TKR RTKR February 12th Recovery thread

[Alice Nutter]

The operation went fine, and I was back home the next day. I have just re-read the Bonesmart guidelines and have realised that I have been pushing myself too hard with the PT exercises the surgeon prescribed. Hence slightly increased swelling and soreness on this, the fifth day post-op. So I will dial back. I had already decided to drop the bridging exercise she said was the most important - the one where you ice your knee, have your leg straight and your ankle on a chair opposite you, and keep the leg straight for 30 minutes. I never managed 30 minutes, and yesterday, after sweating my way to 17 minutes and feeling like I was going to throw up, I said never again. I find that moving around for 5 minutes or so feels good, as does ice (my ice machine is the best investment ever) , that I quite enjoy gently persuading my knee to flex a little more, and I would rather sleep comfortably with my leg slightly bent and elevated than not sleep with my leg straight as prescribed. Fatigue is real. The "no pain, no gain" mantra is pernicious and pervasive, and my surgeon is very much of that school.

 

[Layla]

Hello and Welcome to recovery, Alice! Thankfully you stopped the madness. The exercise that made you almost vomit was clearly too much. All you need to be doing now is resting, elevating / icing and moving around for few minutes every hour or two. A trip to the kitchen or bathroom normally covers that. Check out the ACTIVITY PROGRESSION FOR TKR under No. 5 below in the Recovery Guidelines.
Glad you're surgery went well! I hope you have a smooth recovery!


KNEE RECOVERY GUIDELINES
(Administrative Note: For those reading here, please be aware that these links are a premium service and only available to Insiders Club Members).

As you begin healing, please keep in mind that each recovery is unique. While the BoneSmart philosophy successfully works for many, there will be exceptions. Between the recommendations found here, your surgeon's recovery protocol and any physical therapy you may engage in, the key is to find what works best for you.

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.

If you want to use something to assist with healing and scar management, BoneSmart recommends hypochlorous solution. Members in the US can purchase ACTIVE Antimicrobial Hydrogel through BoneSmart at a discount. Similar products should be available in the UK and other countries.

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. 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?

Nutrition is of paramount importance. Available here are dietary tips, nutrition basics and additional food supplements. These articles are both general advice on food and specific guidelines aimed at people both pre- and post-surgery.

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.

 

[Jamie]

@Alice Nutter …..I’m so glad you decided to join the Insiders Club so you would have access to those very important Knee Recovery Guideline articles from our BoneSmart Library. It’s easy to overdo things in the early days, especially when a therapist is pushing you to do more (as some tend to do). Since you are seeing swelling, it’s definitely a good idea to scale things back. The number one thing you want to do in the first month or two is to try and avoid inflammation, pain, and swelling. They all tend to feed each other and can slow things down for you in terms of recovery.

The extension exercise you mention can be painful for early knee recovery. It’s okay to do it, but never to the point beyond mild discomfort. If you decide to start it up again, wait until whatever pain and swelling you have now has lessened. Don’t put any weights or ice on your knee when you do it. That just makes it hurt more.

The gentle bends and stretches are best for these early days, so you’re on the right track there. You can do those for short periods of time throughout the day. Again…just do them to the point of mild discomfort, hold for a count of 5, and release. You will get pain if you try to sleep with your leg completely straight. This is why we suggest using the Lounge Doctor. It is scientifically designed to give your legs the slight bend that is best for recovery.

Since your surgeon believes in the “no pain, no gain,” you may have to go your own way with recovery. Don’t worry about any threats of a “window of opportunity” or a Manipulation Under Anesthetic (MUA) that might be given. We have thousands of BoneSmarties who followed our guidelines and did just fine.

We’re here for you! Ask whatever questions come to mind.

 

[Alice Nutter]

Day 16. I am down to Tylenol on an as-needed basis. I am finding it extremely hard to strike the balance between doing enough and doing too much. I live alone so I'm quite active around the house, and I do the prescribed exercises at least twice a day and most days three times. The swelling, which is entirely around my knee, is stubbornly resisting, in spite of icing a lot and serious elevating for at least two hours a day (ie flat on my back with my leg up on a wedge pillow). I can't find any correspondence between what I do or don't do and when it goes down by a centimetre or up by a centimetre. My ROM has diminished as the swelling increased, which it started to do on around day 7; I was doing quite well with flexion by then (116) but now it has gone down to 106 and my quads SCREAM when I try to push it. My other problem has from the start been the bridging exercise, where you have your butt on one chair and your heel on another and let gravity stretch the back of the knee. I was told to do it for at least 30 minutes, and the most I have managed has been 15 by which time I thought I was going to throw up, the pain was so great. I hadn't been able to get my knee flat on the floor for years before surgery, so I suspect everything back there is shortened and requires gentle coaxing, but I don't know how to gently coax it. I have quite high pain tolerance, and am quite determined, but this exercise has been simply too much for me. Does anyone have any ideas?

 

[Jockette]

Does anyone have any ideas?

Yes, I have several ideas.

I live alone so I'm quite active around the house,

This is what I call “natural PT” and is all you need at this point. It gives your brand new knee all the mobility it needs.

I do the prescribed exercises at least twice a day and most days three times.

There is no need to do these exercises any more than once a day (and none in the weekends) and with all your natural PT that you are doing, you really don’t need these exercises at all. These are the reason your stubborn swelling is resisting all the elevating.

My other problem has from the start been the bridging exercise, where you have your butt on one chair and your heel on another and let gravity stretch the back of the knee. I was told to do it for at least 30 minutes, and the most I have managed has been 15 by which time I thought I was going to throw up, the pain was so great.

Any exercise that causes this much pain can’t possibly be helping. Give your leg some time to heal before doing this again. I never did this exercise and managed just fine without it. Since your leg hasn’t gone flat in years, this exercise is way too aggressive for you at this point. It will take time and gentle treatment, after you have healed for it to possibly help.

At only 16 days post op what you need most is rest, ice, if that helps, and elevation, and very gentle bending motions. You’ll have lots of time later to exercise the way you want to. Right now, less is more.

 

[Alice Nutter]

That is so helpful. I have now re-read my thread and realised that this approach is what you have been advocating all along. It’s just so hard when all the experts and a lot of patients are telling you to do it differently, telling you that if you don’t do it their way you’re doomed. A not-very-helpful gentleman said I must cut way back on all my activities around the house. I said that I am not doing anything at all that doesn’t absolutely have to be done so that I eat and remain clean. Interestingly he did not suggest that I cut back on the exercises…The thing is, certain sorts of movement just feel right - walking around the house, stretching naturally, even a little seesaw on the stationary bike. I would rather incorporate my PT into what I have to do anyway than force myself to do movements that feel unnatural. Does that make sense?

 

[Jockette]

Yes, that makes a lot of sense.

I agree, it’s hard, when there is conflicting advice, especially from our medical teams. So, remember, 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.

Many of our members have cut back on the list of exercises and reported that their pain reduced quite a bit, which helped to not need as much pain medication. A win, win!

 

[mendogal]

@Alice Nutter
At your very early stage of recovery there's no need to worry about extension. For many of us extension lags weeks later than flexion.

Neither extension nor flexion are gained via pain - any increase created by pain is erased by the resulting swelling in a matter of hours because pain is our knee's only way to say NO!

In my experience, extension comes naturally over time via mindfully practicing a good heel to toe gait and via relaxation into very very slow gentle stretching.

Again, this early in recovery I wouldn't worry at all about it.

I agree 100% that you can radically cut back on formal exercises.

 

[Layla]

Down to only Tylenol on an "as needed" basis is progress. Good for you, Alice!

It can be difficult to strike a balance between doing too much, or doing too little as both can cause swelling. It is a trial and error process in finding that sweet spot and it's ever evolving as your body heals, strengthens and is able to endure more. Right now you're still healing from the controlled trauma of major surgery.

It definitely sounds like you were overworking your knee, leading to inflammation and swelling which can reduce your ROM. It creates stiffness making it more difficult to move your knee properly. Balance is key, you need to challenge your knee a bit without overloading it. Reducing the frequency and length of time you spend exercising should help with the swelling as should eliminating aggressive exercise or reps that produced discomfort and pain. Give your knee time to recover after light exercising or activity while icing / elevating.

The thing is, certain sorts of movement just feel right - walking around the house, stretching naturally, even a little seesaw on the stationary bike. I would rather incorporate my PT into what I have to do anyway than force myself to do movements that feel unnatural. Does that make sense?

The movement that feels right is the type of movement you should engage in. Your essential daily tasks, personal care activities, routine daily activities, stretches and seesawing on the stationary bike all the movements that don't cause you discomfort or pain, but keep you mobile without overdoing it.
Take it s-l-o-w and easy. You'll get there!

 

[Jamie]

Since you’re so early in recovery and having pain and swelling, please consider taking your Tylenol on a set schedule until you get this behind you. If you wait until you “need” pain relief, it actually takes more medication to deal with it than if it is already in your system. You can take up to 4000mg of acetaminophen in any 24 hour period and I suggest you start with the maximum 4000mg. That would be 1000mg every 6 hours through the day and night. Be sure you aren’t taking any other medications with acetaminophen in them like cold or sinus medications. Once your pain is decreasing, you could reduce the Tylenol to 1000mg every 8 hours. If you can take NSAIDs, you can also add that to the Tylenol to help with the inflammation.

 

[Alice Nutter]

Thanks Jamie. Yes, I'm still taking the Tylenol regularly, and adding ibuprofen on an as-needed. The pain is considerably less now; it's more a feeling of stiffness and tightness, with on-and-off deep ache. When that's on, I take a couple of ibuprofen. I woke up at 3:00am this morning and had a lightbulb moment. (I always wake up at 3:00am - it's not the knee, it's me). I thought how grateful I am to the surgeon who put a new knee in me, and how grateful I am to Chris, my PT guy, for his advice and expertise. They are experts in their field. And I am expert in the field of me. I had a vision where AI would make it possible to tailor a post-op PT programme to each patient's specific circumstances, taking into consideration their lifestyle, their state of health, their activity levels before surgery, their tolerance of discomfort and yes, their mental health. Just as there is not a one-size-fits-all titanium knee, there isn't really a one-size-fits-all PT approach. The gentleman who told me to 'cut the hell back' on my activity did me a favour. He has found an approach that works for him; I know that if I lay on the couch 22 hours out of 24 I would be incredibly depressed and anxious and that would not work for me.

 

[EalingGran]

already decided to drop the bridging exercise she said was the most important - the one where you ice your knee, have your leg straight and your ankle on a chair opposite you, and keep the leg straight for 30 minutes. I never managed 30 minutes, and yesterday, after sweating my way to 17 minutes and feeling like I was going to throw up, I said never again

That is a crazy exercise for early on.
My extension came back fine without ever doing that.

 

[EalingGran]

The thing is, certain sorts of movement just feel right - walking around the house, stretching naturally, even a little seesaw on the stationary bike. I would rather incorporate my PT into what I have to do anyway than force myself

Doing what feels right is a good approach. My knee loved walking. I gradually built back up to 10,000 steps/ day by going out to coffee shops and taking rests. My knee also liked the seesaw movement. I had a rocking stool left over from my daughter nursing my grandson. I used to sit watching TV with my foot up rocking gently.
I also used pilates for gentle pain-free exercise that developed flexion. Once you are able to get on to the floor again, have a look at my excellent pilates teacher's free classes on YouTube. Google Katja pilates and they come up.

 

[Alice Nutter]

I was going to a Pilates reformer class twice a week for about 3 months before surgery and I can’t wait to get back. The Pilates studio I go to offers one-on-one sessions for people who have rehab needs, so I’m thinking I will splurge on that when I’m ready. Yeah, walking feels good!

 

[mendogal]

I'm another one whose new knees each really liked walking!
With my first knee, done in winter, I mapped a route in the house (fortunately it's all on one level and with a very long hallway). I worked my way up to 1/4 mile non-stop (hatchmarks on a pad to track each lap as I passed the kitchen counter).
It's a wonder I didn't wear a rut in the flooring! Once I felt brave enough to venture out, my husband drove us to a big home improvement store to walk.

 

[Alice Nutter]

I'm another one whose new knees each really liked walking!
With my first knee, done in winter, I mapped a route in the house (fortunately it's all on one level and with a very long hallway). I worked my way up to 1/4 mile non-stop (hatchmarks on a pad to track each lap as I passed the kitchen counter).
It's a wonder I didn't wear a rut in the flooring! Once I felt brave enough to venture out, my husband drove us to a big home improvement store to walk.

I got out onto my driveway yesterday after all the ice finally melted. I didn’t go far but it felt glorious and the dogs were very happy with me.

 

[benne68]

That first outdoor walking excursion post-op is the absolute best, isn't it? The sunshine and fresh air -- even when it's chilly -- renew us.

Glad to read you and the pups got outdoors, @Alice Nutter. Let's hope spring arrives soon so you can do it more often.

 

[Alice Nutter]

Thank you! I remembered that feeling from last year when I had my hip replaced. This year though the weather has not cooperated - the area outside my house has been a skating rink for about three weeks....More melting today though!

 

[Jamie]

I think you’ll find the splurge on personal Pilates classes very much worth it….when you’re ready, of course. I’m glad to hear you got an outside walk. It is true that an exercise such as walking or cycling is the best form motion for a new knee or hip.

 

[Alice Nutter]

Thank you all so much. This forum is very much helping me sort my thoughts out. I think I might be heading for a Dear John letter to my PT guy. Yesterday he had me doing quad sets with ankle weights, at post-op 17 days. This is ludicrous. I am not interested in building strength yet; I am interested in stretching, bringing down the swelling, and using my new knee. He advised me to take a tramadol before the next session, which is a red line for me. I would think that if you have to take an opioid before you do something, then probably that something isn't something you should be doing right now.