Stiff knee replacement

So you finally decided to have your arthritic knee replaced. You got through the surgery just fine. As expected, you had some surgical pain, but almost immediately you realized that your arthritic pain was gone. Awesome! Things seemed to be going very nicely, and now you are home...

Your knee may begin feeling tight and warm. This is normal and expected. Healing occurs in part through an inflammatory process. Inflammation shows up as swelling, warmth, and pain. You have been told to stretch, but may be questioning this recommendation now. You may be concerned that because it hurts you could be damaging yourself or your new knee. This is a very common concern. Please resist the urge to stop stretching.

The knee is a complex joint. There several moving parts and potential spaces (otherwise known as tissue planes). During total knee replacement these parts are moved around , the tissue planes are opened. I think it makes sense to patients when they have some pain after surgery. But as the wound is healing on the outside, why does it feel like things are getting worse on the inside?

As the healing process proceeds, the tissue planes that have been opened begin sticking together. Gradually adhesions, or scar tissue, may form between these planes preventing them from gliding properly. Initially this scar tissue is weak, but it will get stronger every day. For this reason, there is some urgency to regain range of motion as soon as possible. This is because after about 6 weeks or so from surgery this scar tissue becomes strong enough that a patient is unlikely to be able to stretch it out any more. The range of motion you have achieved at this point will be how far your knee will move permanently...without additional intervention. 

To better understand knee range of motion lets begin with a couple of definitions. Flexion of the knee means bending. When you sit in a chair and your feet are flat on the floor, your knee is bent, or flexed. Extension of the knee means straightened. When you stand up and your knee is straight it is extended. 

Now lets discuss these tissue planes a bit.

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Tissue layers in the knee that must be stretched following total knee replacement.

The skin must be able to slide over the kneecap (patella). The body achieves this by only loosely attaching the skin to the patella. This loose connective tissue allows motion to occur. Under abnormal conditions, fluid can collect here and create swelling. A potential space such as this is referred to as a bursa. The loose connective tissue found here is called bursal tissue. The specific space, or tissue plane, between the skin and the kneecap is called the pre-patellar bursa. It is shown in purple in my sketch. 

The kneecap (patella) is embedded within the tendon that attaches your thigh muscles (quadriceps) to your shin bone (tibia). A tendon is the tissue that attaches muscle to bone. The quadriceps tendon must be able to slide relative to the thigh bone (femur). The area above the patella shown in my sketch as orange is called the supra-patellar pouch.

If either of these tissue planes  sticks together, the knee will not be able to bend completely. 

In the back of the knee there is a sheet of tissue called the posterior capsule. This is green in my sketch. ​This tissue is irritated during surgery and will gradually tighten as it heals. If this is allowed to happen, the knee will not fully extend. 

So, how do you prevent a stiff total knee? It is not by walking around a lot. It is not by cycling the knee back and forth a lot. It is by gently and progressively stretching. Even though it hurts. The longer you are from surgery, the longer these stretching sessions must be because the scar tissue becomes stronger each day. Gentle progressive stretching works by taking advantage of the viscoelastic nature of biologic tissues. 

My basic recommendations:

1. Extension: Place your heel on something. Make sure your toes are pointing straight up. Leave your knee completely unsupported. Gradually relax your muscles to allow gravity to pull your knee straight. You can assist by trying to gently force the back of your knee down. Maintain this stretch for as long as you can. Longer is better. Try to measure the duration of stretch in minutes as opposed to seconds.
2. Flexion: Progressively bend your knee. It is very important to relax your quadriceps muscle while doing so. You can use your other leg to help. Place your good foot in front of your ankle and pull back attempting to bend the knees together. Again, do this slowly but progressively. Hold the endpoint for as long as you can. Although it will hurt, do your very best to relax your body. Measure the duration of stretch in minutes as opposed to seconds. 
3. You do not need to repeatedly swing your knee back and forth from full extension to full flexion. In my experience, all of the mid-range range of motion done will not help increase end range of motion, and could actually cause swelling and inflammation which will slow down your progress. It is much better to slowly and progressively focus on one motion at a time.

Future posts will further develop these concepts.

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