PKR Reoccurrence of pain after Episealer implant surgery.

[sistersinhim]

PT is still going ok although my knee needs about a 24 - 30 h recovery from it which feels ok for me as long as it helps.

Actually, having to recover from PT is not good PT and sets you back those 24-30 hours. There is probably no need for any more PT or exercises since you are so far out and it might be causing your soft tissue inflammation and pain. I am over 6 years out and if I use my new knee more than normal, I'll have a couple of days of discomfort.

I also have full ROM with is less likely with any Impingement but I am a bit hypermobile so maybe that explains it?

Here's another reason you probably don't need to continue PT. Try a month or so without it and do just normal daily activities and see if your pain lessens. I bet it will!

 

[Celina]

Wow thanks for your informative reply @sistersinhim. That really makes me conflicted about to continue or pause PT. I actually rested from PT for the last 3 months except for 2 or 3 non-weight bearing exercises with machines because I did not want to loose the muscles I worked so hard on to build them up. I do notice my right leg is a few inches slimmer and weaker. If I do any exercises my right leg starts shaking a lot faster than left. I discussed it with my local PT (not my knee rehabilitation PT) and he said that it is good to strenghten but I shouldn't get too much reaction afterwards. So we decided to limit the weight bearing exercises and keep attention on my knees reaction (which was less than last time). I do the weight bearing exercises for 3 weeks now at PT and so far my knee hasn't gone worse or better compared to before. I also mentally really want to continue PT because it feels like it is the only thing I can control to improve my knee besides resting all day. I will pay closer attention to my knees reaction and if necessary pause my PT. Thanks for pointing this out!

 

[EalingGran]

Have a look at pilates. My teacher is excellent. She has loads of free classes on YouTube. Google Katja pilates.
I did a 20 minute side lying no squats or kneeling post injury glute strengthening class most days. It didn't over stress my knee and really helped.

 

[Celina]

@EalingGran Thank you for sharing! I loved the workout. Definetly need to work on my glutes more often, I had a hard time to keep my leg elevated for so long.

My favorite: a seated mini loop workout. Because it is seated there is less pressure on the joint but you still need to bend and extend a lot (with resistance). Just search for seated mini loop workout on youtube.

From next week I am back to aquajogging (holiday break is finally over). My knee reacts to all activities but the reaction to the Pilates routine was pretty mild. I got a referal to another hospital which is more specialised in Sports medicine and therefor I think in the soft tissue of the knee. Waiting for an appointment from them.

 

[Celina]

I did have my sports medicine doctor appointment but I guess I overestimated their specialism. I thought he would know more about the soft tissue in my knee but not really. Over the last few weeks I have developed a painful spot in my knee and a hard lump. The doctor said it was exactly on the joint line indicating that it might be osteoarthritis. My orthopedic surgeon did say that my cartilage at the opposite side of the implant might be thinner than it should be but I really thought (and think) that one spot can't cause this much pain and heat. The lump might be thickened Hoffa's fat pad according to the sports medicine doctor.

I got some perculiar symptoms I can't seem to find on the internet: I would like to know if these sound familair or if anybody can explain them:

- Knee warms up after inactivity, especially while straightened.
- My bad knee can be up to over 2 degree celsius warmer than my good knee. It daily reaches 38 degree celsius.
- Most of the warmth will improve with walking and then later come back when resting again.
- A non-painful hard lump under my kneecap, mostly inner side (location of possible damaged tibia cartilage).

I would like to know if these sound familair or if anybody can explain them.
Thank you in advance

 

[EalingGran]

Sorry to hear this and that you are still having problems.
Heat after rest is very different to my experience. My knee got warmer after exercise and then cooled down with rest.
At 10 months post my PKR the heat difference is pretty marginal now- certainly not 2 degrees. Have the doctors definitely excluded any inflammatory or infection cause? There is a blood test called C reactive protein. It's not expensive. It's raised with infection or inflammation. Mine was raised when I had an unrelated infection a few months after my surgery.

 

[mendogal]

Oh dear.... concerning! If it were me, I'd want some kind of imaging (ultrasound? CT or MRI? I have no idea which) to work towards a diagnosis on the lump esp in presence of the warmth you describe.

 

[Layla]

Hi Celina,
Your best bet is to call your surgeon's office with the concerns you've raised above and go from there.
Since you've experienced symptoms for a few weeks now, it isn't too soon to make contact with your OS's care team, at the very least, for reassurance, or guidance on next steps to take. Wishing you only the best, Celina.
@Celina

 

[Celina]

Thanks for all the replies!

Sorry to hear this and that you are still having problems.
Heat after rest is very different to my experience. My knee got warmer after exercise and then cooled down with rest.
At 10 months post my PKR the heat difference is pretty marginal now- certainly not 2 degrees. Have the doctors definitely excluded any inflammatory or infection cause? There is a blood test called C reactive protein. It's not expensive. It's raised with infection or inflammation. Mine was raised when I had an unrelated infection a few months after my surgery.

@EalingGran I did read that implants can cause warmer than usual knees but indeed that should be during activity and decrease with rest. On the other hand for osteoarthritis I read that it can be the opposite because your knee might increase blood flow to heal. Still I haven't read that it can be this bad. In July I went to my GP to check for Rheuma factors and signs of infection in the blood (including CRP and leukocytes). All was fine.

I am glad to read that your rehabilitation is going well again

Oh dear.... concerning! If it were me, I'd want some kind of imaging (ultrasound? CT or MRI? I have no idea which) to work towards a diagnosis on the lump esp in presence of the warmth you describe.

@mendogal Yes it is very concerning. Especially that I can't find any similar story and that my doctors doesn't know what it is either. I've had x-ray, CT and ultrasound. The ultrasound was at PT and it was from before the lump. At my sports medicine appointment he said it might be thickened Hoffa fat pad but I still don't understand why it happens. I had an MRI but there was too much scattering so you can't see anything useful on it.

Hi Celina,
Your best bet is to call your surgeon's office with the concerns you've raised above and go from there.
Since you've experienced symptoms for a few weeks now, it isn't too soon to make contact with your OS's care team, at the very least, for reassurance, or guidance on next steps to take. Wishing you only the best, Celina.

@Layla My first symptoms started in January 2023 but those were really mild (some pressure and some sharp stings with turning inwards). But over the time they got worse. Since March I am icing my knee and needing aid with sleeping (ice machine). It got worse over time. I've had all possible diagnostics and my orthopedic surgeon said he doesn't know what is wrong either. At my last appointment a month ago they said they didn't want to scope (yet). It feels like either I need to wait for it to get even worse (impair ROM?/ more swelling?) or to wait for a longer time with these symptoms. My doctors are very specialised in cartilage damage and repair. I am thinking about maybe getting a second opinion as it might be something not cartilage related but related to the multiple surgeries? I would like to meet with a "soft tissue expert". I have found one knee-specialised hospital but their waiting time is up to 12 months....

I forgot to mention that the sport medicine specialist also checked the strength of different muscles. He noticed that my right glute is very weak. So I started doing exercises for it. My other muscles are ok. I will go back to my specialised PT on the 19th of Septembre and hope that he might be able to explain my symptoms and hopefully we can work on them.

 

[mendogal]

I agree it's time for second and third opinions to try for a diagnosis and treatment. Hoping you start getting answers soon.

 

[Layla]

I think you’re wise to get a second opinion, Celina, and even a third if necessary as, mendogal, mentioned. I hope you’re able to meet with someone soon that helps you obtain the relief you deserve. Stay in touch, we’re here for you.
@Celina

 

[Celina]

I never knew that using ice would be the reason of my worsening symptoms. After my visit at PT last tuesday, in which he said I might rely on icing too much, I decided to quit the icing completely. And already the next day my knee doesn't get that hot during the day anymore. If you want more information you could look for "Non Freezing Cold Injuries" (NFCI). My knee is now barely warmer than my left knee during the day, even after activity (just 0,5 degree celsius max.). The downside is my knee feels weird, pressure, irritation about all the time. I guess I didn't really feel that anymore due to the heat overruling everything.

Nights are a different story. I do miss my ice machine at night and often wake up multiple times a night with a (very) hot and painful knee. Either the pressure of the blanket or the warmth it gives is aggravating my knee pain at night. I've now borrowed a blanket lifter and it does help to sleep better.

My PT suggested that I would do some neurological testing at a specialised PT. As preparation I've read into nerve pain especially "infrapatellar neuralgia". Symptoms: "an uncomfortable painful sensation at the front and inner side of the knee. Patients complain of severe burning and stabbing pain." This exactly sounds like my pain!

This tuesday I had the neurological testing at pt. I hoped they would do some nerve conduction test but unfortunatly it only was manual testing. I don't have "pain to the touch" of which this PT said it would be expected with nerve pain. She thinks it has something to do with my patella maltracking, caused (partially) by a weak vastus medialis muscle. I think the reason of the weak vastus medialis might be my change in activity and a more lateral walking pattern to prevent pain. It might be good to strenghten my vastus medialis besides my glutes.

I got an appointment with the same pain specialist as who gave me the RFA treatment prior to my implant surgery. It is on the 2nd of Novembre. I will ask for a injection into that nerve to temporary disable it to know if it is the cause of my pain. If it is not the nerve I am still debating if I still want a new RFA treatment as the reason the pain started in January might be that the earlier RFA worn off. I think a new RFA treatment will solve the pain but it doesn't solve the cause which could lead to (further) knee damage.

 

[Nivea]

It’s funny you said that about icing. I know it’s the Bonesmart way, to ice and elevate and fully thought that was what everyone did. I bought an ice machine and wedge so that I could ice and elevate easier, as I am going for 2 TKR. I am 10 weeks out from the first one and getting my 2nd done 10/23. My OS does not believe in icing or elevating, go figure. Back went the ice machine, but kept the wedge as that may be needed down the line.

Take care of yourself. Hopefully the pain management team will be helpful in alleviating your pain.
@Celina

 

[Jamie]

@Nivea Many surgeons do not support the icing we recommend, but our experience over almost 20 years with recovering joint patients has shown that lots of icing helps reduce pain and swelling, which result in less inflammation. It’s certainly possible to recover with no ice or elevation. But using neither of these tools can increase the risk for swelling or pain that makes things more difficult or uncomfortable. You have to find what works for you.

@Celina, if no ice is working for you, that’s great and you should continue with what works. But, I am a bit concerned by your remark about your knee feeling strange. The pressure and irritation you’re feeling are likely due to swelling and inflammation, which is what the ice improves. Heat in a knee, in itself as you’re recovering, is not necessarily a bad thing. Heat is generated during the healing process and it is not abnormal to have one knee warmer than the other.

 

[Nivea]

@Jamie sorry, didn’t mean to sound as though the Bonesmart way was wrong. I agree, find what works for you. In my experience, nobody has heard of no icing or elevating and look at me as though I have 2 heads. Lol.

 

[Jamie]

No worries…..I didn’t take it as though you were questioning our advice. Actually it’s more common than you think for hospitals, and sometimes doctors and therapists, to not understand the need for ice after joint replacement. We just offer our opinion based on experience and our BoneSmart surgeon’s expertise and let patients decide what works best for them.

 

[Celina]

I am sorry for my very late reply. I thought I already had replied. I was trying to focus less on my knee as I had to wait 5 weeks for my next appointment (2 to go now). I can't imagine to recover without using any ice. I definetly needed it especially since I reply bad to the opioids. My ice machine has been wonderful before and just after surgery. I just never thought ice couldn't have any negative impact but it does on my current issue.

@Celina, if no ice is working for you, that’s great and you should continue with what works. But, I am a bit concerned by your remark about your knee feeling strange. The pressure and irritation you’re feeling are likely due to swelling and inflammation, which is what the ice improves. Heat in a knee, in itself as you’re recovering, is not necessarily a bad thing. Heat is generated during the healing process and it is not abnormal to have one knee warmer than the other.

Yes the strange knee feeling isn't normal. It would be good if it is the nerve, meaning my knee mechanism is ok, my Episealer surgery has worked and the slimmer cartilage tibia spot isn't causing problems. My last surgery was 16 months ago so the heat should have been gone. I will update after my appointment. I am so hoping he will do another RFA (radio frequency ablation).

It’s funny you said that about icing. I know it’s the Bonesmart way, to ice and elevate and fully thought that was what everyone did. I bought an ice machine and wedge so that I could ice and elevate easier, as I am going for 2 TKR. I am 10 weeks out from the first one and getting my 2nd done 10/23. My OS does not believe in icing or elevating, go figure. Back went the ice machine, but kept the wedge as that may be needed down the line.

Take care of yourself. Hopefully the pain management team will be helpful in alleviating your pain.
@Celina

I hope you recovered well from your first TKR. Good luck with your second TKR surgery and recovery next week.

 

[Nivea]

Thanks @Celina It’s certainly a roller coaster during recover.

 

[Celina]

Last thursday I had my (pretty short) appointment with the pain specialist. The orthopedic surgeon already requested a nerve block and the pain specialist quickly agreed with it. He said that it is possible that it is saphenous nerve damage. He wants to do the treatment, either RFA or just an injection, in a sterile environment. Understablable, especially with the implant, but unfortunatly that means I need to wait another month (13th of Decembre for the appointment).

I must say that last month was better than the previous month likely to the lower temperature. I even had a few nights without waking up. I've waited so long already I can manage this month as well!

I might be totally pain free around Christmas ^^

 

[Jamie]

Gosh, I sure hope this treatment gives you some relief. Less pain would be a great way to start the new year.