Manipulation under anesthesia
Uncommonly, a patient is unable to regain adequate range of motion in a reasonable period of time following total knee replacement surgery. When I observe a patient gradually falling behind with rehabilitation, I begin following them in my office more closely to provide guidance, and motivation. This can be a very frustrating situation for both the patient and surgeon.
I have previously written about the tissue planes in the knee that need to be encouraged to glide, and on some stretching techniques to accomplish this. My recommendations are based in part on the viscoelastic nature of these tissues.
I believe the quadriceps muscle can sometimes thwart a patients efforts to regain flexion. In the years prior to making the decision to proceed with knee replacement, a patient likely experienced episodes of giving-way or jolts of pain. The quadriceps would need to contract aggressively to prevent the knee from buckling. Additionally, many patients develop an abnormal, stiff-legged gait pattern which likely minimizes joint motion and pain. This quadriceps activity is likely subconscious, but by being repeated over a long period of time create neural pathways in the brain that are hard to break.
Postoperatively, the habitual quadriceps contraction in response to pain may make rehabilitation more challenging for these patients. I have developed this idea after hearing many patients explain how hard their physical therapist is pushing on their knee, and it simply will not bend. Ive been told the physical therapist is actually off the ground being supported by the patients knee. It sounds horrible. The only way for this to be possible within the first 6 weeks or so from surgery is for the patients quadriceps to be pushing back.
How can I be so certain? Because of my experience with manipulation under anesthesia. At around 6 weeks from surgery if a patient and I agree that their range of motion is not acceptable I perform this procedure.
A patient is briefly placed under anesthesia. I gently flex the knee while flexing the hip. Pressure is then progressively applied through the tibia and soft tissue releasing is felt and sometimes heard while this occurs. The goal is to re-establish the pre-patellar tissue plane (between the skin and the kneecap) and the suprapatellar pouch (between the quadriceps tendon and the femur).
Once this has been accomplished the knee will generally flex to 120-130 degrees under the force of gravity alone. This verifies that no more joint adhesions are obstructing motion.
So again, how do I know the quadriceps is fighting back? Because it only requires me to apply gentle pressure. Maybe 5-10 pounds of force. Worst case 20 pounds or so.
Based on this I recommend focusing on relaxing the quadriceps while stretching. Additionally, consider pre-fatiguing them. This is a technique where you would attempt to extend your knee while blocking it from moving (isometric quadriceps contraction) Then relax the quad and enter directly into the stretch. This can create significant gains. My experience has been most positive with prolonged, low force stretching as opposed to shorter, more aggressive stretches.
Relatively early manipulation of a stiff knee when necessary helps the vast majority of patients get back on track. By breaking up immature scar tissue it extends the rehabilitation window a bit. Patients still need to work hard on their stretching exercises on a daily basis, but by using this technique we can "catch them up," and help to ensure adequate function and pain relief.
8/27/2021 01:55:14 pm
In your experience, would a patient who cannot get quads to relax benefit from taking a muscle relaxant or anti- anxiety Rx such as Valium prior to doing the techniques mentioned in this article?
9/1/2021 03:52:43 am
This is an excellent question. While it is up to your surgeon, we have found valium to be helpful for some patients who experience anxiety and inability to relax enough to allow proper stretching.
10/17/2021 07:55:59 pm
What if the issue is not flexion? I am 62, medial pkr after an injury. I have complete extension and 125-130 flexion, but 13 weeks out and quads still lag. I can not properly load knee, which makes walking clumsy and I can't go up or down stairs other than one step at a time.
10/21/2021 07:01:15 pm
Quad lag is different than a flexion contracture. Can you passively extend your knee fully? If so- you have quad weakness than must be investigated ASAP as you could have a quadriceps tendon tear.
11/2/2021 10:51:46 am
11/3/2021 09:04:44 pm
You found the most appropriate article. I think you are a good candidate for manipulation under anesthesia. Usually best performed around 6 weeks post-op, you should have a very good chance of regaining around 120+ degrees of motion. Remember, this procedure is not magic, it will break through some adhesions, and buy you a few more weeks time. You will need to put in the hard work as I describe throughout this website. Definitely discuss this procedure with your surgeon. Best of luck to you!
12/16/2021 03:53:53 pm
Hello. Is it advisable to undergo the manipulation under anesthesia procedure if one is on blood thinners or should they be discontinued for a day or two prior to the procedure?
12/16/2021 03:59:04 pm
This will be up to your surgeon.
12/16/2021 04:55:23 pm
Thank you. Will being on blood thinners tend to make swelling control more difficult?
12/29/2021 08:31:53 am
Blood thinners can make patients bleed more into the joint and/or soft tissues. This will result in swelling. The recommendations include elevation of the extremity above heart level as much as possible, and to consider using gentle compression when it is not possible to elevate the limb.
Cheryl C Cormier
11/29/2021 05:49:23 pm
I had kneecap replacement July 2020. Had MUA AMD ARTHROSCOPIC SURGERYAY 13 2021. 4 Days after the MUA and surgery I fell down 3 steps. I caught myself on railing and did not hit the ground but my knee bent completely tearing a quad tendon badly. I was brushed off by PA blocking me from seeing my surgeon telling me not to believe it was a quad tear keep doing Pt. My physical therapist called the surgeon. It was 3 weeks after fall. I got in sent to get x-ray and next day had repair. June 9. In knee brace for 5 weeks. Quad tendon strength has improved but just sitting here typing this it's throbbing. My knee is stiff. I can extend leg but flexion has remained 65 to 70 degrees which is what the surgeon got during repair surgery. It feels like something directly below my kneecap is a brick wall. My surgeon said if he does an mua he may break my femur. Push through the pain. If I were to fall again it would be damaged. The quad tear was so bad he didn't have much hope
12/16/2021 04:03:39 pm
This is a very difficult situation. While it is not possible to address your specific issues adequately online, I understand the situation.
12/9/2021 06:37:38 am
12/16/2021 03:47:11 pm
I would definitely recommend manipulation for a knee that only has 95 degrees at postop week six. What did you end up doing?
12/16/2021 08:01:31 pm
At my 6 week checkup the bone is healing well reviewing the xray. He recommended a JAS brace. He doesn't want to do a manipulation as he fears its a last resort due to thigh bone perhaps breaking.
12/16/2021 04:44:09 pm
My doctor says the healing is going well Based on the x-rays.He wants me to try a JAS brace.. And see how the next 4 weeks go. He does not want to do a manipulation yet. It's a last resort..
12/29/2021 08:34:13 am
Long duration stretching is the key to success. Use any means necessary to hold the stretch for longer. Do this as often as possible, for as long as possible. Best of luck!
12/20/2021 05:24:04 pm
RTKR completed 9/16, MUA completed 11/17. Leg kept seizing for 1 month after MUA and there are persistent pain issues to address. Pain MD says synaphonous nerve may be issue and will inject analgesic to diagnose on 12/23. ROM sticking around 80 degrees even though MUA broke to 130 degrees. Feel tight band around knee during PT. Is the band due to scar tissue. Is it possible to get another MUA?
12/29/2021 08:46:25 am
The feeling of tightness is common after surgery. Early on, this is due to inflammation. Progressively, scar tissue and adhesions form. These adhesions create physical restrictions/tether the joint. It is crucial to push through the inflammatory tightness such that when the adhesions form, they constrain the joint outside of a functional range of motion. In my experience, a patient typically has 6 weeks following knee surgery to regain a functional range of motion. If motion is inadequate at 6 weeks, I recommend manipulation.
1/31/2022 08:57:54 am
I had internal fixation (with wire) of my patella after a displaced fracture. For that reason, the initial priority was to keep the knee straight so as to not pull the fracture apart. Is healing, ROM, comfort timeline different than what is typical for a knee replacement? I'm confused in that I'm told it'll take months to regain ROM and comfort which seems to be different than what I read here for knee replacement patients. Thanks for your insights.
2/26/2022 03:24:04 pm
Yes, the timeframe is significantly different following fracture surgery. You can expect to regain motion for many months, even up to a year following the surgery you described.
2/26/2022 03:41:32 pm
Thanks for the reply and insights, this is wonderful news.
2/19/2022 11:13:40 am
I’ve had both knees replaced. Right knee 2 years 8 months ago, left 2 years 3 months ago. Right knee is at about 115 degrees flexion, left 105. I had arthroscopy/ manipulation on left knee 1 year ago and there was no gain. Would a second procedure have a chance of being more successful at this point? I went to two different PT’s with different philosophies. One used extreme
2/26/2022 02:52:45 pm
Unless you have a plan to approach your rehabilitation significantly differently next time, I would recommend against repeat surgery on your knee. It seems like all risk and no reward. If you were not using long, slow stretching from the beginning, and could commit to doing so in the future, then perhaps it could be worth the risk. In my experience slow, steady stretching, done multiple times throughout the day, every day, is the most successful way to stretch.
3/2/2022 04:10:49 pm
Thank you so much for all your repliesI had a knee replacement 6 weeks ago I am only at 60 degrees. However my other problem is that my quadricep has not fired since surgery.the surgeon ordered an emg and after he gets results he wants to do a mua. Do you think the MUA will be beneficial if my quadricep is not firing.
4/9/2022 04:34:42 pm
A manipulation procedure will help you with range of motion, but will not help your quadriceps to fire. Consider asking your physical therapist to use e-stim to help retrain your quad to fire. I am very curious about your EMG results. This is a very unusual complication following knee replacement surgery.
4/3/2022 01:10:46 pm
If I am supposed to have a manipulation done in a couple days, do I need to stop taking my meloxicam.
4/9/2022 04:28:54 pm
I do not have my patients discontinue anti-inflammatory medications for this procedure. I recommend you check with your surgeon though.
4/12/2022 07:16:08 am
Had TKR in Feb. I am an active 61 year old.
5/24/2022 10:34:51 pm
10 weeks is a bit later than I prefer doing manipulation. Usually, after 12 weeks arthroscopic lysis of adhesions is required to regain any motion. What did you end up doing? How are you doing now?
5/25/2022 08:05:40 am
I did have a manipulation in April, without much success.
6/29/2022 12:38:08 pm
Just as with your manipulation, the arthroscopic procedure would be expected to successful in that your surgeon will be able to regain knee range of motion. The unpredictability is the extent to which you will be able to rehabilitate adequately and maintain this range of motion. In my experience, long duration stretching is the key to success.
I am 4.5 weeks S/P TKA, and my surgeon suspects arthrofibrosis. He says he would like to perform MUA on me after seeing me six weeks postop if my flexion doesn’t improve above the 90-95 degrees that I currently have.
5/24/2022 10:49:59 pm
Most patients do get improvement not only in range of motion, but also with pain, soon after manipulation. Consider this procedure getting "caught up" with rehabilitation exercises. Generally postop pain impedes motion. Then stiffness results in ongoing pain. Manipulation breaks through this stiffness, and because the knee is otherwise fairly well healed the only tissues that are disrupted with the procedure are the ones that were abnormally tight. Hopefully this will be your experience as well.
7/24/2022 08:46:03 am
Thank you so much for all the information provided. I have read all the articles and watched all your videos on TKR. I had mine 24 days ago and I was discharged the same day after being able to bend my knee 90 degrees and lift it unassisted. About 24 hours later I had my first in-home therapy visit and I couldn't bend past 45. Since then, I have made a very slow and painful progress to 70 degrees assisted by PT 3 times a week (1h sessions), CMP machine at home (about 2 hours a day broken in 1 h sessions), one deep tissue massage, and stretching on my own daily (I am using your suggestions but I can't hold it for long, so I rest it for a quick second and try again).
7/29/2022 07:43:04 am
I think the best time to do manipulation under anesthesia is around post op week 6. This allows you as the patient to have a chance to rehabilitate properly. It also allows your incision to heal solidly (skin and arthrotomy- the incision into the joint). I would increase frequency and duration of stretching immediately with the goal of trying to avoid manipulation. If you have not adequately regained motion by week 6, then do the manipulation AND make sure your rehabilitation efforts are more inline with my recommendations after this procedure. Long duration, frequent stretching. This is crucial. Manipulation without adequate postoperative rehabilitation is useless. It is normal for pain to worsen for several days after surgery. This is a normal part of the inflammatory cascade. Use ice/NSAIDS as much as possible to control this. Most importantly, do not let pain convince you not to stretch. Everyone is different with regard to pain tolerance and need for stronger pain medicines. I think NSAIDS work the best (if tolerated). In my opinion, rehabilitation is so important that pain medication should prescribed generously in the early couple of weeks after surgery.
9/11/2022 10:04:06 pm
Dear Dr. Gorczynski
9/17/2022 08:35:09 am
Unfortunately, it is getting a bit deep into the postoperative period to expect much in the way of gains. Getting more motion 3 months after knee replacement is unpredictable at best. Any gains will require long duration stretching at the endpoint (hours each day). I would expect this to be unpleasant and cause inflammation. This is because the scar tissue gets increasingly organized/tough as time progresses. Be generous with ice and endpoint stretching. 105 degrees is about the minimal amount of motion for most activities of daily living, but certainly isn't a great result. It is possible that with time, and effort, he may gain a few more degrees over the entire first year following surgery, but you definitely can not count on this. In my opinion, you do not lose much by stretching diligently for the next few months, see if some gains can be made. The alternative would be arthroscopic lysis of adhesions followed by repeat manipulation. With this procedure, your surgeon would cut the scar tissue adhesions (primary between the distal quadriceps tendon and the femur) and then force deep flexion again. This would regain motion again- but rehabilitation would be started again as well. If this ends up being necessary, make sure you are generous with ice and frequent, long duration stretching to make sure gains are made, and kept this time.
12/12/2022 08:22:45 pm
Dear Dr. Gorczynski
12/16/2022 08:13:59 pm
Unfortunately in a case like this, the only thing that will help is stretching. Biking may be counterproductive, as it really does not have the ability to increase range of motion much, certainly not efficiently, and the downside is potentially increased inflammation. My advice would be focus on LONG duration stretching. Use the JAS brace, or yoga strap, but hold those stretches for long periods, and repeat as much as possible. Patient, persistence is the key.
4/2/2023 04:34:07 pm
I just had a MUA post op TKR 2 months ago. My knee felt like a cement block and had only gotten to 99 degrees with do PT everyday and pushing it, including 1 min intense holds. I started PT day after and now 5 days after I a. Feeling I over did it with the rehab and my adductor muscles are so painful I am backing off today. Do I need to just take pain meds and push through it anyway or back off a little? I use straps to flex my knee farther and hold 30 to 60 secs. Do I need to increase the frequency of the holds? These are what is the most painful.
5/7/2023 03:19:25 pm
I am not sure what you mean by "intense holds." If this means you force your knee and fight the pain by tensing your muscles, then this is likely to be ineffective. Check our my videos where I describe slow, gentle, progressive stretching, held for many minutes at a time. The goal should be holding the endpoint of your motion for a minimum of an hour each day cumulatively. When stretching is referred to as intense, the patient is likely fighting back against the stretch way too much.
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