TKR BoneSmart Works!

[Susie-Q]

I had to get new orthotics after knee #2 also. After struggling to move them from slippers to shoes to dog walking shoes every day I relented and bought a second pair. Much better!!! I believe insurance paid for at least part of it.

 

[mendogal]

I have an eval appointment Thursday morning with the PT who saw me intermittently through much of 2022, when we were trying to treat the acute L knee conservatively.
My ortho doesn't concern themselves with soft tissue issues, but were happy to refer me for my ongoing R knee localized swelling connected to issues with the lateral quads. And according to the intake person at PT, they DID include both knees in the prescription!!! Yayyyy!
I trust Andrew, a very perceptive PT who sees us as collaborating, to do a good assessment and hopefully come up with a plan.

 

[mendogal]

PT REPORT
I'm so glad I asked my ortho team for a new referral for my R knee!

Andrew did an amazing assessment. He saw immediately how the slight patellar tracking was causing a little grating at the lateral tendon; watching (and taking slomo video on my phone) as I walked and squatted, we saw my R knee go too inward as I went down (this is in line with what my podiatrist saw, due to pronation, and my custom orthotics will help with that); as I come up the patella has to track laterally to come to return to midline, which is probably the cause of the chronic inflammation and swelling.

My bilateral flexion and extension are fine (IIRC, L knee +3 126 without any stretching or pulling; R knee -3 120). However when he passively raised and extended my R hip, my active R knee flexion reduces to about 95 or 100. He ascribes both this and my pain with sitting to chronically tight, shortened quads.

Re my complaint of longstanding (since at least my R ACL blowout) hamstrings pain when I attempt to strengthen them. He investigated and finds my R gastrocnemious is incredibly tight (the podiatrist had the same finding: chronically shortened and tight). I hadn't realized the origin of the gastroc is the lower femur: they and the hamstrings cross behind the knee, so it's easy to blame one for an issue with the other.

For now, I will do quads and gastroc stretches twice daily. After a couple of weeks he'll start me on light strengthening for the glutes, quads, and hamstrings. I'll see him once a week.

He's still working for our local medical monopoly; however, since moving to a satellite office he's apparently been mentored by the PT who did my 2016 shoulder rehab. No more "three sets of ten" nonsense! He's now converted to the sensible regimen I love: don't count reps; work each target muscle as slowly as possible in both flexion and extension til it's absolutely exhausted, and only do it once every 5-7 days. This ensures that both slow twitch and fast twitch muscle fibers get activated.

 

[AnnYo]

Wish I knew as much about anatomy as you do @mendogal! I would have a much more informed participation in my PT decision-making. I guess it's time to to start educating myself a little better.

 

[EalingGran]

we saw my R knee go too inward as I went down (this is in line with what my podiatrist saw,

This kind of careful analysis is really helpful. My pilates teacher does similar work with me - like working on vastus medialis to help tighten my MCL.
I still have to be careful not to let my knee twist inwards particularly when coming up from a low seat. I sometimes just gently push it out with my hand on rising- just to ensure it stays over my foot.

 

[MSuki]

I had a PT several years ago sho moved away. Her name was Valerie and I have never had another one like her. She would spend a lot of time having me walk/move and would watch me for issues. If she was telling me for example that my hips were slightly rotated she would come and put them in the correct position so I could see how it felt.

My most recent PT is a wonderful person and is great in the water and I think she is also pretty good about looking for issues, but nowhere near the level of your PT. Glad you found this guy!

 

[mendogal]

@AnnYo Don't feel badly....

I started taking life drawing classes at age 15, was a 40 yr career RN, 20+ years doing partnered martial arts, and am certified in massage.
I often have to look up names of muscles and what attaches where, but I've spent a lifetime watching and feeling my body and those of others' in rest and in motion to the point it's second nature.

Fortunately there's a lot of ways to gain good information, from getting an anatomy coloring book to taking a tai chi course adapted for folks with functional limits, to simply watching your body or even just your arm or leg in very slow movement in a full length mirror .

 

[MSuki]

@mendogal it’s so interesting to hear your background. I wondered where you learned all this stuff but it makes a lot of sense that you have become so knowledgeable between being an RN, an athlete, and the massage certification. It has always been clear to me that you know your stuff when it comes to anatomy and function. I’m almost surprised that you don’t have a physical therapist stint in the mix.

You rock!

 

[mendogal]

@MSuki thank you!
I briefly considered about 15 years ago going for an advanced degree in kinesiology to meld all this stuff. Physiology utterly fascinates me: how do we function?!?!
But, just as when I considered going to acupunture school in the 1980s or to get an advanced degree in nursing a few years later (actually submitted applications for both!), I simply doubled down on letting my RN work subsidize my first love (painting and drawing).
Life is funny, no?

 

[AnnYo]

@mendogal Thank you! Your varied background is fantastic and gives you such a holistic orientation to anatomy, physiology, and rehab! Your suggestions are great and I am going to get on it!

 

[mendogal]

PT update.
Today he palpated along the R lateral quads and ITB along my lower thigh and found a lot of trigger points. He did some deep tissue work on those.

Then he did slow intense Proprioceptive Neuromuscular Activation stretching of the R quads, finding a position that would mostly target the lateral. I've had this done various times over the years and I trust Andrew, so was able to breathe and relax into the discomfort.

Finally, he wanted to start on more active glutes strengthening. Well, I always thought the black theraband was the tightest and it's what I've been using. He wanted me to do a static hold at maximum effort. Well... after a ridiculously long time (3 minutes) the muscle wasn't nearly exhausted so he brought out The Really Tough Band - beige colored and wider and maybe there's actually a little elastic in it? - I was able to work both sides past slight burn to muscle shaking exhaustion. The good thing is with this kind of workout, once every 5-7 days is enough.

So after PT I drove to my volunteer gig, spent an hour moving between computer and standing/walking, and when I then walked to my car and got in I realized I hadn't noticed my knees at all during the past hour. Not even the R one!!!!

 

[sistersinhim]

I realized I hadn't noticed my knees at all during the past hour.

This is fantastic news and something everyone strives for!

 

[mendogal]

Yes!!! A real milestone for the newer knee!!!

 

[mendogal]

Big day yesterday! I got my new post cataract eyeglasses AND my new custom orthotics. The orthotics aren't compatible with some of my minimal, bunion friendly shoes, so I'll be buying one new pair of shoes.

Today I had PT again for my R knee soft tissue issues. More deep tissue work on the lateral quads, more PNA quad stretching. The stretching is very uncomfortable during the process; I just breathe into it and relax. My knee does seem to be happier after the stretching session.
I'm not sure Andrew's deep tissue work on the distal lateral quads just above the knee is productive. I suspect my trigger points are up up in the meat of the muscle while this problem area may be somewhat inflamed and needs a gentler approach.
The R knee swelling isn't any better or any worse. The evening deep muscle ache has been gone gone at least ten days but the localised pain remains on the lateral quads.

Fingers crossed that improved structure with the orthotics eases strain on the knees and promotes resolution of this nagging issue.

 

[kiwicurls]

New glasses and orthotics! You’ll be a new person. I hope the orthotics help you. They were miraculous for my husband, almost overnight success.

 

[CricketHip]

Janet, I agree about the productivity of the deeper work on your lateral quads and ITB, for me it just tenses me up even more. But someone else might love it.
I liked using my fingers and pressing them horizontally across the ITB and lateral quads.. like a cross fiber friction with light to moderate pressure. I found that a lot of the time the quads felt stuck to the ITB.
I wonder if that technique would help any? Maybe you've already tried that.

 

[sistersinhim]

I have used a rolling bar for my IT Band. It hurts, but helps.

 

[mendogal]

I have used a rolling pin for my IT Band. It hurts, but helps.

When I'm more limber, for decades my technique was using my body weight on a foam roller to get the TPs out of my quads. I a not getting enough purchase with my elbow so will try a wooden rolling pin tomorrow!
Yes it can feel like your leg is breaking!

 

[mendogal]

@CricketHip - I do like deep work further up in the bulk of the quads, but the ongoing pain is closer to the knee where muscle starts getting ropy as it transitions to tendon. I think your approach is way more appropriate there!

 

[MSuki]

I was just looking back to see when your cataract surgery was. I’m having one done on 3/19. I had different type of cataract several years ago so only one to do now (first was not age related, they called it a Christmas tree cataract but this type is also called glare which doesn’t sound as nice). I’m cautiously excited. Last time my plan was to go monovision and first eye has focus at about 12 inches. I am used to being very nearsighted anyway so I actually see better at all distances with the operated eye, I can even read some road signs. After reading (100-150 books per year, almost every year since I’ve been old enough to read, but unfortunately mostly mystery, sci fi, some werewolves, a little romance, and occasionally something techy I want to learn), my second most common activity is sitting in front of a computer. That includes work, hobbies, and gaming. Even when I started a whole house decluttering project (on hold since surgery) I started by making an Excel spreadsheet with a pivot table to show progress!

All that to say I was planning to get eye #2 distance, but was a little tempted to go with computer distance and wear glasses to drive. my doctor even said he would not recommend that for most patients, but he could see it working for me. Fast forward to my preop….there is a lens that my eye doctor highly recommends which will give me intermediate and far. No rings and vision should be sharp. It costs more and the surgery takes longer apparently, but it should not be too bad with the sedation although I won’t be asleep. I remember my last surgery and was surprised I stayed awake but didn’t care….

Back to you, how are the orthotics working? Is there an adjustment period for the affected muscles? Or is it a smaller change?