TKR The Snail and Her Walker - A Slowpoke's Recovery<

[Teecup]

Had six-week post-up visit this morning. Had been practicing walking with crutches over the weekend so was quite happy when I was able to use them, rather than my walker, to the visit. Yay!

I had planned to do some hamstring stretches and heel slides to get my flexion warmed up before the doc came into the treatment room. He's usually late, but not today. He walked in during my standing hamstring stretch, so I didn't have the chance to warm up my flexion, and I told him so. He only chuckled.

I got up onto the exam table, sitting with my legs hanging over the side. He proceeded to examine my right knee, wriggling it from side to side (I hate the popping!) and eyeballed my extension (which I know is good, but he said nothing about it). Then he pushed for flexion to pain tolerance, again eyeballing. Told me that he had left about 1/2cm of spacing on my right (9/24 TKR) knee so that I wouldn't have as much trouble bending as I had on the left knee (7/9 TKR).

He started talking about the three-month window of opportunity to break through the scar tissue that was forming and preventing fuller flexion, and recommended a follow-up visit in two weeks where he would check again. If I was still stuck, he would MUA that week; didn't clarify one or both. Then the Thanksgiving holiday occurred to him and he pushed the visit back to the following week, saying that was just under the wire for MUA without risking bone breakage. Lovely.

He wrote me a PT order with these special instructions: "Aggressive flexion bilateral knees." Told me I would need to "work my butt off" during these three weeks to gain enough flexion to avoid MUA.

Then his gentler side appeared. He said as a doctor, he wanted to see the perfection of 140. But he knows some people don't care if they never get that and are fine living with less, and that it was my choice ultimately. We agreed to wait until the follow-up visit to decide.

We talked about the note I needed for work, script refills, and then he left. I thought he was coming back. I was going to ask him to actually measure my ROM so I would know what it was. But he didn't come back, the nurse did. I ended up having the doc's resident measure my ROM. As I was struggling to flex as tight as I could, he said, "Don't hurt yourself." (Funny, that's not what my doc would say!) He measured my older left knee at 105 and my newer right knee at 110.

My left knee is the one that went through 11 weeks of the grueling pushing/pulling, stretching/strengthening exercises my PT thrust upon me and which I faithfully completed at home as directed. It's the one that was manipulated 6 weeks ago during my right TKR. And yet it's no better off now than it was after the first MUA. Why would I manipulate it again? And why would I manipulate my right baby knee when it's doing better than its older sister?

I can see the upcoming three-week visit might be a bit awkward as I'm not going to PT between now and then, and I'm not having another MUA either. It's possible that my flexion will improve to 140 in three weeks. But in case that doesn't happen, I hope he takes disappointment well.

 

[Celle]

My left knee is the one that went through 11 weeks of the grueling pushing/pulling, stretching/strengthening exercises my PT thrust upon me and which I faithfully completed at home as directed. It's the one that was manipulated 6 weeks ago during my right TKR. And yet it's no better off now than it was after the first MUA. Why would I manipulate it again? And why would I manipulate my right baby knee when it's doing better than its older sister?

Exactly!

Very, very few surgeons even think about doing an MUA once your flexion has passed 90 degrees. It's not necessary and it won't improve matters, but will cause further soft-tissue damage.

Even if your surgeon wants to do an MUA, it's your knee and he can't do anything without your permission. Refuse to give that permission.

It's unlikely that your flexion will improve to 140 in 3 weeks, but then it doesn't need to. There's no magic window of opportunity. ROM can continue to improve for at least a year post-op.
Don't be persuaded into more unnecessary surgery, just because your surgeon is an impatient man.

I've probably given you these before, but here's a reminder:
CONSENT: what it means and how it can be used
Saying no to therapy - am I allowed to?

 

[Teecup]

Thank you so much, @Celle! I remember the soft tissue damage I felt in the recovery room after the MUA. I came very close to asking him why I would subject myself to that again when it didn't help the first time, but decided to hold that thought until possibly next visit. Until then I'll be icing, elevating, and babying my babies.

I'm also going to buy a goniometer so that I can track my monthly progress and post it here as I've seen others do. So encouraging!

 

[kmak81230]

As a person who obsessed about measuring - had my own goniometer and had to buy a second one when my PT confiscated the first one - I can say 18 months later, don't worry about it! Your ROM will come when it's ready if you don't overdo it with the aggressive exercises. You may never get to 140 and still have a great functional life. I was about 120-125 prior to my first TKR and it took me a year to get back to that flexion. I'm currently at 130 and can do all that activities I want to. It's hard to not focus on the numbers . . hang in there.

 

[sistersinhim]

I can see the upcoming three-week visit might be a bit awkward as I'm not going to PT between now and then, and I'm not having another MUA either.

Then cancel that appointment. If you aren't having any problems, why go? Or if you feel you have to go, then put your foot down about having another MUA. You are doing so well without one! It's just another way for the OS to get some more insurance money! There are a few people who did benefit from a MUA, but most don't. You are one of those that didn't get any benefit at all. All you got was a set-back.

 

[flsungirl]

I quit PT 2 weeks ago. I measured @102 the last time I was there. I doubt it will get much better considering before surgery it was probably around 70. I did this because I couldn’t live with the pain anymore. I just don’t care if it increases or not! I can get my shoes on, walk normally, and a host of other things. That was my end goal...no pain. I’m happy with my progress and in the end...that’s all that matters to any of us.

 

[sistersinhim]

It's function that matters with the knee bend, not the numbers!

 

[Teecup]

beachy, sistersinhim, Jockette While TKR definitely qualifies as one of the most challenging, stressful, life-changing events for me--especially regarding patience, loss of control, embarrassment, and pain--your words remind me of what I need to do to get through! Philippians 4:6-8.

 

[Teecup]

As a person who obsessed about measuring - had my own goniometer and had to buy a second one when my PT confiscated the first one

Too funny!

Your ROM will come when it's ready if you don't overdo it with the aggressive exercises.

And that's where I need to exercise restraint. I've cut out 95% of the exercises my PT had me doing. It was scary at first, but now, two weeks later, I see definite improvement in my flexion, my attitude, and my mobility.

One week ago, I submitted my photos for Josephine to estimate my flexion. I'd given myself one week to rest and heal from the strenuous PT-assigned regime. She estimated me at R 80 degrees and L 90 degrees. Add one additional week of rest and healing to that, and voila! The doc's resident measured me at R 110 an L 105. That's headed in the right direction, don't ya think? That's the proof I need to keep doing what I'm doing. Less is more, no pain more gain!

Regarding attitude, well let's just say I haven't cried myself through an exercise or had those wish-I'd-never-done-this thoughts running through my head since I cut back.

And finally (this is the drum roll moment) I used crutches, not my walker, to walk the long distance to my doc appointment and to stand in line 35 minutes yesterday to vote. I was able to do this because my legs felt less stiff, less swollen, and I had better control of them than I've had since my first TKR in July. My walker has been my constant companion, but I see a parting of ways in the near future. The calluses on my lower palm will be a reminder for months that she was there for me when I truly needed her.

I was about 120-125 prior to my first TKR and it took me a year to get back to that flexion. I'm currently at 130 and can do all that activities I want to. It's hard to not focus on the numbers . . hang in there

I'm so happy for you! And what an encouraging example for me and others that our surgeries were worth the cost. My personal goals are to walk my dog, ride a bike, and hike beautiful, backwoods trails. I found these flexion minimums in the BoneSmart library

• 65° to walk
  
• 70° pick an object off the ground
• 85° to climb up stairs
• 95° to stand from a sitting position
• 105° to tie shoelaces

• 115° (or greater) to squat or sit cross-legged
• 125°+ covers most activities. However, squatting or sitting on your heel may always prove challenging.

So I have only two more hurdles to clear. I'll get there!

 

[Teecup]

Then cancel that appointment. If you aren't having any problems, why go? Or if you feel you have to go, then put your foot down about having another MUA.

Wish I could cancel it! I have to go to get a release to return to work. But I WILL put my foot down about not having another MUA. And I'm hoping to be at 120 on both legs at which point I will enlighten him on how I achieved this by not following his orders. Hope to see this from him but won't be surprised to see this .

I do hope he will be cooperative with me and give me a few more weeks to continue healing before I have to return to the office and sit at a desk all day; only causes swelling and pain no matter how much I try to ice, get up and and move frequently, and elevate as best I can with legs under a desk. Not sure how his ego will respond to a gone-rogue patient who challenged his expertise and authority. Time will tell.

 

[Jockette]

Not sure how his ego will respond to a gone-rogue patient who challenged his expertise and authority. Time will tell.

If he’s happy with your progress I would wait to enlighten him as to how you achieved it. You need him to agree to more time off, this is not the time to irritate him. Plenty of time later to tell him that backing off the exercises worked better for you.

 

[Teecup]

@flsungirl That's quite a comeback! You must be elated with your transformation!

How wonderful that this surgery provides such tremendous, life-improving changes. According to orthoinfo.aaos.org, the first TKR was performed in 1968. Think about the poor people who had to live with their pain and immobility prior to that! We have so much to be thankful for.

 

[Teecup]

Good strategy @Jockette! I will go with that!

 

[SusieShoes]

With your current flexion, chances are no one will want you to undergo an MUA. You're doing just fine!

Go with Jockette's strategy. I did a lot of that during my recovery.

Medical person: "Looks good. You're doing your exercises?"

Me: (Big Smile and Enthusiastic Nod)

I didn't tell them I was skipping all home exercises recommended by PT. I did do walking. Walking is exercise.

All the OS is really going to care about is that you have good results from his/her wonderful handiwork.

 

[kmak81230]

Good for you for having the courage to cut back, despite what the "experts" say. You will achieve your functional goals with time. I'll never be able to sit on my heels -- I don't think I've been able to do that since I was 12 -- and my quality of life will not be diminished as a result. You are on the road to an excellent recovery. I do the same as Susie with my OS: "Are you working that knee? " - "Yes I am" . . . since I want him to be feeling good about me as we head into #2 next week I'll wait to have the talk about the smart way to recover until after I am well on my way to recovery. Fortunately my PT is on board with the BS way.

 

[sistersinhim]

I will enlighten him on how I achieved this by not following his orders.

You don't have to tell him a thing. I never took PT and never told my OS that I didn't. He was always happy with my outcomes. What they don't know won't hurt you!

 

[Josephine]

He started talking about the three-month window of opportunity to break through the scar tissue that was forming and preventing fuller flexion

Absolute tosh!

Told me I would need to "work my butt off" during these three weeks to gain enough flexion to avoid MUA.

Oh brother!

and that it was my choice ultimately.

Absolutely!

He measured my older left knee at 105 and my newer right knee at 110.

That is EXCELLENT for only six weeks out!

But I WILL put my foot down about not having another MUA.

Good for you!

 

[Teecup]

Had a stellar day yesterday! Replaced my walker with two crutches the ENTIRE DAY and also for nightly potty trips! Now I'm free to incorporate the correct gait and muscles!

Before I ended PT visits, the PT told me to "tighten everything" when I walked, and strike the heel first, then roll forward through to the toe, but don't walk straight-legged, not even to build muscle (she did have me walk straight-legged to build up to walking after my THR). But as I've learned, the knee is a different beast!

Well, tightening everything makes for a stiff soldier walk with an awkward, unstable bend, so I've scoured BoneSmart and the web researching the "correct" way to walk. When to tighten what? Push off the back foot or have the tightened glute pull you forward? Like anything else, the are differing opinions, though tightening the core was a constant.

I asked hubby, who is in very good shape, to tell me what he tightens and when during his gait. It's such a natural, fluid movement for him that he couldn't break it down.

So to those of you who have just started walking again and can identify where/what you're tightening and when and are you propelled forward by a push and/or pull, or those of you who remember or can slow your gait enough to feel what's happening when, could you share the gait mechanics that work for you?

 

[Jockette]

I think you are overthinking it. Just walk. As you heal you will walk better.

I would occasionally think, heal to toe. If I was really tired, or hurting, I would walk stiff legged, it didn’t cause me problems and now I don’t need to do that.

PTs tell us to do lots of things. Not all of it is necessary.

You are early in recovery with lots of time to improve. Just use common sense.

 

[Celle]

Walking with heel-toe gait. Note that the leg is bent when lifted forward for the next step, before it is straightened as your heel meets the ground. At that stage, the back leg is straight.
So that I bent my forward leg enough, when I was learning to walk again, I used to pretend that I had to step over something on the ground.