As you navigate through this website, it should become quite clear how much I emphasize regaining range of motion as soon as possible after knee replacement surgery.
Ability to walk does not indicate adequate knee range of motion.
One of the first questions I ask my patients at each follow-up visit after undergoing knee replacement surgery is: " How is your range of motion doing?" For some reason, a very common response is: "I am able to walk (x amount of ) distance."
Clearly patients value ability to walk. And while I agree that walking is important, it is crucial to understand that regaining knee range of motion early after knee replacement is absolutely crucial to an excellent long-term outcome.
Try a quick experiment. Take a few steps trying to keep one of your knees as straight as possible.
See? It can be done. You will have a strange gait, but you can walk with almost no knee range of motion.
Now walk normally while watching your knee move. Once again, very little range of motion is required to walk normally.
Now sit in a chair and put your feet flat on the ground in front of you. Notice how your knees are bent to around 90 degrees.
Now without bending your knees beyond 90 degrees, try to get up from a seated position without pushing off with your arms or thrusting your upper body foward to generate momentum. It is not possible. This is because your center of gravity is behind your feet. To stand up from a seated position, you simply must be able to bend beyond 90 degrees.
It is essential to regain functional range of motion by 6 weeks after surgery.
Remember, patients can only reliably regain knee range of motion for the first 6 weeks following knee replacement surgery. Beyond this point, scar tissue becomes too stiff and inflexible for simple stretching to be successful.
When patients have not achieved an acceptable, functional range of motion by 6 weeks postoperatively, I recommend manipulation under anesthesia.
My message is NOT - "Don't walk."
Walking is important. It helps to prevent blood clots, it will help reduce swelling, and it is good for the lungs after surgery. Walking is just not sufficient to obtain an excellent result following knee replacement. As much as patients are focused on walking as a sign of recovery, I focus on regaining knee range of motion as the true indication of progress.
1- Walking is important to patients and surgeons following knee replacement.
2- Walking does not require very much knee range of motion.
3- A patient's ability to walk after knee replacement does not necessarily indicate adequate knee rehabilitation.
4- The focus, particularly early after knee replacement (first 6 weeks), must be on regaining as much knee range of motion as possible.
5- The closer your knee range of motion is to normal following knee replacement, the more functional your knee will be for all activities (not just walking).
6- There is a limited time period (6 weeks) after a knee replacement for a patient to reliably regain range of motion. This is why I fixate so much on regaining motion as soon as possible after surgery.
7- Walking, comfort, confidence, strength, coordination, and endurance all will improve for months/years after knee replacement surgery. These factors all are improved when a patient has regained excellent range of motion. This means we should be patient with all of these parameters while focusing on early, consistent stretching to help ensure a good result.
We previously discussed the importance of regaining range of motion as soon as possible following knee replacement surgery. While some patients make this process look very easy, others struggle. It is important to relax while stretching (mentally as well as physically.) If your muscles are contracting while you are trying to increase joint range of motion, you are really just performing an isometric strengthening exercise, and causing pain and inflammation. I recommend extended duration stretching, with duration of stretch measured in minutes, not seconds. This takes advantage of the viscoelastic nature of biologic tissues.
While knee flexibility is diminished you could consider using a non-flexible yoga strap to help you stretch. Below, I have provided a few examples of how I would use such a device to rehabilitate my knee. Feel free to be creative...I am sure you can figure out additional ways to use this strap. Click here for a link to the device I used to make these videos.
The first 3 videos will help you regain flexion while the final video focuses on extension.
Flexing the hip while also flexing the knee focuses most of the stretch on the knee joint. These first two videos demonstrate different ways to accomplish that. In the video below, notice how I am using my torso to generate the force needed to flex the knee. I then take up the slack created in the yoga strap with my arms. Also feel free to use your other leg to help generate flexion force as I demonstrate.
The next video demonstrates how to use the strap to improve knee flexion while keeping the hip extended. This is done in the prone position. This will focus more of the stretch on the quadriceps muscle. I recommend stretching in each of these positions for the best result.
Excellent knee function also requires full knee extension. The strap can help you achieve this as well. In the following video, I loop the strap over the knee to be stretched. I then place my other foot through a loop in each limb of the strap so that it does not touch the ground, but applies an extension force to the knee.
The use of a yoga strap for knee replacement rehabilitation is certainly not mandatory, but simply provides another option to assist you. Always remember to use ice after stretching, hold the stretches for as long as possible, and relax your mind and muscles as much as possible during the stretch.
Total knee replacement surgery is an effective way to relieve arthritis pain when non-operative measures have failed. A substantial portion of the outcome, however, is based on adequately rehabilitating after surgery. The most important part of the rehabilitation program is regaining normal range of motion.
This is easier said than done.
At the time of a properly performed knee replacement surgery, the soft tissues are balanced and the range of motion should be full. That is: all the way straight, to all the way bent. This is something we test during surgery. Then the incision is closed and the healing process begins. Initially, there could be some swelling and acute surgical pain from the incision/surgical approach. Soon this acute pain subsides and stiffness begins. The stiffness is experienced by many patients as pain, especially when moving against the endpoint.
In a prior posting I discussed the tissue planes that need to glide to allow proper motion. Each day that passes after knee replacement surgery, more healing occurs. This process can create connections, or adhesions, between these tissues. After about 6 weeks, enough scar tissue has formed, that most patients are unable to obtain more range of motion by stretching. In other words, at around 6 weeks from surgery no more progress with regard to range of motion is possible.
The trouble is, in order to regain excellent function, adequate knee range of motion is necessary. Most patients are anxious to walk, ride a stationary bike, and are often quite focused on regaining strength. While these are fine things to do, and I certainly understand this desire, redirecting the focus to stretching appropriately remains my priority during the first 6 weeks postoperatively. Once range of motion is reestablished, all of these activities will be possible. Because we have a limited time to regain this range of motion this needs to be the priority early on.
Thankfully these stretches are simple. Gently and progressively force the knee straight. And then gently and progressively force the knee bent. Simple! Except when it's not.
Sometimes, and fortunately it is rare, a patient really struggles to regain range of motion after their total knee replacement. This can be a very frustrating situation for the patient and surgeon alike.
I recommend stretching early, often, gently, but progressively. It is better to regain motion early than to attempt to catch up when stiffness is setting in.
The simplest stretches are shown below:
This is one of the easiest stretches for extension. Place your ankle on a pillow. Relax your muscles to allow your knee to sag down. Then attempt to push the back of your knee down. This is a side view of my knee. It is important to note that my kneecap and toes are pointing straight up. This stretch can be held for minutes, gradually relax your muscles more and more, allow gravity to do the work. The longer the stretch the more the viscoelastic tissues will elongate.
This is the wrong way to stretch. This is a view of my knee from above. There is a natural tendency to externally rotate as your hips relax. Our goals are not being accomplished if this is allowed to happen. If you find this happening, simply place additional pillows or folded blankets along the outside of your foot and thigh to hold your toes and kneecap pointing up.
Now we are working on regaining flexion. In this example we are working on gaining flexion in my right knee (in the back ground of this photo). Here I have placed my left leg in front of my right ankle. I am using my left leg to help bend my stiff right knee more. This works best when done progressively over a period of minutes as opposed to seconds. Use your hamstrings in both legs to try to flex both knees further.
For deeper flexion than the previous stretch, this position utilizes a step-stool to provide deeper knee flexion. As shown, leaning forward and applying pressure with your hands can increase the stretch.
This is a stretch that can achieve extreme flexion. This time I am lying on my back. My knee is pointing up toward the ceiling. Flexing the hip relaxes the quadriceps. The hands are used to to pull the leg toward your body. The effect is increased hip and knee flexion.
Please note: if you have a total hip replacement, be very careful with this position as it can produce significant hip flexion.
These stretching positions should take care of 90% of total knee replacement patients. These stretches should be done everyday, ideally multiple times per day, with no days off. The longer the stretches can be held, the better. Remember to relax as much as possible while stretching and remember that a little pain is normal an expected. If no pain is encountered, I would recommend pushing a little bit harder. As always, if you have any specific questions about your particular case, discuss with your surgeon.
Occasionally we encounter a patient that has a very difficult time regaining motion. I have a few additional recommendations in these cases and will address that situation in an upcoming posting.
Orthopedic Surgeon focused on the entire patient, not just a single joint.