MUA Unsuccessful Manipulation?<

[faroboy]

Hello everybody. I had ACL reconstruction in October 2015. Pre-op my ROM was 90/5. 3 months after surgery my ROM was about 15 degree extension and bending was great.

I went through manipulation January 12. My surgeon was able to get it to 5 degrees of extension. However, a week later and I'm starting to lose ROM again. I'm so scared that I won't be able to get full extension. What can I do then? If they were not able to get full extension during manipulation, how will I get it with just physio?

Please help me. I'm in my 20s and feeling extremely depressed. This is effecting everything in my life

 

[Jaycey]

Welcome to BoneSmart! So sorry you are struggling with ROM. Are you icing and elevating your op leg? Taking medication for the pain?

Do not let any physio force your knee. This only adds to the swelling that is causing the pain. Get that swelling controlled and you will see much better results.

Here's a couple of articles from our Library on this:
Myth busting: no pain, no gain
Swollen and stiff knee: what causes it?
Myth busting: the "window of opportunity" in TKR
It's never too late to get more ROM!
It's worth the wait for ROM

 

[Josephine]

Hi and welcome to BoneSmart! Let me put this all into context for you.

1. your ACL repair is only 16 weeks post-op
2. your MUA was only 5 days ago.

Recovery for an ACL repair can take months sometimes a year to get any improvement. During that time, the ROM is likely to be fairly poor and about 70-80% of this is due to swelling from the surgery. So I'm not at all surprised by your numbers. In addition, it's next to impossible to improve extension with an MUA so though he could press it down to 5 degrees, it's going to spring back like a bungee cord once he releases it.And any attempt at MUA is also going to increase the swelling exponentially thereby decreasing the ROM. Read the article on the swollen leg to see what I mean.

It would also depend what kind of procedure he used for the repair/reconstruction. Did he just repair it or did he use a graft (allograft meaning from your leg), or an artificial tendon made of something like Teflon. Each of these has their own impact on post-op ROM which I will explain later, when I know which surgery he did.

So all in all, you're still pretty early out in your recovery. If you follow the advice Jaycey offered and rest more, you might find things improve.

In the meantime, I'd like to ask you some questions if you don't mind, and it would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. And don't compare this with the bone-on-bone pain you had before surgery! ) Also don't forget to include other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how often are you icing your knee and for how long?

4. are you elevating your leg, how often and for how long?

5. how swollen is your leg?

6. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

7. what kind of PT exercises and exercises at home are you doing? How much and how often?

These examples are how I would like you to describe your exercise regime. This is the most crucial question so please make sure you describe them as I've requested.

Exercises done at home: 3 sessions a day
Heel slides x10 (reps)
Straight leg raises x10
Steps x10

At PT
Squats x5 (reps) x2 (sets)
Wall slides x5 x2
Clamshells X5 x2

 

[faroboy]

Hello Jaycey and Josephine. Thank you for answering my question.

They used allograft (my own hamstring)

1. resting pain level: 0
-walking with crutches: 5. i wouldnt be able to walk wothout crutches yet
- exercising: ranges from 5-10 depending on the exercise and how hard i push it

2. oxycodon hcl/acetaminophine 5/325mg. I'm not taking them now b/c i feel no pain when i'm resting. i only feel pain when exercising or walking

3. I ice 4 times a day for 15mins

4. elevate most of the day. anywhere from 10mins to 20mins. i even put weights on my thigh/knee to make it go down. its one of the more painful exercises i do

5. swelling: moderate

6. I don't do much housework right now. I live with my family and they take good care of me

7. exercises at home:
- elevate with no weights: about 10 times a day for at least 10mins each time
- elevate with weights on knee: about 5 times a day for at least 10mins each time
- heel slides: twice a day (i don't do much b/c my bending comes along fine)
-push down on thigh, while having the leg extended on an angle

At physio:
all the above + use the electric stimulant to help me squeeze my thighs.
- sometimes they push really hard on my leg tothe point that i feel like screamin so loud.

Although the physio are able to get my knee straight after putting me through so much pain, soon after my knee loses the extension gained. The next day i wake up and any extension gained the day before is lost. Also, i have a bit of a hyperextension in my good leg (right leg). do i have to avhieve the same hyperextension to play sports again

Thank you!!

 

[Jaycey]

i even put weights on my thigh/knee to make it go down. its one of the more painful exercises i do

I'm going to let Josephine comment on your answers but why ever would you do this bit with weights. You are only adding to all the swelling and trauma. Sounds to me as if you are doing far too much exercise and not letting anything settle.

 

[Celle]

Here are some exercises you can do gently at home, to help with extension.
Extension: exercises for improvement
Just choose one or two that you like and never do them to the point of pain.

It's not unusual for extension to take longer to achieve than flexion. The muscles and tendons at the back of your leg may have shrunk a bit and it will take time (and gradual progression) for them to lengthen again.

 

[Josephine]

1. resting pain level: 0
-walking with crutches: 5. I wouldn't be able to walk without crutches yet

Well that's about what I imagined it to be.

2. oxycodon hcl/acetaminophine 5/325mg. I'm not taking them now b/c i feel no pain when I'm resting. I only feel pain when exercising or walking

There is a clue here!

3. I ice 4 times a day for 15mins
4. elevate most of the day. anywhere from 10mins to 20mins. I even put weights on my thigh/knee to make it go down. its one of the more painful exercises i do

You accomplish little or nothing in 20 minutes. Ice for at least 40-60mins and more than 4 times a day. DO NOT use weight on your leg. As you describe, it simply pops up again because of the swelling. You are achieving nothing by this. Much better to allow your knee to progress on its own.

5. swelling: moderate

Okay

6. I don't do much housework right now. I live with my family and they take good care of me

Jolly good!

My comments in bold
7. exercises at home:
- elevate with no weights: about 10 times a day for at least 10mins each time - do you mean resting elevation? Read what I said about that earlier
- elevate with weights on knee: about 5 times a day for at least 10mins each time - no, NO weights. NO good!
- heel slides: twice a day (i don't do much b/c my bending comes along fine) - well good.
-push down on thigh, while having the leg extended on an angle - no pushing, no pressure - far from achieving anything it's actually doing the opposite

At physio:
all the above + use the electric stimulant to help me squeeze my thighs - if you can't squeeze your thighs without that, then just let it take its time
- sometimes they push really hard on my leg to the point that i feel like screaming so loud. - do NOT ALLOW this. It's traumatic and will only increase the swelling that is the problem in the first place.

Although the physio are able to get my knee straight after putting me through so much pain, soon after my knee loses the extension gained. The next day i wake up and any extension gained the day before is lost. Also, i have a bit of a hyperextension in my good leg (right leg). Do I have to achieve the same hyperextension to play sports again

Exactly! It's unproductive and unnecessary. Your extension will come good but it can take a year or more. Pushing only slows that down so don't do it and don't let anyone else push.

 

[faroboy]

Thank you ladies very much I will definitelty give your advice a good try. I appreciate you taking your time to answer my questions

 

[Josephine]

You're very welcome!

 

[charmed-life]

How are you doing? Have you been doing more icing and less painful PT? Any improvement at all?

Sent from my iPhone using BoneSmart Forum

 

[faroboy]

It's been 5 months (22 weeks) since my acl surgery, and 11 weeks since my manipulation, and my rom hasn't improved by much since the manipulation. i still wake up with a stiff knee, and walking is horrible in the morning. once i work on extension however, extension increasses and walking improves. but if i stay a couple hours without working on extension, the knee becomes stiff again

At this poiny in time, will my rom actually increase, or is it past that now?

I've also started working full time. so, that means 8 hours less spent working on my knee, how much of an effect would that have on my knee?

Any thoughts on a second manipulation?

 

[Pumpkin]

faroboy,
Since your extension improves when you walk, a MUA may be questionable. Stiffness is pain and needs to be addressed, with Rest, Ice, Elevation, and Medication on schedule as prescribed.
We have had members continue to gain ROM at a year or more.

 

[Josephine]

Thank you ladies very much I will definitely give your advice a good try. I appreciate you taking your time to answer my questions

Was this comment not genuine? I just ask because you seemed to be right on board with what I'd said here.

i still wake up with a stiff knee, and walking is horrible in the morning. once i work on extension however, extension increases and walking improves. but if i stay a couple hours without working on extension, the knee becomes stiff again

Which clearly indicates that your exercising is counterproductive. The more you do, the worse the repercussions are. Can't you see that?

At this point in time, will my rom actually increase, or is it past that now?

You primary surgery was only 6 months ago and the MUA was only 10 weeks ago. You are expecting miracles. ROM can continue improving for a year or more but you must give your knee a rest!

I've also started working full time. so, that means 8 hours less spent working on my knee, how much of an effect would that have on my knee?

Well, consider your work to be instead of your exercises and you might have a fighting chance. Do them both and you're risking being dead in the water.

Any thoughts on a second manipulation?

Yes - forget about it!

 

[kneeper]

In some ways the mua is like a re-injury so when you say you're at 5 months in some ways you aren't--see what I mean?
Also 5 months is not long in the tkr world. It is not abnormal at all to feel stiff after sitting or being inactive for a while. That takes a long time to go away. I found at that point that my ROM got a bit better/easier just by doing normal activities (paced according to what the knee allowed) and waiting. Time is a big element.

 

[faroboy]

Hello everyone,

I just had my 2nd scar tissue removal surgery 2 days ago. Steroid pills were prescribed to me because they reduce inflamation, which uktimately reduces adhesions and scar tissue.

Unfortunately, one of the equipment they used was not sterilized, so there is a risk of infection in my knee. They gave me antibiotics for it. The surgeon advised not to take steroids with antibiotics.

Has anyone used steroids before to treat arthrofibrosis? How helpful are they at combatting scar tissue formation

 

[skigirl]

Wow, how bad is your knee? Do you know for sure you have adhesions (scar tissue)? Steroids have so many side effects---they made me crazy, I would overreact to everything!!

You had a MUA in January--was that when you realized you had adhesions? If you are worried about infection, I think the antibiotics are more important right now than the steroids---did the same doctor give you both? I am going to tag @Josephine , our forum nurse who can advise you. But, first give us more details of your knee saga.

 

[faroboy]

october 2015: acl surgery
january 2016: lysis of adhesions + manipulation
may 2016: posterior capsular release

do you know if thr steroids helped though? i was only supposed to take the first 5 days after surgery, but now that i'm taking thr antibiotics i'm not allowed to take the steroids b/c that would have a negative effect

 

[Celle]

I think your question about using steroids when an infection is present is one that Josephine is best qualified to answer. I see that skigirl has already tagged her. (I've read a bit about that, but only in connection with racehorses, not humans. LOL)

 

[Josephine]

Unfortunately, one of the equipment they used was not sterilized, so there is a risk of infection in my knee.

WHAT??? That's outrageous! And you definitely need antibiotics above everything. You need to ask why the instrument wasn't sterilised. That's really a very seriously incompetent and unprofessional thing to happen. You also need to register a complaint about it just in case anything untoward should happen like an infection. Please do this. You cannot be too careful.

Steroid pills were prescribed to me because they reduce inflammation, which ultimately reduces adhesions and scar tissue. The surgeon advised not to take steroids with antibiotics.

Steroids don't 'treat' arthrofibrosis, nothing will treat it. They just lessen the general inflammation and swelling. So since the instrument wasn't sterilized, you should take the antibiotics.

 

[amberpep]

OUCH! Everything you're telling us makes me cringe ..... manipulation? weights on your thigh? I'm not a doctor or nurse, but all that sounds just plain nuts. You sure you're seeing an Orthopedic doctor? I was always told by my P.T. and my doctor to just do the exercise "up to the pain" not "into the pain." Seems like some of these things are intentionally making you have pain. And that infection situation ..... I would never use that hospital/clinic ever again. And I wonder about the doctor too. When I had my revision, it was delayed by several hours because the doctor told me two of the pans (which they put the instruments in) were not sterilized. I hope they're giving you the right antibiotic.
I don't want to sound snarky, but I wouldn't have much faith medically in this crew. Follow what Josephine is telling you and if you have to argue a bit with your Ortho. and P.T. do it. There are always others you can use. I have found that Josephine is always right on ..... really sharp lady ..... follow her advice.
abby