Stiff Knee Replacement Algorithm
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.
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.
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.
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!
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!!
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.
7/6/2022 01:32:48 pm
I am 1month past TKR .I have 100 degree of bending bt I have still swelling and too much .I do my PT everyday.during exercise I feel that my knee is slightly moving and I hear some noise from the knee .At night I my pain become more and also stiffness .
7/8/2022 07:42:56 pm
@Ajahar - A knee replacement is a mechanical system. It is not uncommon to feel/hear mechanical symptoms as it moves. Particularly early after surgery, while your knee is still swollen, clicks and clunks can occur. I recommend continuing to rehabilitate your knee by stretching on a daily basis. If you have ongoing concerns, your surgeon should examine your knee, and perhaps obtain a new x-ray in the office at your next followup visit.
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.
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.
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.
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.
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?
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).
6/29/2021 07:20:32 pm
Dear Dr. Gorczynski,
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!
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.
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.
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.
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.
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!
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.
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.
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.
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!
2/18/2022 01:30:26 pm
My total knee replacement was nine and half months ago and progress
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.
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!
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.
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
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.
6/23/2022 06:09:02 pm
6/29/2022 12:24:59 pm
Your range of motion is definitely less than optimal. Unfortunately, this often results in knee discomfort. Most patients will experience improvement for an entire year after surgery, even with suboptimal range of motion.
8/3/2022 08:57:52 am
8/24/2022 12:28:05 pm
It is unusual to have such dissatisfaction with a knee replacement with the range of motion you report. It is not unusual to experience ongoing improvement for a year or more following surgery. If you feel you have plateaued at a level that is not acceptable, and your knee X-rays look good, assuming no other symptoms, I would advise trying to be patient with your knees as they hopefully continue to gradually improve. If they do not, or this is not an acceptable plan, perhaps you should consider getting a second opinion from a surgeon to make sure they agree the X-rays look good and the soft tissue balance looks good. If this all checks out, then I would consider getting evaluated for metal/material sensitivity. I have an article elsewhere on this website discussing this issue.
11/6/2022 05:00:40 pm
I had a TKR 12 weeks ago today, and I only just attained 90º of flexion a few days ago. On average, I've gained 10º every 14 days over the last six weeks. Prior to that, I barely had 45º. I didn't get onto an Exercycle until nine weeks post-op.
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Orthopedic Surgeon focused on the entire patient, not just a single joint.