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Stiff Knee Replacement Algorithm

2/20/2021

28 Comments

 
A stiff total knee replacement can be extremely frustrating for patients and surgeons. The best way to manage a still total knee is prevention. I have written many articles on this website focusing on how to rehabilitate your knee replacement effectively. Unfortunately, some patients will experience stiffness in spite of their best efforts. The management pathway I have outlined below is how I recommend dealing with this problem. For a bit more explanation, check out the video posted below. 
Stiff total knee replacement management algorithm
Stiff total knee replacement management algorithm
28 Comments
Holly
3/26/2021 05:32:29 pm

May I ask your thoughts on icing and elevation after TKR? She has been told to ice every three hours for 45 minutes and elevate every time she is laying down and all night.
My mom had her knee replaced on 3/8/2021. She came home on 3/9 and then returned to the hospital on 3/11 to 3/13 for acute fluid overload. She missed a week of PT and now the therapist is very discouraged she has not achieved at least a 95 degree angle as of 3/26. She has now become very discouraged and down as well. She has also had both hips replaced and when he tries to push the knee to 90 degrees it causes excruciating pain in her hip.
I appreciate your website. Thank you!

Reply
Christopher Gorczynski, MD link
3/28/2021 11:16:21 am

Ice and elevation is helpful after knee replacement surgery. This, alone, will not result in good range of motion. I would encourage her to stretch on a routine basis, every day, as recommended throughout this website. If hip pain is interfering with her ability to rehabilitate- this is not normal. She should be evaluated by her surgeon.

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Holly
4/26/2021 12:56:13 am

I appreciate your reply. She went back to the surgeon who stated she should not be having this pain because everything is fine. We went for a second opinion and this doctor has ordered an MRI. He said it appears that there is extensive damage to the veins possibly due to the tourniquet used during surgery and she was not in good enough health for the surgery to begin with. He said his mentor in Med School taught him that it is of utmost importance to know when NOT to do surgery and to look at the entire person and not just the knee itself. I wish more doctors would follow your example of no tourniquet. Thank you!

Regina Montgomery
7/31/2021 09:43:55 pm

I cant find advice on ORIF right knee surgery--only knee replacement--is there another post I should use? I see a lot about knee replacement but I need information on right ORIF, (first ever surgery)--way after the fact---do I need a consultation or is that possible? Thank you!!

Christopher Gorczynski, MD link
8/19/2021 04:26:12 pm

@Regina - You have not provided me enough information to answer your question. The management of fractures is very much individualized based on your bone quality, the exactly fracture pattern, the fixation technique utilized, etc. Your surgeon should have given you instructions after surgery with regard to weightbearing status, range of motion restrictions (if any), etc. If you haven't been given this information, I recommend you call your surgeon's office and request this information.

Kristofer Van Wagner link
4/24/2021 01:42:13 am

I do agree that when looking for an orthopedic surgeon, we need to ensure they are qualified and experienced. The other day my dad mentioned he needs to have his knees replaced. I will remind him to look for a trusted and reliable surgeon to have his knees replaced.

Reply
Holly
4/26/2021 01:03:46 am

From my experience with my mom, I would say to make sure you find a doctor who does NOT use a tourniquet. In addition, I would ask if they use a CPM device. My father-in-law in Italy had his knee replaced at 82 and his best friend at 83 and their knees are absolutely perfect, as if it were their own knees. NO tourniquet and CPM immediately. Kind regards.

Reply
Christopher Gorczynski, MD link
5/11/2021 05:18:12 pm

While CPM will not likely cause any harm, it also will not help with terminal extension or deep flexion. In my experience, these devices were best used when patients stayed in the hospital for several days following surgery. Now, most patients are able to be discharged safely the day following surgery. This is why I strongly recommend slow, long duration stretching to regain terminal extension and deep flexion ASAP. Everyone regains mid-range of motion (which is what CPM helps with) without difficult.

Holly
5/12/2021 10:03:18 am

Thank you for your response. My father-in-law spent several days in the hospital after his knee surgery, which is standard protocol for knee replacements in Italy. So the CPM makes perfect sense. I wish they had used it on my mom when she was readmitted to the hospital within 24 hours of being sent home.

Rich link
5/15/2021 06:10:00 pm

I’m 63, male. Bone on bone Knee replacement 5/3/21. PT increased flexion from 35 to 53 degrees in first 2 weeks. Very stiff. Question: past compound commuted fracture of femur 4 inches above knee. Casted 6 months. Max flexion about 105 prior to surgery due to frozen knee and adhesion mid thigh where bone came through. Could a new knee and release of adhesion give me more flexion?

Reply
Christopher Gorczynski, MD link
5/26/2021 10:26:46 pm

I would expect you to regain additional range of motion (beyond 105) as a result of your knee replacement (and proper post-op rehabilitation).

Reply
Cindy Hellstern
6/29/2021 07:20:32 pm

Dear Dr. Gorczynski,
I am 14 weeks post-op l TKR. I have been diligent with my PT, and have full extension. I had flexion to 126, 2 weeks ago, at which point I increased my activity to include caring for my 11 month old granddaughter part time, and bringing home my 11 month old gun dog male puppy in rally and obedience training. My medical history includes a severe trauma MVA 20 years ago leaving me with a very well controlled dx CRPS Type II. The insult of this surgery , and not well managed immediate post-op pain control led to quite a lot of increased inflammation at the joint post surgically for the first 3-4 weeks. The next 6 weeks went very well, in PT and with pain management. I am now struggling to achieve115 degrees of flexion, which is not sustained after a brief extension. I am unable to tolerate oral anti inflammatory medication, but can utilize topical Voltaren and Arnica. My background is ortho-neuro ( first few years) then ED RN. My father was an orthopedic surgeon. I would very much appreciate any advice you could offer me. I admire and appreciate your educational information and approach. Thank you for your consideration, Cindy Hellstern

Reply
Christopher Gorczynski, MD link
7/28/2021 09:10:25 pm

It sounds like you are doing the best you can with a variety of additional demands placed on you. Other than controlling inflammation using ice, and long duration stretching, I don't have any other tricks. I will say that 115 degrees is not terrible, and should allow you to enjoy a good functional result. If you continue stretching, I have seen patients in your situation continue to make gradual gains for up to an entire year from surgery. Best of luck to you!

Reply
Jil Pelletier
7/14/2021 01:28:25 pm

I looked and read all material for pre OP what I couldn't find was pre exercise muscle strengthening before surgery.

Reply
Christopher Gorczynski, MD link
7/28/2021 08:59:23 pm

This is an excellent question, and it probably deserves it's own blog post. When a patient has a knee arthritic enough to undergo knee replacement, it is unlikely that they would be able to regain much muscle before surgery. It would be too painful. Additionally, in the modern day, most patients are not allowed unlimited physical therapy visits and/or each visit is very expensive. We can usually get the joint replaced within 6 weeks or so from the date the patient decides to proceed surgically. Even if significant muscle building were possible in the arthritic knee, the amount of increased muscle mass that would be developed in a few weeks would be negligible. For these reasons, I recommend most patients save their PT efforts until after surgery.

Reply
Karen
7/23/2021 07:04:16 pm

Thank you, Dr Gorczynski, your videos and posts have helped me. I am 8.5 weeks out from a TKA, 4 days out from a MUA. I have had a really difficult time. I wasn’t prepared for the physical and emotional toll of this. I found a new PT that agrees with your approach of sustained stretching. I also ask my doc for a CPM machine post MUA, because i worked very hard at therapy post TKA and still built up so much scar tissue.
My question: i have a ton on soreness in my quad and have had a hard time walking. How much rest, ice or heat should I implement post MUA? I dont want to lose the valuable time to get to 120 degrees flexion. Is it ok to stretch out an already so sore quad?
Thanks, Karen

Reply
Christopher Gorczynski, MD link
7/28/2021 08:02:32 pm

I recommend consistent icing after your procedure. This should help reduce inflammation. I would not wait for pain to subside before stretching. This needs to be done immediately and consistently from the start. Long distance walking or other exercises can definitely be deferred until you feel better. Please don't stop stretching.

Reply
Karen
7/28/2021 10:32:16 pm

Thank you Dr Gorczynski. I will keep stretching. My quad actually started feeling better today. Thanks for sharing your expertise and for all of your work on this blog/website You are such a blessing!

Va jordan
8/13/2021 10:40:07 am

Hi. I am 84 yr female 8 wks out from total knee replacement. Have pain , redness heat swelling and red streaks down shin bone to ankle and on incision site and approx 8” up thigh. Sediment rate 54 crp normal. Seen Dr last week and redone sed and cpr. Send dropped to 34 ( had finished antibiotic for UTI) and cpr normal. Run about 1 degree of feverMy concern is that May have deep infection in replacement .doing pt exercise and stretching at home. Have been tested for DVT. Drs comments wait and see. Don’t want this to get worse. Comments please.

Reply
Christopher Gorczynski, MD link
8/19/2021 04:16:31 pm

With a dropping sedimentation rate and normal CRP, a deep infection is quite unlikely. I recommend you continue to follow-up with your surgeon for additional recommendations.

Reply
Darieus link
10/13/2021 11:10:54 am

Dr. Thank you for this site. I am at 6 months post TKR, my daily ROM is at 110 or so extension is 0. My problem is that I can stretch and I do daily, I can get to 140. When I wake up in the morning the Stiffness and swelling has me right back at 110 or so. I am diligent and have gotten to 140 as stated, it just doesn’t hold.

Could it be that when the stiffness and swelling go away that I will hold at 140 or so?

Thank you for any guidance.

Reply
Christopher Gorczynski, MD link
10/17/2021 06:50:33 am

140 is a lot of flexion for a total knee patient. This is truly outstanding range of motion. Unfortunately, modern life does not usually demand such extreme knee motion on a routine basis. This means that the only time you really bend your knee that far is when you are stretching. If keeping 140 degrees of motion is important to you, I would recommend you continue stretching as you have been, perhaps remind yourself to flex your knee to 140 degrees a few additional times throughout the day. This will help maintain the deep flexion you have achieved, and over time, it is more likely this motion will be maintained. Very impressive rehab!

Reply
Shashi Gupta
2/18/2022 01:30:26 pm

My total knee replacement was nine and half months ago and progress
in spite of therapy and doing personal therapy to 4-5 times a week. My knee becomes like a rock after standing 30- 45 minutes. And then I walk so slowly and go put ice pack on. I feel mentally very down and wonder how much longer it will take. My surgeon has never called to check or his assistant no support and never directed after surgery to stand or walk. After 6-7 hours I was taken to the room. I will appreciate if you can guide me. I am so grateful your time you take to write to patients who're going through so much. Shashi Gupta

Reply
Christopher Gorczynski, MD link
2/26/2022 02:57:29 pm

This is definitely not normal at this stage. While you may expect progress for up to a year or more following knee replacement surgery, your knee does not seem to be calming down at a normal pace. If you are not able to see your original surgeon, I would encourage you to seek a second opinion. In my opinion, you should have a surgeon examine your knee, get new x-rays, and strongly consider work-up for possible low grade infection or material sensitivity.

Reply
beatrice
3/21/2022 12:46:23 am

I had my TKR on 2/25/22. My knee is very stiff. My ROM is at 80 and my extension is -5. Will I still benefit from your stretching exercises to increase my ROM to 125 by week 6. Thanks!

Reply
Christopher Gorczynski, MD link
5/24/2022 10:53:24 pm

Yes! It is always worth trying to stretch as I recommend. If unsuccessful, I have outlined a reasonable treatment algorithm in this article. Step one is to maximize normal rehabilitation. Long duration stretching tends to be much more effective when patients struggle with stiffness.

Reply
Joan Ball
5/14/2022 05:24:53 pm

Hello Doctor I would like your opinion. I am 12 weeks after a tkr. My flexion and extension are very good. The problem I have is a pain at the back of my knee. My surgeon has said this is tissue from my op as he had to straighten my leg at the same time. The pain can be very bad and doesn’t seem to be going away. Do you have any thoughts on this. I am cycling walking and doing some physio. Thanks joan

Reply
Christopher Gorczynski, MD link
5/24/2022 10:55:11 pm

There are a variety of things that can cause posterior knee pain. If your motion is "very good," I would expect your pain level to improve as you get further from surgery. Sometimes a popliteal cyst can persist in spite of a knee replacement. If present, and symptomatic, this can be treated by your surgeon.

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