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Manipulation under anesthesia

5/24/2016

32 Comments

 
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.

Guaranteed. 

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. ​
32 Comments
Kellie Crowe
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?

Reply
Christopher Gorczynski, MD link
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.

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Jon Shestack
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.

Reply
Christopher Gorczynski, MD link
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.

If you are not able to fully extend your knee passively, then you have a flexion contracture. This is very difficulty to fix at this stage of recovery. I would recommend trying a progressive static bracing system. An example of this is JAS (Joint Active Systems).

Reply
Reed Bernhard
11/2/2021 10:51:46 am


Hello,
I had tkr 5 weeks ago and I’ve only achieved 85 degrees flexion thus far. I mistakenly was less aggressive with rehab in those first couple of critical weeks. Am I now doomed to never get more than about 100 degrees? The 85 degree point has held steady for about the last 12 days- I’ve reached a plateau of sorts, no matter how much I aggressively rehab, the knee is stiff and “stuck”.
Have you any encouraging advice for me? I’m very discouraged.
Thanks.
Reed

Reply
Christopher Gorczynski, MD link
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!

Reply
Reed
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?

Christopher Gorczynski, MD link
12/16/2021 03:59:04 pm

This will be up to your surgeon.

I do not have patients discontinue anticoagulation for this procedure.

Reply
Reed
12/16/2021 04:55:23 pm

Thank you. Will being on blood thinners tend to make swelling control more difficult?

Christopher Gorczynski, MD link
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
I'm seeking a 2nd opinion tomorrow because I don't feel he cares that I am doing everything. I have pt and home regimen I also bought all the tools the therapist uses. The ball, massager, ultrasonic tool. My knee is giant. What is your take on this

Reply
Christopher Gorczynski, MD link
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.

In my opinion, to regain more motion, you will require arthroscopic lysis of adhesions prior to manipulation. This will allow disruption of the scar tissue that has likely formed between the distal quadriceps tendon and your femur. This allows manipulation to be done with much lower force.

Reply
Wendy Whyte
12/9/2021 06:37:38 am

Hi
I just found your website. So much useful information.I am 56 yrs old female who is a gardener so my thighs are pretty muscular. I am almost 6 weeks out and just reaching 95 degrees on my left total knee replacement. I could not even bend it after the first week. I called my surgeon office and physio therapist panicking weekly doing the exercises recommended. I was not informed that I should be 90 degrees first week just that by week 6- 110 degrees. By 3rd week I asked for physio 2x week making slow improvements. I can't even pedal around on a stationary bike yet. The surgeon did mentioned at my 2 week follow up I might have to have a manipulation but this scared me and I have been doing my best. I have found by heating the muscle prior to exercise seems to help..but the leg is so heavy every morning . I am elevating and raising it...the swelling is just above the knee and I think inside of it.. Could I just be a slow and work through a few more weeks or have a manipulation done at the 6 week mark. I see my surgeon next week for 6 week checkup.

Reply
Christopher Gorczynski, MD link
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?

Reply
Wendy Whyte
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.
I have to keep pushing through it. I am about 95 to 100 with physiotherapist pushing on it...so I have decided to rent the JAS Brace..hopefully things work out. I have also another physio therapist that I am going to as well...so all hands on deck. I need to get this knee back on track as I need it working by April for gardening work. Walking is still a task as its stiff but maybe this is because my leg is realigned properly too now. Fingers crossed

Wendy Whyte
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..

Reply
Christopher Gorczynski, MD link
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!

Reply
Pat Cerna
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?

Reply
Christopher Gorczynski, MD link
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.

While it is possible to manipulate a knee again, this would need to be done 4-6 weeks following the first manipulation.

The need for a re-manipulation should be extremely rare. It suggests an ongoing problem with rehabilitation and/or implant balance. Considering your surgeon was able to achieve 130 degrees of flexion after manipulation, This seems to be more of a rehabilitation issue. I would encourage longer duration stretching, done more frequently. Always remember to try your best to relax your muscles during this stretch. Unless your rehabilitation approach is significantly changed, repeat manipulation is unlikely to be helpful.

Reply
Phyllis
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.

Reply
Christopher Gorczynski, MD link
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.

Reply
Phyllis
2/26/2022 03:41:32 pm

Thanks for the reply and insights, this is wonderful news.

Mary Bertrand
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
force, the other time to stretch muscles , in that order. I would appreciate your advice. Thank you,
Mary

Reply
Christopher Gorczynski, MD link
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.

Reply
Lori kragnes
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.

Reply
Christopher Gorczynski, MD link
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.

Reply
Jennifer smith
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.

Reply
Christopher Gorczynski, MD link
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.

Reply
Lisa Rosen
4/12/2022 07:16:08 am

Had TKR in Feb. I am an active 61 year old.
At 97 degrees at 10 weeks. Knee is stiff. Had lots of swelling..Been doing PT 4-5x/week and myofascial massage 2x/week to get the fluid moving.
Dr. wants to do MUA next week. Is it too late to have MUA at 10 weeks? Or should I consider arthroscopic/manipulation option?

Reply
Christopher Gorczynski, MD link
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?

Reply
Steve link
5/15/2022 07:06:14 pm

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.
I have read much literature extolling MUA because it can dramatically increase flexion. My current condition is one of continual and significant knee pain postop. IF arthrofibrosis is the correct diagnosis and I get a good improvement of flexion after MUA, can I ALSO expect a significant reduction of pain in a relatively short amount of time after having the procedure? Thank you

Reply
Christopher Gorczynski, MD link
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.

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