TKR TKR - increasing ROM?

[TripleB]

I had total knee replacement surgery on May 1st (2023). Due to having a DVT blood clot back in 2019/2020 (not sure what caused it) I had to be put on blood thinners for two weeks after my TKR surgery. Because of this, I wasn't able to take the anti-inflammatory meds (celebrex), therefore the swelling and pain in my knee were greater than if I wouldn't have had to be on the blood thinners.

During the first week my home physical therapist was able to get my ROM up to 120 degrees so I though I was well on my way. I'm not sure what happened but days 5 and 6 after surgery were awful - physically, mentally, and emotionally. So when she came back a week after surgery trying to get past 100 degrees was excruciating. She was disappointed and I was frustrated.

At my two week check up my doc seemed disappointed in my 91 degree ROM (even though his book said that's were I should be even without the extra swelling because of the blood thinners). So I left his office pretty dejected.

The last two weeks of out of home physical therapy have been incredible - the two ladies I've worked with have helped me tremendously, with the physical side of therapy, but probably more importantly the mental and emotional sides as well. At times I've been a wreck thinking I'm not progressing fast enough but they were so encouraging they really put my mind at ease.

Doc said if I'm not at 120 degrees at 6 weeks he may have to put me under and perform a knee manipulation, or if I don't do that I may never have a full range of motion again.

After working me out for about 50 minutes the physical therapist have been able to get my ROM from 91 to 98 to 108 to 115 to 120 over the 5 sessions...although by myself I feel I'm between 110 and 115 and they sort of push me the rest of the way.

I saw my doctor's assistant yesterday and he seemed to be pleased with my progress but would like to see more range of motion than what I showed at the appointment (a little over 100 - although I had just sat in a car for 45 minutes and hadn't had a chance to warm it up). He said my walking looked very stable and mentioned that he could tell I had been on blood thinners because of the extra swelling. He again mentioned the possibility of knee manipulation.

I showed him a photo of me on my stationary bike and he said that looked great - ROM around 110 or maybe a little more. He said to lower the height of my seat one notch every 3 or 4 days and that would help increase my range of motion.

Other than this, what are some of the other ways to help increase my range of motion at home?

Not only do I want to avoid the knee manipulation but I also want to get as much range of motion in my knee as possible. I go back for my 6 week check up on June 12th.

I apologize for the long post but felt you needed to hear my whole story in order to offer the best advice.

Thank you for any and all help!

TripleB

 

[Layla]

Welcome to BoneSmart, TripleB! Thanks for joining us!

I am sorry you struggled through such painful and emotional early days. Thankfully that is behind you now and your days are feeling brighter.

Easier said than done, but try not to stress over ROM.
Please refrain from 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 find MANY stories on this site of members that bought into the same false notion. Many felt threatened by the thought of MUA. Given time and healing they realized their ROM isn’t something you fight for, but that it naturally returns as your body heals from the controlled trauma of this major surgery. What you need now is the proper rest, ice / elevation and any meds you were prescribed. Beyond that, time and healing will bring the ROM you need.

I encourage you to read others stories here. Scan the titles for other’s questioning this just as you are and read the responses from those farther along in their healing journey.

I wish you comfort and all the best as you continue up healing. Please stay in touch and share your progress with us.

 

[Flashlight]

Hi, at 2-weeks when getting my staples out I was at 90. I drove about 45 mins to my 10-week OS appointment, and he eyeballed my ROM at 110. My knee was stiff and swollen from the trip. I'm not sure why you have to go back at 6-weeks, and I would give it more time. My therapy plan had me increasing my walking every 3-4 weeks. I didn't start the bike until 10-weeks. I did mostly the extension exercises and the heel slides with stretching, Icing and elevating to try and get the swelling down. You have to remember you are still healing on the inside and you are swelling inside and out. I'm at 140 now and doing great. You will get there!

 

[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.
@TripleB

 

[Layla]

Hi again
Which knee was replaced? Will add that info to the signature we created for you.
Thanks!

 

[sistersinhim]

Doc said if I'm not at 120 degrees at 6 weeks he may have to put me under and perform a knee manipulation, or if I don't do that I may never have a full range of motion again.

Your doctor can't do anything that you don't agree to. Your bend will improve for even a couple of years.

although by myself I feel I'm between 110 and 115 and they sort of push me the rest of the way.

Allowing someone to push your knee past where you can do it yourself is only causing extra swelling and inflammation. That decreases bend!

Other than this, what are some of the other ways to help increase my range of motion at home?

TIME. Your knee needs to heal. As it heals the swelling will go down and you can bend it better. Fill up a water hose and leave the end nozzle closed off so the water stays in there. Now, try and roll up that hose. Can you roll it up? No, the water won't allow that. Well, your knee is the same way. Get the swelling down by icing, elevating, and resting as much as you can and your swelling will go down. Then you will be able to bend it more. It's actually common sense. You can not bend a swollen knee very well.

For many of us, we have found that gentle, daily activities rehabbed our knees better than exercising and aggressive PT. Because of birth defects, I've had 12 knee surgeries and never did knee exercises or took PT. My knees are doing just fine!

 

[TripleB]

Hi again
Which knee was replaced? Will add that info to the signature we created for you.
Thanks!

It is my right knee! Thank you for all of the helpful advice!

I had microfracture knee surgery on my left knee back in 2012 - it went AMAZINGLY well! Haven't had a bit of pain since...even playing tennis and pickleball which I was advised not to do. For that surgery I was on a CPM machine for several weeks after it so no ROM or scar tissue problems - so the swelling, pain, inflammation, etc. with the TKR is something brand new to me.

Anyway, I appreciate the advice from you and the others! It makes me feel a lot better about my situation!!!

TripleB

 

[Roy Gardiner]

Doc said if I'm not at 120 degrees at 6 weeks he may have to put me under and perform a knee manipulation, or if I don't do that I may never have a full range of motion again.

You will not get full range of motion if you have adhesions; where soft tissue has stuck together. MUA will break these adhesions by main force (hence the A part of MUA, it would be too painful otherwise).

If you don't have them, and they are not common, ROM will continue to improve with gentle stretching and just life. We think that 6 weeks is far too early to tell.

I showed him a photo of me on my stationary bike and he said that looked great - ROM around 110 or maybe a little more. He said to lower the height of my seat one notch every 3 or 4 days and that would help increase my range of motion.

Excellent. Here's my routine for a bike

• Set the bike to zero resistance
• Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
• Gently turn the pedals, through discomfort but without pain.
• Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
• Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
• Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
• And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't

Here is a bit more chat and some pix and how 'healing' and 'training' are different

 

[Roy Gardiner]

I had microfracture knee surgery on my left knee back in 2012 - it went AMAZINGLY well! Haven't had a bit of pain since...even playing tennis and pickleball which I was advised not to do.

Me too, in the mid-90s. Mr Dr said I'd be back 'within 10 years' for TKR, but it lasted until 2011.

 

[TripleB]

Doc said if I'm not at 120 degrees at 6 weeks he may have to put me under and perform a knee manipulation, or if I don't do that I may never have a full range of motion again.

You will not get full range of motion if you have adhesions; where soft tissue has stuck together. MUA will break these adhesions by main force (hence the A part of MUA, it would be too painful otherwise).

If you don't have them, and they are not common, ROM will continue to improve with gentle stretching and just life. We think that 6 weeks is far too early to tell.

I showed him a photo of me on my stationary bike and he said that looked great - ROM around 110 or maybe a little more. He said to lower the height of my seat one notch every 3 or 4 days and that would help increase my range of motion.

Excellent. Here's my routine for a bike

• Set the bike to zero resistance
• Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
• Gently turn the pedals, through discomfort but without pain.
• Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
• Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
• Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
• And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't

Awesome! Thank you so much for this information! It is extremely helpful!!!

In regards to the bike:
- At what point could I start using the bike to build back the muscles in my legs (ie: move past 0 resistance)?
- It seems as though my knee starts stiffening up around the 9 minute mark (I know, shouldn't have gone that long but PT had me go 7 minutes so I figured what's another 2 minutes) - but it also doesn't seem to get fully loose until about the 3 minute mark. Should I still stick with short (2 minute) 'rides' throughout the day?

And to everyone. At home I try to emulate what they have me currently doing at physical therapy:
- Heating pad to the knee while I work on tightening the muscles around the knee cap
- 5 to 7 minute stationary bike ride
- 20 knee extensions over the edge of the table with a 3 pound weight on ankle
- 20 high knees ('marching in place') with weight on ankle
- 20 heel "kickbacks" (lift heel back and up as far as I can, like I'm trying to get my heel to my butt)
- 20 "steps" where I put the surgery foot on a step and raise up the other knee as high as possible while keeping balance
- 10 leg stretches (from 100 degrees to 0 degrees) after I do the steps
- 20 squats (with no weight)
- Heel slides
* the only one I can't emulate is the leg press

I think all of this is not only to help with ROM but to strengthen the muscles around the knee. And obviously I ice and elevate once I finish.

My questions are:
How many times a day should I be doing this routine?
Is this too much for my knee at one time even though that's what they typically do in my PT?

Again, I appreciate everyone's fantastic help!

TripleB

 

[benne68]

@TripleB Oh my goodness! The list of exercises you describe seems like too much too so soon! You are barely a month post-op and you leg still has a lot of healing to do. You can't rush this recovery by pushing through pain.

Take a look at this chart about how long it takes to heal from the trauma of surgery.

Unfortunately, very few PTs are trained in how to help patients like us heal from joint replacement surgery. They apply the same training techniques they use on athletes recovering from injury -- it's counterproductive and can slow your healing.

Please read the article Roy posted above about how 'healing' and 'training' are different!

 

[TripleB]

@TripleB Oh my goodness! The list of exercises you describe seems like too much too so soon! You are barely a month post-op and you leg still has a lot of healing to do. You can't rush this recovery by pushing through pain.

THANK YOU VERY MUCH!!!

I felt like it was quite a bit but when they are taking me through the exercises (I go to PT twice a week) it really does make me feel great...the ROM increases, I feel like I'm being asked to do things that are challenging but not painful, and it helps my mental state because it feels like I'm accomplishing something.

But I'll definitely dial it back when I'm at home and concentrate on getting the swelling down (ice and elevation) and stretching the knee. The only time my pain level has ever been above a 7 (on a scale from 0 nothing to 10 excruciating) was one week after surgery (on a Monday) when the home PT was trying to get my ROM back to where it was the Friday before when she was there. Other than that, painful, but not unbearable.

Again, I appreciate your honest advice!!!

TripleB

 

[Roy Gardiner]

but it also doesn't seem to get fully loose until about the 3 minute mark. Should I still stick with short (2 minute) 'rides' throughout the day?

My schedule is a guideline; I'd say go to 3 minutes and stop. I say take the shorter time to discourage people from overdoing things.

At what point could I start using the bike to build back the muscles in my legs (ie: move past 0 resistance)?

When you've got really good ROM and are raring to go. Err on the side of caution for, maybe, six months.

 

[LD of Michigan]

Yes, six weeks seems too, too soon for all the range, degrees etc. your doctor is demanding IMO.

It often takes more time. I am almost four months out and had an annoying pain if I positioned my leg side-ways a certain way, softa of the side of leg not knee perse. I worried greatly as it did not happen with previous TKR.

Then as time went on and I got busy I also somewhat willed myself to stop thinking about and now it is far, FAR less. Thankfully, my surgeon and PT never made me feel anxious.

Keep us posted ))hugs((

 

[Layla]

Happy One Month Anniversary!
You're doing great. I hope you have a wonderful weekend.
@TripleB

 

[TripleB]

Thank you to everyone here!

I took your advice...cut back on trying to strengthen my muscles (like they do in my physical therapy) and concentrated on simple, and just a few, range of motion exercises: 5 minute stationary bike ride (0 resistance), walk the 13 steps in my house a few times, and heel slides (either on floor or wall). Do this 4 or 5 times a day with ice and elevate immediately after. I can adjust the stationary bike by lower/raising the seat and by moving the seat forward/backward - thereby increasing the "difficulty" of the ride, hopefully increasing my range of motion gradually.

Within 3 days my swelling went down substantially and the pain I had on the top of my knee cap went away (now more of just a slight tug when I bend it), therefore I feel much more comfortable walking "normal."

I can't thank you all enough for all the advice you've given me...it's been a tremendous help!!!

btw: any advice on what to help with the scar...been told Vitamin E and also been told Silicone gel

Again, I appreciate everyone taking the time to respond and help set my mind, and knee, at ease!

TripleB

 

[Jaycey]

any advice on what to help with the scar...been told Vitamin E and also been told Silicone gel

If you just let nature take its course, the scar will fade to a very thin line. Should you want something more to treat the scar, we recommend Active Hydrogel.

 

[Layla]

Happy Two Month Anniversary!
Glad you're doing so well. I hope you have a nice holiday weekend and a wonderful month of July!
Thanks for the update.
@TripleB