gorczynski manipulation under anesthesia

Manipulation under anesthesia

5/24/2016

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.

40 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?

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.

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.

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).

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

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!

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?

12/16/2021 03:59:04 pm

This will be up to your surgeon.

I do not have patients discontinue anticoagulation for this procedure.

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
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

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.

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.

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.
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

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!

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?

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.

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.

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.

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

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.

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.

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.

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.

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.

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?

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.
The Dr. was able to manipulate me to 120-125 degrees, but I am presently at 100 degrees flexion and -5 degrees extension.
This is with 6 days/week PT after the manipulation and working at the knee at home. Doing lots of stretching exercises. I am very determined.
I have another appt. in June with the Dr. I will probably need the arthroscopic lysis of adhesions surgery. I had an MRI in May that showed scar tissue extending into the gutters, suprapatella pouch and fat pad.
I am going for a 2nd opinion.
Is the success rate good with the arthroscopic surgery?
I am very healthy and active. All I want is to be made whole again, so I can move on with my life.
Please let me know your thoughts.
Thank you,
Lisa

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.

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

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.

Rebeca Chavez

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).

My knee feels very stiff and heavy. I have difficulty walking properly and fear I will develop a permanent limp. Some mornings it takes me a while to be able to walk and I haven't been able to sleep through the night since the surgery. I feel physically and emotionally drained. I am 49 and I had an accident at aged 4 and later tore my meniscus at age 45, both requiring surgery. Before my TKR surgery I was very active and healthy (if I ignore my knee issues) but the pain was becoming worse and worse and cortisone shots stopped working after just 1-2 months.

My next appointment is in two days and I feel MUA is going to be necessary. I have many, many questions but these are the most important ones:

I have read about MUA being done after week 6, but given my slow progress despite making my rehabilitation a full time job, are there any risks associated with having the MUA at week 4?

What are the odds of a positive outcome considering my history?

How do I prevent that 24 hours I reversed like it happened after the surgery?

How bad can I expect the pain to be? I was sent narcotics after surgery but I tapered off 2 weeks after surgery. Do your patients usually need narcotics to manage the pain after MUA?

Any other advice for me?

Thank you so much for your time,

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.

Mary Hesketh

9/11/2022 10:04:06 pm

Dear Dr. Gorczynski

Thank you so much for your wonderful website. It is a wealth of information that we have not been able to get from any other source.

My husband had a TKR on 6/21/22. He was discharged same day, after achieving an ROM of 90. He had only 6 very lame home PT visits during the first 4 weeks post-op, with ROM never over about 90. (This long wait for the post-op checkup was b/c the doctor was on vacation.)

After finally having his first post-op checkup 3-1/2 weeks post-op, he started "real" PT in the PT facility.

He made pretty much no progress in PT. He didn't do any long stretches until we found your website, several weeks after surgery. Even with these, possibly b/c he was so long with virtually non-existent PT, he made pretty much no progress, never getting more ROM than about 100. So at 9 weeks post-op, the doctor said he had a lot of scar tissue, and he did an MUA.

The doctor said he got another 30 degrees ROM during the MUA, which should have put my husband around 120 degrees. We are now 3 weeks post-MUA (12 wks post-TKR), and he has never achieved more than 105 degrees, and that was in PT, with the therapist really whaling on his leg. His last ROM was about 105 a few days ago.

I have a few questions about long stretching. He stretches now, with his legs over the end of the sofa, often with weight of up to 1-1/2 lbs. I have been lately doing contract and release with him, where he pushes up against my hands for 30 seconds, and then releases and I push down on his leg as far as he can stand. This is an attempt to fatigue his quads, which the doctor said are extremely tight. This still only achieves maybe 95 ROM, as best I can tell.

So the question is is he doing these stretches correctly?
He stretches for a few hours a day, but he doesn't stay at the endpoint the entire time. He lifts his leg up from time to time to relieve discomfort. Is this okay, or does that sort of halt the progress made? Also, he doesn't use more than the 1-1/2 lbs of weight b/c he says it is too painful. Should he be pushing through this pain? (The pain is on the inside of his leg, right by the kneecap, at the site of an old knee surgery.) Should he add more weight, even if it is painful? (He is able to carry on a conversation or watch youtube videos with the 1-1/2 lbs of weight.) How do you know how far to go with the discomfort/pain and amount of weight?

Will any of this even do any good at this point, with this little progress so far? We messaged the doctor several days after the MUA to tell him that my husband was at about the same ROM as before the MUA, but he said not to worry - just do the PT for 6 weeks and then we would reassess. He also said they expect the patient to go backwards after the MUA, but then regain ground slowly over weeks. It just seems like there ought to be progress more than an ROM of 100 at 3 weeks post-MUA.

My husband is 61 years old, but was very active up until this surgery. He is a surfer and mountain biker, and was hoping to be back on the board by now, but now he is questioning if he will every be able to surt again. The most he can do now is ocean swimming of about a half mile, which is pretty disappointing.

He has another office visit with the doctor this week. I'm not sure if the doctor will say to continue or suggest another MUA, or the lysis of adhesions. And if he does the exact same PT and the long stretches the exact way he has been doing them, won't he have the same result as now anyhow? We are incredibly frustrated with the lack of urgency shown by the doctor's office, but there's not much we can do about that. Is there anything we can actually do to encourage a better outcome at this point?

Sincerely,
Mary Hesketh

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
Here with an update, and more questions. (See original letter 9/11/22)

My husband has had TKR 6/21/22, MUA 8/22/22 and surgery for lysis of adhesions on 11/16/22. The doctor said there was much scar tissue (and showed us photos!) which he cleaned out. He then manipulated my husband's knee and got another 25 degrees ROM. He was at roughly 95 before surgery, so this would put him at about 115 post-surgery. The PA said at the post-op appointment that it was a struggle to get this much ROM, even under anesthesia, because there was pain, even with the anesthesia. The PA also said that the muscles and ligaments, etc, were incredibly tight.

So now he is almost 4 weeks past surgery. He has been using the JAS flexion device 3-4 times a day, increasing stretch to his maximum tolerance over the course of a 30 minute session. (He is only at his absolute max for a few minutes at the end of the session. He can't hold a conversation at that point, because of pain.) He was also sent home with a CPM machine, which he has used many hours each day, as well. He does short stints on the exercise bike (5-10 min each), too. Also, PT twice weekly, starting the day after surgery. He has minimal visible swelling, and virtually no pain since the last surgery, except when stretching.

On awakening, he has about 105 degrees ROM. After a session on the JAS, he measures about 115 ROM. He has been trying to stay off his feet mostly, to keep down swelling, but today walked a short distance with me and also rode his e-bike to the beach. (A few miles.)
After stretching this afternoon, he measured 103 ROM. He is really discouraged at this point. He feels he should be able to get to more than 115, at almost 4 weeks post-surgery. And now today he has gone backward. I suggested this might be because of his increased activity, but he disagrees!

What ROM is reasonable to expect at this point? Can you suggest anything further he/we can do to increase his ROM? Should he be holding a less painful endpoint stretch on the JAS for a longer period? He is supposed to go back to work after January 1st, and then won't be able to spend all this time on PT and stretching.

Should he expect more gains in ROM from this point? Are there any adjunct therapies that might help? I wondered about acupuncture, but my research seems to indicate mixed results on ROM. I also wondered if Botox could be used to relax the muscles, to allow more movement. He has tried a TENS unit, but I'm not sure if that really helped anything.

He is worried that he will never be able to surf or mountain bike again. Is there any hope of getting back to that point in the future?

Thank you for all your good work and help!

Mary Hesketh

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.

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