TKR ROM issues

[JusticeRider]

Hi @skiforever , it probably seems like forever, but at 4 or 5 months out, you’re still early in the healing process. I would have LOVED to have 105 degrees of flexion at 4-5 months out! You may still have swelling, if not on the outside, then on the inside of the joint capsule. That will limit your bend.

Mine didn’t come easy, but the thing that helped most for me (besides ice, elevation, and a gradual progression of activity and walking) was the stationary bike. I did and still do pedal every single day without fail for about 20 minutes. I started out at 2 minutes and gradually worked my way up. I started out with the seat raised up high and gradually lowered it as it became more comfortable.

For me, the progression was very slow, but it certainly isn’t that way for everyone. I just want to emphasize, I used the bike as a stretching aid for my knee. I used no resistance and didn’t try to pedal fast. I did not use it as a cardio workout, I used as a tool to increase ROM. And I never pushed to pain or even real discomfort. Just to where it felt challenging (tight).

Do you have a stationary bike, or can you get one? I never would have gotten as much improvement as I did without mine.

 

[skiforever]

Thanks, JusticeRider.

I do have and use a stationary bike. I start with the seat very high and try to get my foot flat (heel down) going around. If I can, after a while I lower the seat. The bike has a heavy flywheel and is very scary to use with no resistance. I set a small resistance, what feels controllable.

 

[EalingGran]

Are there other thoughts on gaining ROM, especially when it makes the whole leg hurt for a long time afterward?

Just do the gentle pilates exercises and the tummy lying extension stretch in small regular doses and try gentle self massage afterwards. I also used icing with an Aircast Cryocuff up until about 9 months- for basically as long as I had any pain and tightness. I know there is now some debate about prolonged icing but my body liked it and it seemed helpful.

 

[skiforever]

For the month of October I did not do anything for ROM. That was great because it allowed me to do a pain free week of cold water diving and some hiking at the northern end of Vancouver Island.

For November I am working on ROM and suffering the continuous pain it causes me. Going from bending work to straightening and visa versa is quite painful. When I was going to PT they seemed to be surprised at that. Does anyone else experience that?

I decided to work the bike by pedaling back and forth in the most bent part of the peddling circle. When that works comfortably I make the whole circle. The first full circle does not feel good, but then it is ok.

My flexion is about 105-110. I want to be able to get on the bike with the seat low at the start and not have pain. I think that requires about 115 degrees flexion.

 

[sistersinhim]

For the month of October I did not do anything for ROM. That was great because it allowed me to do a pain free week of cold water diving and some hiking at the northern end of Vancouver Island.

Fantastic! Doing the things we love to do is why we had this TKR.

For November I am working on ROM and suffering the continuous pain it causes me. Going from bending work to straightening and visa versa is quite painful. When I was going to PT they seemed to be surprised at that. Does anyone else experience that?

Why are you working on ROM when your function has already proven to be quite good? Now, you are having pain when last month you were pain-free. You are 1/3 of the way healed and are doing quite well for this short time out.

 

[skiforever]

@sistersinhim
There are two reasons to work on ROM. One, the flexion, is to be able to pedal a bike pain free, as mentioned in my post. The other, the straightening, is to be able to straighten my leg in bed for a better sleep position.

Otherwise I am not sure why the leg should be straight. Walking/hiking with the current 5-10 degrees off straight seems to work just fine.

Can anyone tell me why the ID part of my posts do not include my age? It seems to be there for everyone else. Age does not determine outcomes but it is relevant. I am older than most participants.

 

[sistersinhim]

Can anyone tell me why the ID part of my posts do not include my age? It seems to be there for everyone else. Age does not determine outcomes but it is relevant. I am older than most participants.

You can check your personal settings to see if you have checked to not have it shown.

There are two reasons to work on ROM. One, the flexion, is to be able to pedal a bike pain free, as mentioned in my post. The other, the straightening, is to be able to straighten my leg in bed for a better sleep position.

But, that will come naturally without your having to go through pain like you are now. The more you push your bend to pain, the more you inflame your knee. That means you will have more swelling. When the swelling goes down your bend will go up.

 

[skiforever]

But, that will come naturally without your having to go through pain like you are now. The more you push your bend to pain, the more you inflame your knee. That means you will have more swelling. When the swelling goes down your bend will go up.

I have not seen any improvement in 3 months, in fact it has become stiffer. It hurts to go downstairs now and to put on shoes is almost out of my reach. I think I cannot just let it be or I will not be able to do a lot of things.

I think the key issue is whether it is healed enough for me to work it. The swelling is not much, but it is a little bigger than my other knee. If it does not seem to be improving this month I will probably skip ROM work next month.

 

[mendogal]

When I joined I had to add my birthdate for my age to show. The birthdate is NOT displayed on your profile.

 

[sistersinhim]

You might see swelling on the outside of your knee, but you certainly have it inside and there is very little space in that small knee capsule area. Just a little bit of fluid will cause restriction in your knee's movement. I think you have a good idea to back off of the exercises next month if you don't improve this month.

 

[Fluttershy]

@sistersinhim
There are two reasons to work on ROM. One, the flexion, is to be able to pedal a bike pain free, as mentioned in my post. The other, the straightening, is to be able to straighten my leg in bed for a better sleep position.

Otherwise I am not sure why the leg should be straight. Walking/hiking with the current 5-10 degrees off straight seems to work just fine.

Can anyone tell me why the ID part of my posts do not include my age? It seems to be there for everyone else. Age does not determine outcomes but it is relevant. I am older than most participants.

@skiforever you are an absolute inspiration!
And I absolutely agree on the importance of ROM. It is so critical for function. Of course every person has a different number for their own needs. Maybe some are happy with 100, but not me! I appreciate the joy from the freedom of riding a mountain bike and this is why I stopped all other activity to focus 100% on ROM. I couldn’t pedal a normal bike and it devastated me. I knew I could work on walking and strength any time, but ROM was urgent for me. Without it I couldn’t progress what I wanted to do.

And a good prescription strength knee compression sleeve and compression socks helped swelling immensely. And ice and elevation of course.

Yes, stretches hurt. Yes I had pain after and wouid ice and elevate. Yes I have been a hermit. But I’m pushing close to130-135 max, and easyto125. I was only 70 at 2 weeks. I had been on the fast track to stiffness thinking I had time to let it happen without hurting myself. Some people have won the genetics lottery and may not grow scar tissue as rapidly as others. But me - I have to fight it constantly. Every day I didn’t push, was a day stiffer. Every morning after stretching to the limit, I still stiffened up, but then would get that little bit more by end of day. I gained at a rate of 2 degrees per day because I was so dedicated to hours of total stretch time daily.

For people with shorter legs, the ROM needed to ride a bike comfortable is actually closer to 120-125. This is because the bike industry seems to think one size fits all for crank length. A 6 foot tall person gets a bike with 170-175mm cranks. My 5’5” statue - 170mm cranks on my size small Mtn bike. Our leg lengths are inches different, yet the crank length only a half cm difference…which means I need more bend than a longer legged person to ride a typical bike. I also need flexion to get up after a fall skiing, maintain a yoga practise for spine health, etc.

I hope I don’t get my post here edited or deleted for saying all this - as it may not jive with all of the Bonesmart philosophy. I just wanted you to know I understand how important ROM is to you. Basically the advice I followed says:
1. Stretch at your end range limit (the stuff in between will not increase ROM, just maintain it). It involves getting a bit uncomfortable and holding it (But not torture as it just makes the muscles contract and fight back!). He says the short painful stuff does nothing because of this. But everyone has a different definition of pain. I was about 6-7/10 pain while stretching. I would push to 9/10 at the end just to see if the tissues would let go a wee bit more. I was 1-2 the rest of day.
2. The longer the duration, the greater the benefit, and very important to stay relaxed. I get my iPad ready with a video, then park myself and slowly work into a long stretch, trying various positions to target feeling it different area. We are talking 5-10 minutes or more…..for a combined total stretch time of at least an hour per day. By the end I wouid feel a “crackle” and tingling in my knee tissues, and knew I was succeeding at lengthening the tissues.
3. Your body will want to rebound back to tightness, so in between the long stretches, keep doing short stretches frequently. Every opportunity to stretch, do so, eg while sitting on toilet, standing at counters, etc.
4. Give up strength training, and reduce time on feet for a while. Strength training and exercises like paddleboarding etc will tighten up and tone muscles (which of course has its place -just not yet), and cause a temporary loss of range if inadequate time given to stretching. This is also to reduce pain and swelling. I have learned I cannot do it all! Since flexion has a window of “best” opportunity (meaning the most rapid gains happen earlier, not to say you can’t make gains later), I made ROM my first priority before moving onto strength and fun stuff.…

Because ultimately the ROM was key to me ever having hope to ride a normal bike again. ROM was key to my quality of life. You can increase ROM if you dedicate yourself to it and probably temporarily give up other things. You have probably read enough stories here to see how people can struggle trying to do it all, then double swelling because of double the knee stress. My body could cope with the after effects of stretching because I cut out the other stuff, driving, walking, dishes, strength, cooking, etc…just did the bare minimum.

As for extension, If both knees don’t extend equally, this creates a functional leg length difference, and will lead to body imbalances such as rotated or tilted hips to compensate. And a straight leg can “rest” whereas a constant bend makes quads work harder. Some lucky people can get away with this without ever having back or hip pain. Not me. I need body symmetry. My extension still sucks but at least I am pedalling a normal bike on a turbo trainer!

 

[skiforever]

@Fluttershy
Thanks for your reply. It will take me a bit of time to assimilate all that you have said. Is it too late to get good ROM if my surgery was 5 months ago?

That is interesting about leg vs crank length. I have had trouble peddling after knee replacements while my husband who has much longer legs has not. I never understood that.

 

[Fluttershy]

I don’t think it is too late at all! You made great progress on strength, so clearly your body tissues have the ability to adapt. Anyone at any stage can benefit from flexibility training done properly. All OS’s will say that the fastest rate of gains occur earlier in healing. But as many stories here suggest, ROM gains can still be made later. The rate just might be slower.

I won’t sugarcoat - I did push myself to the point of high pain that made me cry sometimes. But ….and big but….ROM was my sole focus as I was so far behind and knew it was critical to my quality of life to catch up. I probably could have backed off the intensity/pain but I would not have been happy as I wanted to gain a whopping 60 degrees total in a short period of time (4 weeks). Someone who only needs another 10 degrees might not need such intensity. I’m an endurance athlete and am used to some pain…and then recovery. I expected the tissues to react to the micro-tears..and so I planned to do nothing else that would make me swell. That way there was no confusion, wondering “gee did that long walk hurt me…or was it the stretching?”

I iced lots after. And I alternated hard and easy days to give the tissue time to recover. And watched closely for signs the next day I overdid it (Same day pain is normal).

You can still improve, assuming all is well with your prosthetic knee. I can tell you are a strong woman. With more flexion the result should be an easier time descending stairs and pedalling that bike. It wasn’t until I got past 120 that pedalling my bike wasn’t painful. I’m not strong enough to descend stairs well but that will come now that I have the pre-requisite flexibility. My quads are finally starting to relax and wake up.

Caveat: best to of course first seek advice from your OS to ensure everything in your joint is ok, eg no loosening, etc. I just shared an example of how I rapidly increased ROM to get enough to ride my bike, etc.

 

[sistersinhim]

@Fluttershy, I see you do not have your own thread. How about starting one and tell us all about yourself and your surgeries?

Is it too late to get good ROM if my surgery was 5 months ago?

It's never too late to gain ROM, bend and extension. We've had members even gain it into their third year. Even losing weight, and making your legs smaller, can improve that bend. I lost 20 pounds and my bend improved 10 degrees two years ago, 5 years after my TKR! Some people swell longer than others and that causes their ROM to be smaller than others. So there are many reasons why we say it's a time and swelling thing that affects our bend.

 

[skiforever]

@sistersinhim @Fluttershy
I read a lot on Bonesmart about people gaining ROM but usually they do not tell how they do it. Sometimes it is with a 3rd party and sounds very involved. ADL is not producing any improvement at all. Stretching is something I can do; I will try to increase the time. Earlier the pain on long stretches (over a minute) was too intense for me. The pain typically was not in my knee; the most pain is in my ankle (and some other parts) and lasts for days after trying to stretch; it scares me. I think bending the leg pinches a nerve that goes to my foot. Losing weight is not an option; I struggle to keep what little weight I have; very little is fat.

I am working on ROM with bike pedaling and going down stairs for bend, seated lean with leg push and walking long strides for straight. I experience significant pain in the knee at night. It does not hurt at quiet times during the day. I think that this pain is due to the ROM work.

 

[sistersinhim]

I read a lot on Bonesmart about people gaining ROM but usually they do not tell how they do it.

I did nothing but ADL, but they must not be working for you. Are you seeing swelling? That is what normally restricts the bend. It won't hurt to increase your icing and elevating. It's worth a try.

 

[Fluttershy]

@sistersinhim @Fluttershy
I read a lot on Bonesmart about people gaining ROM but usually they do not tell how they do it. Sometimes it is with a 3rd party and sounds very involved. ADL is not producing any improvement at all. Stretching is something I can do; I will try to increase the time. Earlier the pain on long stretches (over a minute) was too intense for me. The pain typically was not in my knee; the most pain is in my ankle (and some other parts) and lasts for days after trying to stretch; it scares me. I think bending the leg pinches a nerve that goes to my foot. Losing weight is not an option; I struggle to keep what little weight I have; very little is fat.

I am working on ROM with bike pedaling and going down stairs for bend, seated lean with leg push and walking long strides for straight. I experience significant pain in the knee at night. It does not hurt at quiet times during the day. I think that this pain is due to the ROM work.

I’m very sorry to hear about your ankle pain after knee stretches. What does your OS or PT say about that? Mine say to not forget about ankle strength and flexibility when rehabbing a knee. My PT says it is not uncommon for hips and ankles to start acting up at some point as they tend to compensate for lack of full knee movement. On the bike is especially where I feel my ankles, because the pedalling involves more ankle movement compared to walking. I sometimes feel pressure through my ankle when using the bike to stretch.

It would be nice if you could try a bike with shorter cranks to see if cycling can be comfortable for you. Stationary bikes often have shorter cranks - which I believe is one reason why the internet can give such a varying opinions about how much knee bend is needed to ride a bike. I remember reading 90 and thought that couldn’t be right as I wasn’t even close to turning a pedal around full revolution when I hit 90! Same thing with the numbers they give for going down stairs - so much depends on how much the hips/back/ankle are bending too.

One of my most productive knee bending stretches I used didn’t involve any pressure through the ankle (unlike a lunge or bike stretch). I would lie on my back on a sofa or bed, pull my thigh up to bend my hip (I’m flexible in hips). Then reach with hands to grab my thigh and upper calf to give the right amount of support while I felt a stretch in front of knee. If it was pinchy in behind knee, I adjusted my legs until I didn’t feel the pinchy feeling. I would play around with it, sometimes adding support from a pillow or even hanging knee over the sofa arm. Once I found a position I could relax in I let it hang. I found that I had to start easy (no pain or pressure to start), and only after relaxed in the quads could I start to let it go bit by bit until I felt it at the end range. Then I held it there as long as I could. Sometimes it was only a minute or 2. But on a good day I could do 5-10 min. Getting out of it was hard - had to ease back out also. Then ice/elevate after. I still need ice at night but I’m only 6 weeks in.

I would think that pain in other body parts lasting for days after stretching would make anyone want a break from it! If playing around with your stretch technique to reduce pain elsewhere doesn’t help, if it were me, I would want my surgeon to advise me on why this could be happening, and hopefully provide some helpful advice.

 

[skiforever]

@Fluttershy
The ankle pain is not as bad as early in my recovery, so mostly ignoring it works. No one has been willing to comment on it. I think a work-up by a nerve/pain specialist is the only way to get more information.

I have many bikes - multiple stationary bikes, mountain bikes, road bikes, even an electric commuter gravel bike that has been my go-to for outside riding during recovery. I will be measuring them!

Tonight I was riding a Peloton and measured the crank at 17.5 cm. I go back and forth through the high bend zone until the knee settles down, then ride normally. I have to keep thinking "Keep the heel down", but it is working.

One more reason to get the extension to fully straight is to make getting out of bed easier. That is a daily struggle. I really want to be able to sleep with a straight leg, at least some of the time. Currently it is bent far too much.

 

[EalingGran]

I’m very sorry to hear about your ankle pain after knee stretches. What does your OS or PT say about that? Mine say to not forget about ankle strength and flexibility when rehabbing a knee. My PT says it is not uncommon for hips and ankles to start acting up

A good exercise for ankle/ calf strength is to stand a short distance from a door or wall with your finger tips lightly resting on it. You can also hold on the back of a chair if balance is a struggle.
Then raise up on your toes and hold for a few seconds. My pilates teacher noticed after a few months that although my glute and quad strength was very good, that my operated side calf was noticeably thinner and weaker still. It is easy to get preoccupied with one's focus on the knee and ignore the lower and upper leg and core work. Any imbalance can give trouble.

 

[skiforever]

Wow! Now I remember why I have not been doing ROM work for the past 4 months. Yesterday I spent maybe 10-12 minutes doing flexion on bike, seated strightening stretch, and Fluttershy's lifted bent leg exercises. I paid the price. I woke up in pain from my knee and leg. Today I have increasing pain as the day continues. My whole leg hurts, including the knee and the ankle - now all the way into my foot. Why do I get this kind of response?

I wish I could get feedback on other's experiences with ROM work. Renaming my thread "ROM issues" or something like that might help a lot. I have no interest in building strength (current thread ID). Strength came back without effort.