PKR Swelling and limited ROM Patellofemoral Replacement

[Sonfanatic118]

Hi All,
Sorry for the novel…
I’m relatively young (33) but was just born with “bad knees”. I’ve had an arthroscopy+ debridement followed by MACI + tibial osteotomy+lateral release done on my right knee for a patellofemoral defect and that has been a success. While recovering from that I developed issues with my left knee and then had a microfracture (which failed and caused more pain than I had to start with) followed by an arthroscopy and debridement. After a lot of thought I was desperate for a more semi long-term solution to my pain and mobility issues and opted for a patellofemoral replacement which I had done June 27th.

Unfortunately, I was under the impression that PKR recovery would be relatively short and that I would be able to go to work in 3 weeks but I’m finding that not to be the case. I’m really struggling with swelling and pain that limits my range of motion and how much I can walk, even just around my studio apartment. My PT and surgeon/ PA have all been pushing for as much weight bearing and movement/walking as possible so the first week or so I really put maybe 80-90% of my body weight onto my operated leg but I think that just made the swelling worse. In fact I feel like the swelling hasn’t gone down since day 2-3 after surgery. In response to my concerns get just repeat “Ice and elevation” which honestly hasn’t helped swelling at all. I have a follow up appointment tomorrow and I have a feeling my surgeon will tell me I’m behind in terms of expected progress (extension =0, flexion =75 (after warming up))

Has anyone found that really limiting weight-bearing helped with swelling and pain early on in recovery? How much weight bearing is too much or too little in your experience?

 

[Layla]

Hello and welcome to the healing side of the forum. Thanks for joining us!
I am not surprised you’re not feeling ready for work, because in reality, you’re not ready this soon after the controlled trauma of your PKR.

Swelling and pain are both common at this point. The swelling can actually last for months. Ice, Elevation and Rest is what your body needs most currently.

Please don’t worry about ROM right now. Avoid engaging in movement that causes discomfort or pain. Do not allow anyone to forcefully manipulate your leg. While your range of motion is currently limited, it will naturally increase as the swelling subsides and the pain eases. Give it time. You will read many accounts here of member‘s feeling threatened by timelines and missing windows of opportunity. The sooner you realize this is not true, the better off you will be. Read the article below.

Myth busting: "window of opportunity" in TKR

This "six week window of opportunity" surgeons often speak about is little more than a myth. It presupposes that all patients have the ability to create adhesions which is far from the truth. It also ignores the simple fact that in the first 3-4 weeks after surgery, swelling reactive to the...

bonesmart.org

I will also leave an interesting account of ROM, from current member, Justice Rider, which may give you a better understanding and hopefully ease any anxiety over regaining ROM.

Justice Rider said -
“I just want to add, for all those coming along, a note on ROM. I want to share this because nearly all of us have a tremendous amount pressure put on us to increase our ROM by certain deadlines, or else.

Mine has been extremely slow coming. First I had to wait out the swelling, which in my case took more than 5 months. Yes, months. At that point I began to see real progress. It has continued to this day. I have seen improvement in the last 2 weeks. It’s still going. A this point I think the limiting factor is tight muscles, ligaments, and tendons from 3 yrs of very limited ROM and actually about 25 yrs of somewhat limited ROM. Those tissues are slowly stretching.

I have had to be willing to let my flexion improve at a glacial pace, be very patient, and tune out the dire warnings of my surgeon, PA, previous PT, and some well meaning acquaintances. I refused painful PT and refused a MUA. I have absolutely no regrets. I know my body, and I believe those things would have caused a domino effect of swelling and pain that may have derailed my recovery long term and even possibly have torn soft tissue, etc. I now know I have the added challenges of hypermobility and an immune condition that causes an inflammatory reaction. I think a MUA would have been very harmful to me.

Instead of forcing it, I have relied on weekly massage and using my stationary bike as a stretching aid every single day. I have been very active, but I have ramped up really, really gradually. I have not measured my flexion, because honestly I feel almost a PTSD type of reaction around it. All I care about is function and what I can do. My knee is very functional now, and still improving. I love my new knee. I’m glad I let it heal on its own timeline even though it was so much longer than everyone (most of all me!) would have liked.”

All you really need to be doing at this point is as follows per our Activity Progression following surgery. You may be ahead, which is okay as it’s only a rough gauge.

Week 1
Just walking around the house - trips to the bathroom and kitchen are included!
Be up on your feet several times a day as you need to but don't get obsessive about it
A 5-6 minute walk every 3-4 hours is plenty
Spend most of your time resting and elevating

Week 2 - add this to previous instructions in Week 1
Start on a plan of walks around the house 3-4 times a day for about 5 minutes but don't
a) get obsessive about it
b) get into too much pain and
c) get too tired. Stop before you get to that point.

Week 3 - add to all the previous
Lengthen the walks to about 5-10 minutes as before
Activity: prepare yourself a small meal or a snack

I will leave our Recovery Guidelines below. Pay special attention to the articles on Ice and Elevate which will help with swelling and pain.

I wish you the best and invite you to share your progress here. We’d love to support you along the way.
@Sonfanatic118

 

[Layla]

KNEE RECOVERY GUIDELINES

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.

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?

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.

 

[Layla]

If you will share the info on your Right knee surgeries, as in exact dates, we will add the information to your signature.
Thanks!

 

[mendogal]

Welcome. This retired RN - and martial artist who has had major and minor injuries - adds to all the amazing links above that for soft tissue injury, whether surgical or athletic in cause, the physiology of soft tissue healing is 6-8 weeks. There are no shortcuts, and further trauma via gross overuse or manipulation can reset the time line to zero or, worse, lead to an acute issue becoming chronic (very common among young, eager athletes!). So.... slow down and be kind to yourself.

 

[Sonfanatic118]

Thank you both @Layla and @mendogal. Out of all my previous surgeries this is by far the most difficult recovery physically and mentally and I have really felt the progress timeline looming over me. But you’ve both reminded me to listen and be kind to my body and take it slow.

@Layla That information about ROM was also very helpful so thank you. Here are the dates for all of my surgeries (Thank you for adding them to my signature!):

3/13/2018 scope, debridement, cartilage harvest (right knee)

8/16/2018 MACI, tibial tubercle osteotomy, lateral release (right knee)

8/26/2021 scope, tibial tubercle osteotomy, lateral release , patellofemoral microfracture (left knee)

2/21/2023 scope, debridement (left knee)

6/27/2023 patellofemoral replacement (Left knee)

 

[Layla]

You’re welcome!
Thanks for the dates, I’ve added them to your signature.
I am sorry this recovery has been difficult. Please stop by often, you’ll find a lot of support here and appreciate the camaraderie.
I hope the rest of your day is peaceful!
@Sonfanatic118

 

[JusticeRider]

Hi @Sonfanatic118 I also had a patellofemoral replacement.

After a lot of thought I was desperate for a more semi long-term solution to my pain and mobility issues and opted for a patellofemoral replacement

I felt the same way, I just wanted it fixed. At 44, I was a few years older than you, but still too young to be so limited and in pain. I’m guessing it was difficult for you to persuade a surgeon to perform it at your age? I know it was for me!

Unfortunately, I was under the impression that PKR recovery would be relatively short and that I would be able to go to work in 3 weeks

Oh, I am so sorry. I was given similar expectations. Could not have been further from the truth. This is a long, difficult recovery. Everyone is different, so I hope yours will be easier than mine. But going back to work in 3 weeks seems very unrealistic. And it really is a similar recovery to a TKR.

I’m really struggling with swelling and pain that limits my range of motion and how much I can walk, even just around my studio apartment

I had a big problem with swelling also. It was the biggest obstacle to healing for me.

My PT and surgeon/ PA have all been pushing for as much weight bearing and movement/walking as possible so the first week or so I really put maybe 80-90% of my body weight onto my operated leg but I think that just made the swelling worse.

That’s crazy. I’m sure that probably IS prolonging your swelling. Your knee will tell you when it’s ready to progress. If it hurts/swells when you try it, go back a level until it feels good. Personally, I was on the walker or 2 crutches (flat foot walking but only weight bearing as it was comfortable) for a week and a half, one crutch until 3 weeks out, then a cane off and on for a few more weeks after that. Again, it’s different for each of us, but if it hurts, it’s your body saying back off.

I have a feeling my surgeon will tell me I’m behind in terms of expected progress (extension =0, flexion =75 (after warming up))

I wouldn’t be surprised. It seems to be very common for surgeons to scare you with threats of permanent disablement if you don’t achieve certain numbers on their timeline. My ROM was very, very slow coming but I am continuing to increase it even now, at 11 months post op! I had similar numbers to yours for the first few months and finally started progressing after that when the swelling finally calmed down.

Out of all my previous surgeries this is by far the most difficult recovery physically and mentally

I completely agree.
Take heart, listen to your body, and be very, very patient. I am wishing you all the best!

 

[EalingGran]

Agree with @JusticeRider that partials can take as long as TKRs to recover.
I think that the quicker recovery times quoted may refer to the much commoner medial partials.
Patellofemoral and lateral partials are much rarer and from what I have read more complex surgeries with longer recovery times.
I had a lateral partial and it is only now at post 6 months ( almost 8 months) that I feel mostly fine. I am still getting stronger and my surgeon has now admitted that full recovery can take 12- 18 months!

 

[Sonfanatic118]

@JusticeRider and @EalingGran Thank you for sharing your insight and support. I just don’t understand why surgeons downplay the recovery time. It’s extremely dangerous, especially if that person doesn’t have the flexibility to extend at home recovery.

@JusticeRider I’m sorry you had such a long and difficult recovery but it is a relief to know that others struggled with swelling and that it does eventually get better.

I had my first post op follow up yesterday and as predicted the PA said since my ROM was still limitedI had to really “push it” in PT and that if pain was the limiting factor they could give give me new pain meds. I just nodded and told them what they wanted to hear but I don’t intend to change what I’m doing. I wish I hadn’t pushed so hard with full weight bearing in the first few weeks so I’m definitely letting my pain and swelling guide me moving forward.

@EalingGran That explanation makes sense as to why shorter recovery periods are advertised, and I wish surgeons should be more explicit about this. Wow, 6 months?! I’m glad you’re finally feeling more normal and continuing to get stronger. Although I’m disappointed I guess it helps to know this will keep getting better for some months. Many Thanks to anyone who took the time to respond!

 

[EalingGran]

had my first post op follow up yesterday and as predicted the PA said since my ROM was still limitedI had to really “push it” in PT and that if pain was the limiting factor they could give give me new pain meds. I just

I really don't think this is good advice to push past pain.
I have great ROM (145+ flexion/0 extension) now and I have never exercised to the point of pain.
I have used a pilates based approach with mainly gentle exercises/ stretches to start with and only very gradually introducing strengthening exercises with tiny weights/ resistance band at about 4 months. My pilates teacher has free classes on YouTube ( Google Katja pilates to find them) She has a fairly gentle side lying, glute strengthening one with no squats which I found very useful once you can get down on the floor easily.

 

[Sonfanatic118]

had my first post op follow up yesterday and as predicted the PA said since my ROM was still limitedI had to really “push it” in PT and that if pain was the limiting factor they could give give me new pain meds. I just

I really don't think this is good advice to push past pain.
I have great ROM (145+ flexion/0 extension) now and I have never exercised to the point of pain.
I have used a pilates based approach with mainly gentle exercises/ stretches to start with and only very gradually introducing strengthening exercises with tiny weights/ resistance band at about 4 months. My pilates teacher has free classes on YouTube ( Google Katja pilates to find them) She has a fairly gentle side lying, glute strengthening one with no squats which I found very useful once you can get down on the floor easily.

I completely agree. It doesn’t make sense if I’m already in pain to push past it. The PA was also “shocked” I hadn’t started doing knee extensions in PT yet to strengthen my quads and boy are those painful when she made me try one. So I think doing gentle side lying exercises and quad sets are a better way forward while I’m still healing. Wow, that’s awesome range of motion! Thank you for sharing your Pilates resource. This is very helpful!

 

[Layla]

It’s one month to date since your surgery. Happy One Month Anniversary!
It is very early days for you and with lots of patience, support and sound advice received here through those that have “been there, done that” I’m betting you’ll do well!
Hang in there and have a nice weekend!
@Sonfanatic118

 

[Sonfanatic118]

Thanks @Layla I hope you have a good weekend too. Unfortunately, I am still struggling with swelling and pain that limits what I can do. Right now a big issue is that the quad strengthening exercises (like knee extensions) are so painful and I am still unable to do SLRs. I wonder if I should try resistance on the bike even with my limited ROM (0-95) It also feels like my patellar tendon is constantly inflamed and when I stand or try to walk my knee cap pinches in that area. Most concerning is that when I try to walk either with crutches or unassisted I can feel my kneecap move slightly to the outside (half the time I can hear and feel my knee click), and the swelling in this area becomes worse as the day goes on. This is what my knee cap did before surgery and my surgeon said he would be able to fix it. Except It’s worse now because it’s plastic on metal which is less forgiving than bone and cartilage when there are tracking issues.

I don’t know if it’s poor tracking or muscle imbalances/ poor gait or something fundamentally wrong but I’m really worried things won’t get better. I decided to do PT from home this week because the swelling was just unbearable to deal with at work afterwards and he’s on vacation next week so I’ll ask what he thinks about situation the following week. I also have a follow up with my surgeon in three weeks and will bring up my concerns. Really just want to be able to walk again…

 

[sistersinhim]

Right now a big issue is that the quad strengthening exercises (like knee extensions) are so painful and I am still unable to do SLRs.

Then your knee isn't ready for you to do this and you shouldn't be trying to do them yet. Please wait a few weeks and let your knee heal more, then try them. There is no time limit, and pushing too fast will only set you back on your healing.

limited ROM (0-95) It also feels like my patellar tendon is constantly inflamed and when I stand or try to walk my knee cap pinches in that area.

At one month out from your surgery, these are great numbers! Most OSs don't expect 90 degrees until 6 weeks out from surgery. Most members would envy your numbers.

I don’t know if it’s poor tracking or muscle imbalances/ poor gait or something fundamentally wrong but I’m really worried things won’t get better

Nope, what you have right now is a traumatized, inflamed knee that needs more time to heal. Normal healing takes at least a year, even for a partial. You are 1/12 of that. As you heal these muscles and tendons will tighten up. It does not happen overnight and you have to exercise that patience muscle!


Remember that you are recovering from a major surgery, not in training. Using only gentle, unforced movements will benefit you much more than doing repetitive exercises. You do not need to worry about strength building yet. Healing this knee should be #1 on your mind. HEALING it, not pushing it to pain!

 

[Jockette]

I don’t know if it’s poor tracking or muscle imbalances/ poor gait or something fundamentally wrong but I’m really worried things won’t get better.

Nope, what you have right now is a traumatized, inflamed knee that needs more time to heal. Normal healing takes at least a year, even for a partial. You are 1/12 of that. As you heal these muscles and tendons will tighten up. It does not happen overnight and you have to exercise that patience muscle!


Remember that you are recovering from a major surgery, not in training.

I agree with sistersinhim. It’s way too early to think something is wrong.

I also have a Patellofemoral partial and it took me way longer than a year to heal, unlike what I read about before the surgery!

Take things slowly and don’t do any exercise that causes increased pain. Give your knee time to sort itself out.

 

[Layla]

Thank you!
I am sorry you're still struggling.
Something I always keep in mind is that "Pain Is Your Body Asking For Change"
So...if it hurts, don't do it, it's not the right time. You're still so very early into the healing process.
Take it slow and easy. With time and patience, you will get there!
Happy Saturday, Sonfanatic.
@Sonfanatic118

 

[Sonfanatic118]

Thank you sistersinhim , Jockette and Layla . You all made really good points. I’m just not being patient enough with my body. Even though I’ve read all the relevant bonesmart guides my brain keeps bouncing back to all the expectations set by my previous recoveries, by my surgeon, my PT, and my desire to get back to better than normal. Sorry for complaining so much! Thank you for taking the time out of your days to respond and I hope you all have a great week .

 

[Layla]

Sorry for complaining so much

No apologies necessary! Taking it slow and easy, without enduring pain, may take time, but will guarantee the best outcome without sidelining yourself because of overactivity, or pushing through pain. You are only a few days over one month post op. With patience and TLC you'll get there!

 

[Jockette]

my brain keeps bouncing back to all the expectations set by my previous recoveries, by my surgeon, my PT, and my desire to get back to better than normal

Partials are also promoted to be fast recoveries and I was so disappointed to learn that in many cases, especially mine, that it wasn’t true. I went into my surgery thinking it was a simple thing and I’d be all recovered in about 2 months. All I read beforehand implied that.

I also had some aggressive and painful PT which always set me back, which I learned from Bonesmart, isn’t necessary. That didn’t help my disposition either. These joint replacements are a huge undertaking and it turned out I wasn’t as prepared as I thought I was, because our medical teams don’t prepare us appropriately.