exercise and I could tell as I was doing them that I couldn't quite make that many. I'd just say something like "that's all for today, we can try again next time." And they were ok with that. And I did try again.

My other PTs encouraged me to challenge myself a bit, which was ok, but also gave me a good piece of advice. If you hurt for more than an hour after an exercise session, do a bit less the next time.

A knee that is very swollen isn't going to bend to some magic number no matter how much you try. My PT with my second knee seemed to understand that--they had me focus on ice, but also to move gently in the early days. It won't be painless but it shouldn't be agony. I don't think anyone here ever said TKR recovery would be painless.

Docs are understandably distrustful of the internet (there is a lot of bad advice out there). Most of us don't bother trying to mention Bonesmart. We just do what is working for us.

As Jamie said, we don't encourage people to lie around like a lump--just to avoid the "boot camp" approach.

Keep plugging away and trust your instincts. The knee will tell you what's working.

 

[Powerhouse]

Thanks again for all the support and advice!

I sure am enjoying this do it yourself physical therapy.... I am doing it deliberately yet with wisdom. Some discomfort (good hurt), zero pain. No pain meds for three days, except Advil.

Sunday I was able to do 5 full rotations on the recumbent bike, today I did 10! For 3 days I have been able to walk up the stairs normally (not one step at a time).

Interspersed with quad strengthening, hamstring stretching & a few other exercises......then ice, elevation & rest...it feels like I'm finally making progress in a good way, not being tortured!!

 

[Jamie]

Great to hear that you're making progress. Keep up the good work.