Revision TKR Third and final surgery all done

[Josephine]

I have not done one exercise except today I tried to do five heel slides and five quad Sets and a little knee extension stretch

That's something of an oxymoron! You've not done one exercise except .... Heel slides and quads sets are the very kinds of exercises I advise against! Totally!

I did call Mayo clinic yesterday and asked to talk to someone in physical therapy.

I very much doubt that anyone will talk to you about this.

a) they will be unwilling to even appear to offer advice to patients not their own (unlike me who jumps right in with both feet!)
b) they will likewise be unwilling to discuss their protocols for fear of advising you against you own surgeon's protocols.​

However, you never know - you might be lucky!

My biggest fear is not bending because when you can hardly bend at all

Did you read this article? It was one of the many left in our set or recovery articles Swollen and stiff knee: what causes it?. You see, your knee cannot bend right now because of the swelling so your first priority is to manage the swelling. BUT your swelling is currently being caused by the PT/exercising.

I just have to ask this question, did any of you go through two or three months of lots of rest ice and elevation, no exercise, and then kept going like that for months and not gain back a functional range of motion?

Quite the opposite. I never did any exercises at all for either knee - not even so much as a single heel slide. Yet both times I came our with really good outcomes! I suggest you read my recovery thread to see the truth of that! Knee recoveries UK style Parts I & II (Josephine)

I also have an aunt who had both of her knees done and when I saw her a few months ago she said she never got The bend back in one of her knees. This was a few years ago. And I watched how she walks and moves around and it isn't good.

Yes, that's a very clear picture of someone who was required to suffer aggressive therapy. Poor lady.

did any of you find that Tramadol was particularly helpful for you with pain relief?

I had nothing BUT Tramadol for both my knees. But it wasn't Tramadol alone. I made this chart during my first knee replacement and the schedule worked wonderfully well for me.

The important thing about pain management is that for the first few weeks you take the pain meds by the clock, meaning if you take a dose at 2pm then you know you have to take the next dose at 6pm, regardless of how much or how little pain you have. This was something I learned during a spell in a hospice learning how to look after terminally ill cancer patients. None of them ever seemed to be in pain so I asked the nurse about it and she just smiled knowingly and said "It's simple - we just don't allow pain - period"! A pretty good approach to my way of thinking!

 

[Jajakio]

I'm 11 weeks out and back to normal activity levels with no knee pain ( a little mild discomfort now and then) and almost no stiffness. I took PT for the first 4 weeks but had to stop to save some visits for my other knee. I then exercised at home on my own schedule and I think I got the most improvements between weeks 6 - 8 working on my own.

This is what I did. Worked to the point of mild discomfort and then kept up that level or amount of exercise for a few days or however long it took for that to get easy or pain free then increased again to the mild discomfort level. Some thing are going to be uncomfortable. When I started riding the recumbent bike, the first minute or so was uncomfortable until I loosened up a little. It doesnt hurt at all now. Avoiding all discomfort was not the goal for me. It was not overexerting to the point of pain and swelling that prevented me from moving forward. We are all different. Do what you can for where you are. I'm very interested to find out if Mayo answers you.

 

[kayow11]

After all the reading I have done on bone smart and other info I have gathered, I have decided to continue on the oxycodone for at least another 2 to 4 weeks depending on how long I need it. I am on day 11 today.

I will also try to do more normal daily activities at least for a short period of time until my leg starts to feel tired and achy and then I will lay down and ice and elevate. I need to make sure I am walking probably four times a day and maybe only five minutes since that seems all my leg can handle right now.

I will go to PT maybe one time per week and tell him what my plan is but the problem with that is that ALL the exercises even heel slides and quads sets seem to aggravate my knee, some during the exercise and after for several hours, and that is with just one set of a few reps.

The knee extension stretch is one of the worst for pain.

My biggest concern is that the range of motion on my new knee is only around 60 to 65°. That is a fair amount less than the first knee was at this stage. But with the first knee I was doing much more aggressive PT at The clinic and at home. And I was constantly painful and seemed flared up a lot.

My first knee which is 13 weeks out is still only about 95 degrees. Even walking is more difficult and awkward with so limited ROM with the new knee. If I had better flexion with either knee, I don't think I would be so concerned about any of this.

On the other hand, I don't want to be in pain and flared up all the time either. And I don't believe that is helping my knee to heal. I guess I can just take a chance on being low-key with the range of motion exercises and activities and hope and pray that it increases as time goes on even if it is months down the road. Hopefully it is all due to just increased swelling that is limiting the flexion.

 

[kayow11]

Jajakio, what exercises and/or stretches did you do at PT those first four weeks and what did you do at home on your own? Sounds like it all worked out for you but as I said earlier, even the simple stuff that people on this site, or at least some of them, say they are doing, and what is always taught are the ankle pumps, heel slides, quad sets, knee extension stretch, etc. I guess I learned the wrong things to do but what is acceptable and beneficial exercise with the majority of you on this site?

I know that it is different with everyone but I need some other guidelines or ideas if I can't do anything I've been taught so far. My big issue is swelling and lack of flexion.

I think that many of you have been able to do a lot of fairly normal things because you had good flexion early on. That is not my case and it is very limiting with ALL activities. It seems that many of you who did no exercise, had good flexion anyway early on.

Hopefully, as many of you have said, that the flexion will increase as the swelling goes down. My right knee got a bad start but it is still only 95 degrees out three months out.

The new left knee is way behind that at 60 to 65°. I guess it is time, time, time, that I need to be waiting upon. Also, most normal activity including walking requires little flexion which doesn't increase that ROM. It helps to hear about others that had poor range of motion And that it's slowly slowly increased over many months. But it seems like we are in the minority by far.

Josephine, I was not doing any exercises at all until one or two days ago when I tried the five heel slides and quad sets. So my excessive swelling is from post surgical likely, not exercising since I have not been doing any of them.The PT I saw one week ago after my evaluation wanted me to do the ones that I tried and that was it.

I do think many people get confused on what strength exercises are and what stretching exercises are. There is a huge difference. I am a physical therapist assistant myself so stretching is just that, stretching a muscle without contracting it, with the purpose of lengthening it and to decrease tension in it. Strengthening of course is contracting a muscle in the goal of strengthening it and doing it several times to fatigue To increase the strength.

So I get mixed up on what people truly mean when they say exercises but not PT.

Have any of you had success on trying alternative therapies such as acupuncture, massage, and Kinesiotaping?

Just looking for possible alternatives that might work better for me. My knee seems to rebel from any thing including icing which does not seem to help with swelling. Nothing seems to help it except maybe just weeks and months of time.

 

[kayow11]

And yes, I did read the article on Swollen and painful knee: What causes it and the articles from Josephine on recovery UK style. I know it is likely fluid in there but I just seem to have so much and it doesn't seem to diminish no matter what I do. Icing does not seem to be doing anything. But I have continued to do it because it was recommended.

 

[Celle]

@kayow11 - it's only 12 dayw since you had your TKR. You are expecting far too much, far too soon from your new knee.

.it seems that many of you who did no exercise, Had good flexion anyway early on.

No! I did no PT at all for my left TKR. It didn't bend at all - not one little bit - until 5 days post-op. Then it bent about 2 degrees. That was all, until about 2 weeks post-op. I concentrated on rest, ice and elevation, knowing that as the swelling went down my knee would start to bend.

One day I got up and sat at the table for lunch. I realised that my knee had started to bend and it could already bend to about 50 degrees. Just like that, with no exercises and no worry.

My flexion continued to increase, and was visibly over 90 degrees by the time I saw my surgeon at 6 weeks. He doesn't measure ROM, but just says "Show me what you can do".

The new left knee is way behind that at 60 to 65°. I guess it is time, time, time, that I need to be waiting upon. Also, most normal activity including walking requires little flexion which doesn't increase that ROM. It helps to hear about others that had poor range of motion And that it's slowly slowly increased over many months. But it seems like we are in the minority by far.

I don't think you're in a minority at all. Your knee is doing very well so far, so stop comparing it to the other knee.
Nobody gets good ROM instantly. It is a slow, steady process.

Have any of you had success on trying alternative therapies such as acupuncture, massage, and Kinesiotaping?

Gentle massage is good. Kinesio taping works well for some people, but they are adjuncts, not complete treatment. I wouldn't advise acupuncture, because every time you insert a needle, you risk introducing infection from your skin surface.

I do think many people get confused on what strength exercises are and what stretching exercises are. There is a huge difference. I am a physical therapist assistant myself so stretching is just that, stretching a muscle without contracting it, with the purpose of lengthening it and to decrease tension in it. Strengthening of course is contracting a muscle in the goal of strengthening it and doing it several times to fatigue To increase the strength.
So I get mixed up on what people truly mean when they say exercises but not PT.

It's hard to be a patient when you have some knowledge and in your case I think your training is working against you. You work in an area where PT is considered essential, but sometimes it isn't.

When you're stretching post-op, you are also stretching tendons and ligaments, not just muscles.
I haven't come across much confusion on BoneSmart between stretching and strengthening.

I read that you are worried that walking will not help to increase ROM. It does. You bend your knee as you're stepping forward. If you want to increase that, try lifting your knee higher as you bend. And walking certainly stretches the tissues at the back of your knee, as you push off with your toes. Lengthening your stride will help to increase extension.

Honestly, I think you are over-thinking all this. Your right knee started off well, but its progress was slowed down due to over-zealous exercises. As long as you don't make the same mistake again, your left knee will be OK.

All the activities of daily living (ADLs) are exercise for your knee. It doesn't need formal sets of exercises as well.

 

[Josephine]

I have decided to continue on the oxycodone for at least another 2 to 4 weeks depending on how long I need it. I am on day 11 today.

Do remember that at 11 days you are very early out and will need the full whack of pain meds until at least week 6 or 8.

I will also try to do more normal daily activities

I recommend you don't. Do follow the Activity progression for TKRs and carefully!

the problem with that is that ALL the exercises even heel slides and quads sets seem to aggravate my knee. So I get mixed up on what people truly mean when they say exercises but not PT.

My answer to that is simple - don't do either of them! I see 'PT' or 'therapy' as what's done at a clinic and 'exercises' as what's done at home. In practice there is no difference between the two.

The knee extension stretch is one of the worst for pain.

Yes it will be because

a) extension almost always gets itself sorted in due course
b) stretched and other 'therapy' techniques are counter-productive as they cause pain which causes swelling ... etc., etc.​

I think that many of you have been able to do a lot of fairly normal things because you had good flexion early on.

Not necessarily. With my first knee, my flexion was only about 85 when discharged from hospital.

Have any of you had success on trying alternative therapies such as acupuncture, massage, and Kinesiotaping?

Members who followed the BoneSmart guidelines didn't often have to resort to alternative therapies because they didn't get the problems that required them.

I know it is likely fluid in there but I just seem to have so much and it doesn't seem to diminish no matter what I do.

Of course it's fluid! Fluid by the bucket load! You do know that the human body is 80% water, don't you? So it doesn't take much to have some of that fluid shift into the knee or anywhere else that has suffered trauma.

 

[kayow11]

Thanks Josephine and Celle for your patience with me and reminding me of things that I've already read or have been said. Can you tell I am a goal oriented person, that I am always busy doing things, always have a list and always want to accomplish that list before the end of the day?

It is hard for me to slow down and even to take care of myself. I always want the quickest but best way. They usually don't go together.

I just have a problem with some work and insurance issues now too so that is complicating all of this.

I need to behave and stick with my decision to do things differently with This knee. I hope to be able to salvage the first knee too.

And I also need to sit back, try to relax a little bit and not have high expectations as I always do. And you are right that being in the physical therapy field myself can almost be an enemy for me in my situation. Knowing too much or thinking you know what is best for you, can backfire.

I will try to be quiet for the next couple of days and just let things settle in. I will let you know though about the Mayo Clinic supervisor if he gets back to me.

Take care all of you and thanks again for your response and care and concern for me.

 

[Celle]

Bless you! I hope you can start to feel less worried about all this.
Don't feel you have to be quiet - we're here to help and support.

It takes courage to try something that is different from what you have been taught, but you have to choose what you think is best for your knees.

 

[Jamie]

I will also try to do more normal daily activities at least for a short period of time until my leg starts to feel tired and achy and then I will lay down and ice and elevate.

You've received great advice from Jo and Celle, so I certainly don't need to add much. But I did see this comment of yours yesterday that I felt wasn't addressed completely.

What you DON'T want to do is to exercise, walk, or move about until you feel tiredness or discomfort in your knees. That most certainly means you've done too much and you're going to pay for it. You want to stop BEFORE the knees tire out. I have a hunch that you're up and about more than you should be during the day. If you can, chill out and get that knee up with ice as much as you possibly can. You only need to be up and around maybe 5 minutes every hour or two....nothing more until you get the swelling under control. Keep ice on it all the time, not the 20 minutes you'll usually hear in the therapy world. Just be sure you have a towel between the ice source and your knee to prevent skin damage. If you do that, you can ice almost continuously. I even used two ice packs (one front and one back) when I slept at night. Once you get used to it, it can really feel good on that painful, swollen knee.

Hang in there......you are still early in recovery for both those knees. This is tough surgery and recovery. Sometimes only those of us who have actually been there, done that and have the t-shirt to prove it can understand what a person may go through. You're going to be fine if you just slow way down and let your knees settle.

 

[OJ2]

To me, exercise is movement (aside from isometric exercise which is not movement). Each of us is at a different point in our journey called life and each of our bodies are at a different point. What might be gentle exercise/movement for me might be excruciating movement for you or it might be as easy as pie. And what might be very hard for me today might be easier in two months.

But we each have to start where we are at right now. Wherever we are in this journey, if we do a lot more than we are used to, we will have pain, discomfort, or stiffness in the days to follow. I think the important thing for us with TKRs is to move. It might be just getting ourselves to the bathroom several times today. But we build on that very slowly, as our bodies heal from the trauma of surgery, the swelling goes down, and the pain goes away.

And after we are healed, how far we take this movement idea differs for each of us. Some are happy just doing ADLs. Some want to go on to weight lifting or sports or hiking or cycling. Our potential is way more than we think, but we need to set reasonable goals and go about this in a smart manner, taking one step at a time. And for most of us, our first step is healing.

 

[kayow11]

Hello again and happy Monday,
A PT from Mayo physical therapy clinic called me back this morning. I was happy he called but surprised.
He listened well and answered my questions for the most part. He said that all their total knee patients get the same exercises to do right away, even sometimes the first day, and it is recommended that they continue with these exercises at home and/or also do PT according to what their doctor recommends, which most of them do.
Apparently the surgeons all agree on the same exercises for all their patients so as to avoid conflicting information, unless there are special circumstances, per this PT.
The Specific exercises were Heel slides, quad sets in laying, or sitting with a knee extension movement, active and assisted range of motion exercises, and that they limit their patients or set a max goal of 0° extension to 100° of flexion by discharge time from the hospital! He said some get there while others don't. They also work on full ext. with the towel roll under the ankle to help the knee to hang into ext. (this one always killed me).
I didn't ask about other specific strengthening exercises such as straight leg raise, etc. because I heard what I was most interested in which was active assisted range of Motion which of course is outside physical force to achieve maximum ext. or flex.
He said they believe in "gentle strengthening", until week 12, then to proceed to aggressive strengthening. When I questioned him about active assisted range of motion he said it was always within the patient's tolerance.
Of course he didn't know if the patient's symptoms increased after they left the hospital since he didn't see them anymore.
I reminded him that pain tolerance is very different for everyone, and even if a therapist is helping to push on a leg to increase ROM, a persons tolerance may not be a true indicator or beneficial even if they can stand it. And also that you may have detrimental effects later. He didn't respond to this.
I asked if they pushed the exercises and ROM because of concern for scar tissue/adhesions or possible early beginning formation of contractures. He then said he wasn't clear what the question was, and I decided to not pursue the specifics.
So there we have it, at least according to this source. I was hoping to hear differently.

Jamie,
You are correct in your perception of intensity of my activity level. Yes, I have been doing things until I feel I need to take a rest, but your response is to not wait until I feel that need, but to just keep the activity level low despite how good I may feel. This is so foreign to my personality. But I know it is what most people preach on this forum and I understand why. I am trying to abide by it to my best ability but I can do better.
I find I am not having enough ice packs to keep me cooled down most of the day and Surely not into the night, so I ordered two Cryomax ice packs and they should be arriving tomorrow. That should help me at least be able to ice some at night since the cold is supposed to last for hours.
It is day 12 today, and I can tell that overall I am a little less painful and tender in that leg, and my stamina has increased some. This is where I run into trouble and find it hard to be laying down most of the time with my leg up. I will keep trying to follow the guidelines though, even though I don't see signs of swelling decreasing that much. It probably is a combination of things that will make that happen.
Thanks for the specifics because I need that! Vague descriptions of things give me too much leeway to do too much activity.
OJ2, thanks for your input also.
But I suspect we have differences in our definition of certain words such as exercise, movement, or activity level. I understand what you are saying about healing first though, and then increase activity. I am one of these people that needs the reins pulled back.
I also am the kind of person that is very detailed and specific about everything. Words have certain meanings to me and since I am in the medical field, I feel that it is important to use the right words to describe exactly what is meant so there is no assumption or guessing. That is why I mentioned the difference between the words exercise, and stretching, since I feel some people consider these the same things. I don't. And there is a big difference in the two in my opinion. I was just interested in what people really mean when they say that they were doing exercises for stretching. There is a time and a place for each of those, and frequently they are done separately at different points of therapy.
I just like specifics and details with most things in life.

 

[KarriB]

The "exercises" he mentioned are the same ones I was given in the hospital by my PT with the exception of straight leg raises (which I had a hard time doing).

 

[kayow11]

Yes, those exercises are typical of all hospitals and PT clinics for therapy after knee replacement. That is the problem is that they are all consistently, and possibly, too much before any healing has barely started.
It's amazing to me that so many people seem to do OK with them though. I just happen to be in that small percentage whose knee rebels and flares up it seems.
I was hoping Mayo clinic was a little different for trying new methods of not being as aggressive for the first few weeks, but I guess not. It is the same as most of the rest of them.

 

[liam2015]

good for you researching this and getting a conversation with a p.t. at the mayo clinic. when he mentioned about their goal being 0 degrees for extension and 100 degrees for flexion by discharge from the hospital ~ did he mean discharge from p.t. weeks after surgery or discharge 2 or 3 days after the surgery? i'm just getting to 100 degrees 5 months post op and not at 0 degrees extension yet. that seems very optimistic and even unrealistic if he means a couple days post op, although there's always the exceptions. he makes a good and honest point saying that he doesn't know if patients' symptoms increase after they leave the hospital as he doesn't see them anymore. he talks about "aggressive strengthening" starting at 12 weeks post op and it would be interesting to know if he thought patients could be harmed by increased pain and swelling from the aggressive strengthening. he might not want to talk about that or maybe it would have entailed a much longer conversation as it's not always black and white.

as for myself, i've been very lax about the home exercises, just doing the ones i personally think are helping me: stair lunges, step ups and just walking up and down the stairs for flexion. i haven't done any of the extension exercises consistently at all, hoping that the walking i do will help. no exercise at p.t., just treatments. like you and others, i still have swelling at 5 months post op. we're all different. your goals are likely different from mine ~ well we probably all want the same end goal of good r.o.m., but some want it now...lol! i also realize that some people need to get back to work at a certain date for various reasons and it's difficult to be patient. good luck with the new ice packs. hope you can relax and get that darn swelling down.

 

[kayow11]

He did say 0° extension to 100° flexion by discharge from the hospital. He said that is what they LIMIT people to, because some get there without much trouble and could exceed that but they limit them. Imagine that!
I made that phone call particularly to Mayo clinic, because earlier on this forum, it was mentioned once or twice that some former patients that had gone to mayo clinic, did not have any formal exercises after their knee rehab,.
So the thought from people from this kind of statement would be that maybe mayo clinic is changing their ways and have adopted new ideas. I guess not. It is the same as most of the rest of them.
LIam, I am curious about your flexion and ext. at five weeks postop. Stare lunges and maybe step ups, seem fairly aggressive but at five months I suppose you should be able to do them. Is your flexion still really poor? And do you still feel like you are fairly swollen?

 

[Celle]

So the thought from people from this kind of statement would be that maybe mayo clinic is changing their ways and have adopted new ideas. I guess not. It is the same as most of the rest of them.

I'm glad you got a call-back from this PT, but do remember that she/he is only one member of the staff.
We do have reports here on BoneSmart from patients who had their knees done at Mayo and they reported differently.
At any rate, I'm pleased to hear that there is no emphasis on aggressive therapy, but rather on taking things gently.

 

[liam2015]

Hi kayow...at 5 weeks post op my ROM had not been measured since I didn't start PT until 6 weeks post op. At my first PT appointment i was measured at 79 degrees flexion and I'm not sure about the extension but up until recently my extension was only around 10 degrees.

I did not start the stair lunges and step ups until a few weeks ago when I noted a real improvement. Actually at my 10 day post op appointment to get the staples out, the surgeon recommended stair lunges but obviously I didn't do them at that time. Now at 5 months post op, my flexion is 100 degrees and extension around 8 degrees (sorry I don't remember, she told me it was a couple degrees improved from the last time, which was 10).

I still have a fair amount of swelling but it's not the whole knee anymore. Now I can see pockets, some call dimples lol, so it is subsiding...slowly as everything else. I am functioning very well though with stairs and walking. I still get stiff and in pain when rising from sitting position but it doesn't last long.

It's been a long time coming but I'm finally at a point where I know my ROM is improving. for several weeks/months, I felt stuck; even going to physio wasn't producing any results that I could see, but perhaps internally things were improving.

I haven't done anything that hurts, except one home exercise a few weeks ago, balancing on one leg for 15 seconds and several reps and that set me back with pain for 2 weeks.

My hat's off to you getting both knees replaced in a matter of months.

 

[Fire wolf]

@kayow11, it seems that you and I think similarly about some things. I have learned to tell my OS and PT's that they need to specifically tell me what I am not allowed to do instead of what I can do, as otherwise I won't put any limits on myself when rehabbing from injuries or surgeries. I am also highly goal oriented, focused on progress and outcomes, and do best with very specific information. I hope that you can find the balance you are looking for.

 

[kayow11]

Celle,
I feel like quad sets and straight leg raising are not really gentle exercising in my opinion. . The quad sets really angered my incision area with real pain for many weeks on that first knee. And heel slides, assisted by a therapist to achieve greater range of motion, is also something I thought you were all against. I also don't like the extension stretch with a towel roll under the ankle and let the knee hang down. This was bad for me. I know that Josephine does not like any of these exercises at all.

Even though this therapist said that they all do the same thing, I suppose there are exceptions.

And the ROM limit of 0-100 seems like way too much to even think of for a few weeks.

Liam, thanks for the range of motion specifics. It is encouraging for me to see that you are slowly getting there with flexion range of motion, and it didn't really even start moving much until between four and five months postop. By the way, are you still elevating and icing and if not, when did you stop doing it or doing it less?

Fire Wolf, in my case, I don't even want to do the regular exercises that my PT wants me to do which are heel slides and quad sets and straight leg raise and knee extension stretch. That is mostly what he wants me to do two times a day, two sets of each 10 to 15 reps.

When I am less painful, and slightly less swollen, and feeling better, that is when I need to have limits set for me because if I feel somewhat good, I do way too much.

It appears that you have found a good balance for yourself and are doing much better now too. I hope that is what I have to look forward to. But in the meantime, I'm not sure what to do. On one hand, people say do not do any of these exercises, and on the other hand the PT and probably surgeon want regular physical therapy and regular exercises.

And all of the people on this forum are somewhere in the middle of what they think and what they have done and what they are still doing that works for them. I just know that right now for me, my new knee seems to not be able to handle any real exercise. It easily gets aggravated and feels worse and more painful with anything except some walking for 5 minutes or so, frequently.