Gorczynski teaches how to avoid a stiff total knee replacement

Stiff knee replacement

5/20/2016

Bandaged knee after total 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.

Tissue layers that must glide following total knee replacement

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:

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.
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.
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.

13 Comments

Beverly Stephens link

1/8/2018 10:11:59 pm

I fx my Patella wired and screwed together 6 weeks ago. Currently passive flexion 90, active around 55-60 lots of pain. My surgeon said I should be at 90 plus by now. He said he has done all he can for now He said come back in 8 weeks. Should I get a second opinion? Can I do more. Currently CPM 6 hours a day PT once a day for 1 hour, ambulating as much as possible.

Christopher Gorczynski, MD

1/8/2018 10:48:21 pm

I would also like to see 90 degrees of flexion at the 6 week mark after open reduction internal fixation of a patella fracture. This is not always the case-for a variety of reasons.

First of all- don’t worry- you will make progress for many months yet to come- with the appropriate exercises.

A couple of your comments are consistent with those I hear from patients with a stiff knee- “I’m doing a lot of walking”, and “I’m using continuous passive motion for many hours.” Unfortunately, neither of these things will make a stiff knee loosen up.

Another thing I hear quite often is - I am doing xxxx strengthening exercises all the time.”

Walking simply does not require much knee range of motion. While it is good for many other reasons, it will not help you to regain knee range of motion. The benefits of walking include improvement in bone density, improvement in muscle tone and strength, reduction in risk for deep venous thrombosis (DVT), otherwise know as blood clots. So it isn’t inappropriate to walk when your surgeon allows you to.

Continuous passive motion (CPM) is a machine that gently pushes a joint back and forth, but doesn’t force endpoints very much. These machines were utilized extensively in the past, and for certain conditions can be quite helpful. I have abandoned their use after knee replacements as the majority of my patients are usually up, out of bed, ranging their knees through a 90 degree arc, waking up and down the hall and stairs and are back home within 24-48 hours of admission. These devices were great when hospital stays were 5-7 days or more and patients spent most of the time laying in bed. Using a modern multimodality pain control regimen including regional anesthesia and intra-articular local anesthetics I found CPM was holding patients back.

Strengthening is great for muscle development and is important, but this is only effective after range of motion is restored. Strengthening will not cause joint range of motion to improve.

Getting back to your question- improvement in joint range of motion requires stretching. I have found sustained stretching (holding the endpoint for many minutes as opposed to a few seconds) is much more effective for a postoperatively stiff joint than the 10-15 second stretches most therapists suggest.

As long as your surgeon has allowed you to progress your range of motion without limits at this time, I would recommend stretching for a cumulative minimum of 1 hour each day, with no days off, and for a minimum of 10-15 minutes each session. Only a single maneuver is required: when trying to regain flexion, flex the knee until it stops, try to use your thigh muscles (hamstrings) to bend it more, and apply additional flexion force manually by gently pulling your ankle toward your buttocks. Simply hold this stretch for as long as possible.

Another method is to lie on your back on a sofa. Let your legs hand over the arm. Slide your butt to one end of the couch- right against the arm of the couch. Your hip should be flexed to 90 degrees. This should allow your knee to be dangling in the air. Relax in this position and gravity will be pulling down on your knee. Stay in this position for as long as possible. If desired- wear a boot or use an ankle weight to apply additional flexion force.

Remember- cycling your knee back and forth will not result in improved motion- sustained endpoint stretching will.

In this blog are articles on the viscoelastic nature of biological tissues as well as articles supporting this sustained stretching technique- which is also very helpful for adhesive capsulitis (frozen shoulder).

You are spending lots of time and effort attempting to rehabilitate. Just refocus your efforts toward more effective techniques and I think you will see progress.

I hope this information is helpful.

jacqueline davey

11/26/2018 03:52:15 pm

1 yr po, 90° bend, surgeon said it's functional?

Christopher Gorczynski, MD link

11/26/2018 05:55:22 pm

@ jacqueline davey 90 degrees is marginally functional in my opinion. I would expect you to have difficulty going up and down stairs normally, and to have difficulty standing up from a low chair using your affected knee. If it is otherwise pain-free and trustworthy, you may decide to leave it along. If, however, you do find it functionally limiting, you would be a candidate for arthroscopic lysis of adhesions with a manipulation under anesthesia. This is very likely to help you regain a truly functional range of motion if you work diligently on maintaining the range of motion your surgeon gets. It is worth discussing this with your surgeon if you are not satisfied with your level of function.

Margaret Bartlett

9/5/2018 06:04:51 am

Thank you so much for this advice. I am 3 weeks post op tkr and nearly bought a small pedal machine last night and also went for a longish walk. Woke up this morning feeling very stiff then found your article. Also holding the knee bend for minutes rather than seconds has given me a breakthrough in my recovery.

11/5/2018 08:43:16 pm

Glad to hear that extended stretching is helping you. Consistency (no days off) and long duration, progressive stretching definitely seems to be the most effective, and least irritating method to rehabilitate total knee replacements.

C M Allan

11/5/2018 06:45:08 pm

Thank you for this really helpful information. I'm finding the more lengthy stretches are making all the difference and I've stopped being quite so scared of splitting the scar when pushing further with the knee bends. The exercise involving hanging my knees over the side arm of the sofa is really helping get rid of the deep ache from where the tourniquet was positioned during surgery. Why is that?

11/5/2018 08:44:08 pm

I am pleased to hear that extended the duration of stretching is helping you to make progress with your total knee rehabilitation. Stretching over the arm of the sofa allows your muscles to relax during the stretch. Because the tourniquet creates mild trauma to your thigh muscles, allowing them to relax while they are being stretched is probably why you find this helpful. All too often I hear about physical therapy sessions that sound like torture sessions, or strength contests. Gentle, progressive, long duration stretching makes this process much less unpleasant. Thank you for the comment, and keep up the good work!

Bob McWilliams

11/16/2018 02:08:09 am

Dr. Gorczynski,
I’m 13 weeks out from my TKR. The best I can remember (lots of meds) I have had a tight band running just below my patella (front only) and another on the outside edge running at at 45 degree angle. They are tight and like a rubber band (I’m assuming it’s scar tissue).
Do you think that will that go away over time? I’m out of official PT but ride my recumbent bike daily and do strengthening and stretching exercises.
Now that the swelling has gone away and most of the pain I am very active outdoors and can do most everything I could before except get on my knee.
My last flexion measurement was 102. I’m not giving up though and am shooting for 120 hoping for at least 110.
I have lost a lot of weight prior to and after surgery and plan on keeping that off.
Thank you for taking my question about the band issue. I hsve not seen that addressed anywhere.

11/26/2018 05:36:51 pm

This does sound like some scar tissue. To gain more range of motion at this point, you really need to focus on prolonged stretching exercises, maintaining stretches for 30 minutes or longer, multiple times per day if possible, and every day. Since scar tissue tends to contract over time, it is normal to feel the need to work at range of motions exercises sometimes for many months.

11/27/2018 08:30:17 am

Thank you for your reply. I’m clear on your advice for stretching a minimum of 1 hr several times a day if possible.
My question is is it ok to to keep riding my recumbent bike and do strengthening exercises along with these sustained stretches?
8/7/18 was my surgery date. My surgeon has released me and will not see me again unless I make an appointment. He said after 6 weeks he would not do a manipulation. We did not discuss removal of scar tissue. Should I seek further advice (2nd opinion) for removal of scar tissue OR rely totally on these stretching exercises? Thank you

11/16/2018 02:18:56 am

Dr. Gorczynski, I’m sorry but I did want to add, when I exercise ( bike, stretching etc ) the band tightens a lot right afterwards. After a good nights rest it relaxes to its normal tightness which is tight enough it’s very aggravating and in a way dehabilitating.. Thank you

11/27/2018 09:05:28 pm

It is definitely ok to continue riding the recumbent bike as well as progressive strengthening exercises. A simple manipulation is unlikely to be very effective beyond 6-8 weeks maximum. I recommend that you continue doing exactly what you have been doing. Particularly working for long periods on regaining deep flexion. I have seen patients gradually improve their range of motion for up to an entire year from surgery. Persistence and patience will usually pay off. Ice and anti-inflammatory meds will assist you. If, at a year from surgery, you have not regained a range of motion that is acceptable to you, you could consider undergoing arthroscopic lysis of adhesions and manipulation. But, this is not something I would encourage you to do at this point because there is an excellent chance you will correct this on your own.

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