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TKR Range of Motion decreasing<

Justine-S

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Hi, I am at 7 weeks TKR left knee. Everything went really well, I had virtually no pain and was off all meds 2 days after discharge from hospital. Because it was over the Christmas and New Year period they made me take a passive motion machine home and use it for 4 hours a day. I got up to 102º on that.

Started physiotherapy 3 weeks ago. I saw my surgeon last week on Thursday and he was not at all happy with my range of motion. I can straighten the leg perfectly but bending is really difficult and painful. I have done all exercises they gave me (which were not enough IMO) plus other exercises at home. I am swimming every day and walk a lot. He threatened me with an MUA in 6 weeks if it doesn't improve and instructed the physio to force me more.

After Thursday's session I could hardly walk on Friday. On Saturday I did a lot of exercises, walked and swam and felt like it had improved slightly. On Sunday I could barely walk again, was in agony (whole body) and could barely bend my knee at all.

I just don't know what to do anymore, who to listen to. Terrified of going to physio this afternoon. I don't want to do any exercises as everything hurts. I have done everything they told me and the knee is just not co-operating. I am exhausted and feel like I'm on the verge of a nervous breakdown. The pain is so excruciating when I do the bending exercises that I just don't feel like it can be right. Surely it is my body telling me to stop? But if I don't do them the ROM does not improve either.

Anyone else been here or have any advice? Thanks!

Justine
 

Jaycey

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@Justine-S Big Tip - skip the PT today and every other day. Your knee is very angry at all this "forcing". And letting anyone force it more is just going to add to the problem.

Are you icing and elevating your op leg? I would start with getting that swelling under control. And BTW - no one should be threatening you with anything. It's your body and no, you do not need MUA.

Here's our knee recovery guidelines. It's not too late to get back on track with this recovery:

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

5. At week 4 and after you should follow this 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.
 

Jockette

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Hi, Justine, Welcome to Bonesmart!

I agree with Jaycey, all the exercises and activities you are doing are causing and maintaining and increasing your swelling which prevents the knee from bending. It just shocks me that surgeons and physical therapists can’t understand that.

All your pain is indeed telling you to stop.

My physical therapists forced my knee to a painful place also, so I know how you feel.

What I’ve learned from Bonesmart is this:

It’s not exercising that gets our range of motion back, it’s Time:

Time to recover.
Time for pain and swelling to settle.
Time to heal.

Our range of motion is right there all
along just waiting for that to happen so it can show itself.

In the general run of things, it doesn't need to be fought for, worked hard for or worried about. It will happen. Exercise as in strength training is counter-productive and in the early weeks does more harm than good. Normal activity is the key to success.

I am going to tag @Josephine
our forum administrator and nurse director to address your concerns.
 

Roy Gardiner

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He threatened me with a MUA in 6 weeks
Threaten him with a punch in the face. It's your knee not his.
On Saturday I did a lot of exercises, walked and swam and felt like it had improved slightly.
Cause...
On Sunday I could barely walk again, was in agony (whole body) and could barely bend my knee at all.
...and effect. Overdoing things will compound your damaged knee.
Terrified of going to physio this afternoon.
:idea: don't go :) :-) (:

The pain is so excruciating when I do the bending exercises that I just don't feel like it can be right. Surely it is my body telling me to stop?
:thumb::thumb::thumb: That's exactly what it is, and you should heed its message. Relax, don't do any painful exercise, watch telly, slow down. Your body will heal!
 

SusieShoes

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Hi @Justine-S and welcome. It sounds like your recovery got off to a good start but then got stopped by aggressive activity, both from PT and all that swimming and walking. You’re right that your body is trying to tell you something. The only way your knee can communicate with you is through pain — more pain or less of it — and all that pain in your knee is telling you it wants you to stop working it so hard.

The key to a sane, successful TKR recovery is “listening to the knee.” Our bodies are wonderful good at healing. Bodies know how to heal. Our mission: help the body. Provide a good healing environment. Lots of rest. Good food. Activity appropriate to what the knee and body need and can do. If you’re doing more than your knee can do right now, it will rebel by swelling more and hurting more.

The pain you’re feeling is coming from that increased swelling, so... just what Jaycey and Jockette said. Rest. Elevate. Ice. Do this a LOT. As the swelling goes down, two things will happen. Your knee will hurt less, and it will bend more.

Take a good week or two off from exercising. Get up, walk to the bathroom. Get yourself a snack. Answer the door and go up or down stairs as needed to do your ordinary daily activities. If you want to, and your knee is agreeable, take a short walk. If your knee tells you later that the walk was too long, next time take a shorter walk.

As you listen to your knee and its daily progress reports — not as sore one day, more pain if you do more exercise — you will learn what is working for your recovery and what is not working yet. What doesn’t work now will be easy later... but you will know it’s too much right now.

Your knee doesn’t need an MUA. You had, and still have when not swollen, a good bend for early recovery. Follow your instincts. You have good ones! :friends:
 

maryo52

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The reason you're confused, I think, is because you've done a lot to promote fitness but each increase in effort results in pain and diminished well being. Well that's the message. You're doing too much. When you follow the advice to take a break from exercises, notice what happens. In so doing you'll give the traumatized tissues around your knee a chance to mend. You'll see.

During my 2010/11 I was pushed by PT and ended up with a lot of issues. This time I was told that if anything resulted in more swelling and pain, to back off and ice/elevate.
 

rustic

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I also lost ROM between weeks 6 and 8, due to PT being too vigorous. I had a great 6 week follow up with my OS, but went downhill after that. Classic sequence: pain goes down a notch, feel like doing more, .. do too much, lose ROM, get discouraged.
At 8 weeks, I felt like I was back at 4 weeks, but it was temporary. I had a couple weeks off of PT during the holidays, had extra rest due to getting a cold, and "came back out of the gate" with a new PT (just once a week) for the new year. He had totally different methods, caused no pain, and I look forward to the sessions. I flex above 130 most days now.
 
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Justine-S

Justine-S

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Thanks for your replies. Maybe I was not very clear about my ROM. It was 102 on the machine but obviously that is being forced. The surgeon reckoned it was 50 when I saw him last Thursday although the physio seemed to think it was more.

My knee is not very swollen and it doesn't swell more after physio. I'm icing and elevating several times a day as well.

I just can't seem to get the bend back and am worried if I don't do what they tell me that it'll be this stiff forever. The worst thing is all the 70 and 80 year olds at the centre are fine with the same treatment, all great ROM and I just don't understand why my body won't work.
 

maryo52

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I know what you mean about 70 and 80 year olds rocking their TKR recovery.

There are two ways of measuring ROM. One is "active" where you let your leg bend itself. The other is "passive" where the machine bends you. The pain and stiffness with bending is normal by the way. Improving that is a slow process.

If you sit on a high surface, will your leg dangle straight down or does it stick out?

And you say your ROM is 102 degrees on the CPM machine (BTW 4 hours is too much to be on that). Just trying to clarify matters here.

I use a CPM machine, but I have it on slow, start at a comfortable ROM, and increase every round or two by a degree or two. And the last part is not to stop when the angle it tight but not painful. Does this make sense to you? This takes me 30-45 minutes no more than twice a day. Just a suggestion.
 

Celle

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Hi @Justine-S - and :welome:

Please will you tell us the full date of your knee replacement and which knee it is, so we can make a signature for you? Thank you.:flwrysmile:

You poor thing, you've only done what you were told to do, but unfortunately you were given the wrong advice.

The others here are correct. It's not lack of exercise that is preventing you ROM (Range of Motion). Your poor knee is wounded, because of major surgery. It's not lazy or unfit. It needs time and gentle treatment, so it can heal. It doesn't need lots and lots of exercises.

It may not look very swollen externally, but there's only a very small space inside your knee compartment and it doesn't take much extra fluid in there to lock it up.

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 ROM is there right from the start, just waiting for all that to happen, so it can show itself.

So, instead of exercising madly, stop all the exercises and stop going to PT. Instead, concentrate on trying to reduce the swelling in your knee, with lots of rest, ice and elevation. Just let your activities of daily living be your exercise.

I expect you've been told that hoary old myth about a window of opportunity as well. That's also not true.
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

If your surgeon threatens you with an MUA again, say "No, thank you. I'd like to wait a while." There's no time limit on when an MUA can be done, so don't believe it if he tells you that. Having an MUA now will only re-injure your knee and it won't do any good anyway.

This is your knee and your recovery. You are the only one who has the right to say what will happen to it and no one can do anything to your knee without your consent.
Saying no to therapy - am I allowed to?
CONSENT: what it means and how it can be used

Just in case you think I'm talking through a hole in the head and my advice is going to retard your progress, do be aware that not all surgeons and PTs have the same approach as yours.

My surgeon doesn't allow any PT at all for the first month after a knee replacement. He says your knee needs that time, to start on its journey of healing. For that month, we rest, ice and elevate our leg, and walk around the house.
After that month, we just go to PT once every 2 weeks, where we are shown a few new exercises to do at home.
His patients all do well and achieve good ROM, as I did, and he hasn't had to do a manipulation to help with ROM for the past 4 years. I think that speaks for itself.
 

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Just to encourage you,here are a couple of examples from people whose ROM was slow to develop, but continued to improve for a long time.

First, from Campervan. Look what she discovered her ROM was at 6 years post-op.

"I had a slow recovery. Here's my flex measurements at various points:
92 - 8 weeks post op
105 - 10 weeks
107 - 5 months
110 - 6 months
112 - 7 months
116 - 9 months
119 - 11 months
118 - 1 yr
120 - 1yr 2 months
125 - 1 yr 8 months
128 – 6 years "


This one is from bertschb:
I'm 12 months out from my surgery and have some advice based on my experience:
1- Stop going to PT (all it will do is make your knee swell and reduce ROM)
2- Don't worry about your ROM
3- Be patient - VERY patient!!!

Here is my ROM history (more or less):
1 month - 60 degrees
2 months - 80 degrees
3 months - 85 degrees
4 months - 90 degrees
5 months - 90 degrees
6 months - 110 degrees
7 months - 120 degrees
8 months - 125 degrees
9 months - 130 degrees
10 months - 135 degrees
11 months - 140 degrees
12 months - 140 degrees

I spent waaaaay too much time worrying about ROM. I thought I'd be riding my bike a couple months after surgery but it took SIX months! Looking back on my surgery, if I knew then what I know now, I wouldn't have wasted my time with PT and I wouldn't have worried about ROM.

Time is on your side. You may have had a setback now, but this is likely to be only temporary. You have plenty of time to get where you need to be.
Remember that complete recovery from a knee replacement does take a full year. It's a marathon, not a sprint. You'' need gto pace yourself and ha ve plenty of additional patience.
 

Josephine

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Maybe I was not very clear about my ROM. It was 102 on the machine but obviously that is being forced.
An important point of measuring ROM is that only the number you can achieve on your own counts. Never an 'assisted' number.
My knee is not very swollen and it doesn't swell more after physio
I think you're thinking about external swelling but there is internal swelling too which is much more pervasive and will more readily block ROM.

Three things:
1. make sure you read all the articles Jaycey left you earlier

2. please give us your surgery date. It's very important I know that before I can proceed to 3

3. 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?
 
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Justine-S

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Yes, @Josephine , questions are fine!

My date was 18 December 2018 and it’s left knee.

Thx!
 

Josephine

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Here y'go then!

It would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. And don't forget to factor in other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness).

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how swollen is your leg compared to these?
ai63.tinypic.com_eta39s.jpg


4. what is your ROM - that's flexion (bend) and extension (straightness)

5. are you icing your knee at all? If so, how often and for how long?

6. are you elevating your leg. If so how often and for how long?

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

8. are you doing any exercises at home? If so what and how often?
This is the most crucial question so please help me by using the format I have left as an example
(which means please make a list and not an essay!)

Exercises done at home
- how many sessions you do each day
- enter exercise by name then number of repetitions of each
etc., etc.

Anything done at PT
- how many times a week
- enter exercise by name then number of repetitions of each
etc., etc.
 
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Justine-S

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Thanks. Here are my answers.
1. Pain = none, 1. Stiffness = 5.

2. On discharge (23/12/18) I was prescribed 600mg Nurofen (every 8 hours if needed), 1g Paracetamol (every 8 hours if needed) and Tramadol in the event of extreme pain. I have a very high pain threshold and have not taken any pain medication since 26/12/18 (except for last night) because I have had no pain.

3. Moderate but most of the swelling is at the back of the knee right now.

4. I don't have numbers for extension. On last appointment (31/1/19) surgeon said it was excellent. Flexion was 50 - physio thinks it is more but they did not measure with an instrument.

5. Yes, icing four times a day, about 25 minutes each time.

6. Yes, elevating several times a day - usually because I start feeling uncomfortable and it helps. Maybe 30 minutes at a time.

7. I live alone so do pretty much everything. Live in an area with everything close by so small shop every day, preparing my own food. I have four cats so feeding and cleaning up after them. I do not do any other cleaning as have a cleaner who does that.

8. I was doing exercises at home but stopped everything after writing this post. I was swimming every day, about 500m. Walking half an hour to an hour.
Exercises: (not sure of proper names)
Ankle circles to warm up
Quad pressing down (on towel) 10 reps
Quads pressing together (with towel) 10 reps
Leg raises on rolled up towel 10 reps
Heel slides 10 reps
One session a day and more often if I remembered or had time.

9. Physio 5x a week.

Monday, Wednesday and Friday
15 mins on passive motion machine at about 75
10 mins on TENS/EMS machine
Quad exercises as above 10 reps each
Raising left leg lying on side 10 reps
Standing against wall and sliding to seated position 10 reps

Tuesdays and Thursdays
All of the above plus session with PT manipulating and massage

Yesterday went very wrong. I don't think they are taking the pain seriously. Have read that this is an issue with women and the medical industry. You are just seen as being that "silly woman" rather than that you are actually in pain. I could barely walk when I came out and struggled to get home. I am going to phone in sick today. Have been in bed since, except to get out this morning and take care of cats, make myself some tea. Feel better now but my leg felt really twisted last night and I had terrible muscle ache in both thighs and buttocks. First time I have taken a painkiller this year.
 

Josephine

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1. Pain = none, 1. Stiffness = 5.
You misunderstand. All those other types of pain ARE pain and not something other than it! So if you say you have stiffness with a score of 5 then that's a pain score of 5 and needs to be treated as such.
2. On discharge (23/12/18) I was prescribed 600mg Nurofen (every 8 hours if needed), 1g Paracetamol (every 8 hours if needed) and Tramadol in the event of extreme pain. I have a very high pain threshold and have not taken any pain medication since 26/12/18 (except for last night) because I have had no pain.
After a TKR? My giddy aunt! I don't care if you do have a high pain threshold, you need more than that!

For one thing. ibuprofen is not very effective as a pain killer, in fact, very inadequate. Paracetamol is probably better but still totally inadequate for a pain score of 5. I suggest you take the Tramadol 50mg with 1g paracetamol 3-4 times a day.
3. Moderate but most of the swelling is at the back of the knee right now.
And did you factor this swelling into your pain score? (Swelling/pain comparisons) Moderate swelling = 4 extra points on the pain score!
4. I don't have numbers for extension. On last appointment (31/1/19) surgeon said it was excellent. Flexion was 50 - physio thinks it is more but they did not measure with an instrument.
So your ROM is 50/? - not very good. You can assess your extension yourself. A good way to check extension yourself is like this:

1. put your leg on a bench, seat, bed, floor or anything similar but preferably something fairly firm.
2. with not too much pressure, press the back of your knee down - use your leg muscles, not your hand!
3. slide your hand, palm down, under the back of your knee
a) if you can get your entire hand under easily, it's probably about +10 degrees
b) if you can get just your fingers under, it's about +5
c) if you can get your fingers under but it's a push, it's 0
d) if you can't get your fingers under at all, it's -5 or more​

Here's a graphic to explain the degrees involved


And I can measure your flexion if you would post a photo of your leg in one of these positions

goniometry-horz.jpg


Please note the bare leg and inclusion of the leg from wait to foot.
5. Yes, icing four times a day, about 25 minutes each time.
You accomplish little or nothing in 25 minutes. Ice for at least 40-60mins and more than 4 times a day.
6. Yes, elevating several times a day - usually because I start feeling uncomfortable and it helps. Maybe 30 minutes at a time.
You accomplish little or nothing in 30 minutes. Elevate when you ice
As for elevating, are you doing it correctly? The rule is 'toes above nose'. Look in this article for instructions Elevation: the do's and dont's
7. I live alone so do pretty much everything. Live in an area with everything close by so small shop every day, preparing my own food. I have four cats so feeding and cleaning up after them. I do not do any other cleaning as have a cleaner who does that.
That's okay!


I was swimming every day, about 500m - about the best exercise you can do but 500m is a bit extreme. I'd suggest no more than 10-15 minutes at a time
Ankle circles to warm up - this is only for blood clot prevention in the first few days after surgery. Now you have been so active, you don't need to do these any more
Quad pressing down (on towel) 10 reps - this tends to increase swelling and does nothing for the extension!
Quads pressing together (with towel) 10 reps - this does the same
Leg raises on rolled up towel 10 reps - another extension exercise which is useless
Heel slides 10 reps - these are not going to improve your flexion
One session a day and more often if I remembered or had time - better yet, try none!

Walking half an hour to an hour - did you read this article Activity progression for TKRs amongst the Recovery Guidelines in post #2 of this thread? You will observe in there that the recommended activities

Weeks 6 and onward - add to all the previous
Start taking car trips to the shops but keep them short and sweet at the start, no longer than 15-20 minutes
Take at least one 5 minute rest while you are out
Activity: a very little ironing, washing, meal prep but get someone else to clear up after. Wash up but someone else clears the table, brings you the dirty dishes, dries and puts them away after



9. Physio 5x a week - I suggest you stop these altogether
Monday, Wednesday and Friday
15 mins on passive motion machine at about 75 - machines aren't going to improve your flexion
10 mins on TENS/EMS machine - this I would adhere to but you can get a little device off Ebay and use it at home. TENS machines for pain management
Quad exercises as above 10 reps each - not the best way to improve your quads!
Raising left leg lying on side 10 reps - also not a good way to get improvement
Standing against wall and sliding to seated position 10 reps - also known as wall slides, not a good exercise

Tuesdays and Thursdays
All of the above plus session with PT manipulating and massage - depends what they do, massage might be okay but not keen on the manipulation

Summary: I suggest you
1. alter your use of pain medication as I have suggested
2. adjust your pattern of icing and elevating as suggested
3. stop your PT sessions and exercises that are crossed out completely
If you are concerned about refusing to do therapy, you need to read this Saying no to therapy - am I allowed to?
 

sistersinhim

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You should never, ever have pain like that during or after PT. Did you read the articles left for you? Therapy is not supposed to hurt. If it does then your recovery is being set back. Tell them you will not be hurt anymore.
 

maryo52

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You are just seen as being that "silly woman" rather than that you are actually in pain.
This is a pet peeve of mine. I notice in old movies how emotional women apologize for "being silly." You are 100% right. I had this happen to me when I had ROM 85 and "they" (PTs) wanted me to improve. They pushed me. It pretty much made resolved to never cross their threshold again in life. Fortunately my current PT is not of that ilk.

I understand how they want to see you improve, but they seem to forget that you want it even more, and pushing you doesn't solve anything but instead will alienate you. OK, rant over.

The other part of this is that making the knee angry IMO is like throwing fertilizer on weeds (adhesions). It is totally counterproductive. See attached article.

So sorry you're in this fix. But we are here, people who have seen many others go through the same thing.
 

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traceys

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Hey @Justine-S :wave:

Wow. Like reading my own thread when I first started this tortuous journey. Growing up athletic felt like I had to do more rehab, go harder, lift more, push further.

About 2mnths ago I got tired of the pain every single time after pt and going backwards. I took 2 wks off and then took on the Bonesmart way and had the talk with my pt about it. I stopped worrying about rom numbers and focused on healing and function. I already know my numbers and how to count. I didn’t know how to use my knee right and do things I hadn’t done in decades.

So mad I waited so long to change my thinking cuz now I’m seeing changes every week. My walk. My movement. My life.

Go easy. If you broke an ankle and were in a cast you wouldn’t be running a marathon 5x a week. Yet you just had 2 bones cut out of your leg and all the muscles pulled everywhere and you are trying to override them. Trust your instincts to let time heal you.

Look forward to seeing how your journey progresses!!
 

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