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.

108 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.

Caroline

1/19/2020 09:27:32 pm

I am 5 wks post op TRKR. My range of motion is from 68-80. My knee is tightening up so much my bend is not getting better. Would you suggest a MUA at this point or do I still have time to really push for better ROM. It is so terribly uncomfortable and extremely tight.

1/22/2020 06:01:27 pm

@Caroline... You are facing a difficult situation. If I am interpreting your question correctly, it sounds like you are stuck with a bent knee. We call that a flexion contracture. That makes walking extremely difficult.

It is a very challenging situation.

I do not think a manipulation is likely to help much with a flexion contracture. The best plan is prevention, by avoiding this from the beginning, always forcing the knee straight from the day of surgery.

At this stage we are unfortunately beyond prevention. My best recommendation at this point is to begin using a static stretching brace that will help you to gradually force your knee straight again. The brace I use when this problem happens is called JAS (joint active systems). I would recommend you get in touch with your orthopedic surgeon immediately and discuss this option.

Lissette Lopez

1/29/2020 10:52:12 pm

I had my surgery 11 weeks ago and my knee only bend 80 my surgery just bend my knee for on January 24 but while I was in surgery on November 4 they pinched my nerve so it’s traveling all the way from my leg to my back I’m in so much pain and today the spine surgery put injection on my back so I’m praying that it works because having a pinched nerve you really can’t do the things you want to do for your knee

Yvonne

2/16/2020 07:11:17 pm

I had knee surgery and I go to therapy when they bend my knee and measure it’s measure 100 and they say that not good enough and if I don’t get up up 125 I well have problems walking is that true

2/17/2020 07:42:35 pm

@Yvonne: I addressed this exact question in a recent blog entry.

https://www.yourorthomd.com/orthopedic-knowledge/stretching-is-more-important-than-walking-after-knee-replacement

Basically- you do not need very much range of motion to walk reasonably well. Increased range of motion does help your knee to function normally. Getting up from sitting, climbing and descending stairs, getting into and out of the car, and trimming your toenails are all activities that require much more range of motion than walking. I think your therapists were trying to explain that 100 degrees of flexion is not optimal for a normally functioning knee. If your only goal to to walk, you have plenty of motion. Most people will do better with range of motion of 120 degrees or more.

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.

Cathleen

1/3/2019 05:18:07 pm

I am 6 weeks post knee replacement. I achieved 115 deg. range of motion at 10 days post op. I now have 121 deg. ROM but don't seem to be progressing beyond that. I have been relatively pain free but my knee is very stiff. I am very flexible and do extensive stretching 5 times a week. I will begin stretching daily per your advice. I will begin holding my stretches longer.
I am not understanding why I seem to be stiffer and more uncomfortable than a week ago. I am using ankle weights on both legs for 2 exercises..1 1/2 lbs.weights each. The weight is causing lower shin minor bruising on my knee replacement leg. I ride my recumbent bike 30 minutes with resistance each exercise session to warm up before stretching.

Any ideas about why my knee stiffness is worsening? Thank you for your help.

1/4/2019 11:51:02 am

A 121 degree arc of motion is excellent, and should be sufficient for all reasonable activities following total knee replacement. It is possible to regain even more motion, but this takes a great deal of work and is not a guarantee of better function. Scar tissue tends to thicken and contract over time. This could be why you are feeling a bit stiffer. Thankfully, this process does not last forever. I would expect this feeling of increasing stiffness to end over the next couple of months. Simply continue gentle, long duration stretching to maintain (or slightly improve) your already excellent range of motion. As for the 1.5 pound weights, if they are causing irritation, I would discontinue them. Simply walking, riding your resistance bike with low resistance, and time will help you to regain function. Gradually add double leg squats, then consider single leg squats, holding something to help with balance.

1/3/2019 05:20:07 pm

Sorry I forgot to mention on my previous post that I am a 68 year old woman in excellent health.

1/4/2019 01:55:09 pm

Dr., thank you very much for your encouraging reply. You have saved me worry and second guessing my progress. Very much appreciated!.
I am not sure if any of your patients cannot tolerate narcotics Since childhood I have been deathly allergic to all narcotics. I was naturally very concerned about pain after my knee replacement. I religiously did leg/knee strengthening exercises and stretches for 6 weeks prior to my surgery. I had a block during the surgery and was fully awake. I have had very little pain....just stiffness. I take Celebrex and tylenol for pain. I have not really needed anything else. I also used an ice therapy machine for 2 weeks after the surgery. My second knee replacement is February 25.
Cathleen

1/4/2019 02:29:08 pm

I do have patients that either don't want or don't tolerate narcotic medications and are similarly able to rehabilitate their total knee replacement using only ice, tylenol, and NSAIDS. The regional anesthetic block we use definitely makes a big difference for the first 20+ hours or so. Best of luck on your second knee replacement! The nice thing is that after this....you have no more knees to work on....

Sharon

1/13/2019 11:37:24 pm

Dr., I'm only 5 days post op from my TKR surgery and have yet to have my follow-up appt. with my surgeon or my first PT session. I'd been improving daily... less pain and discomfort... easier to walk and stretch. I've been doing my exercises religiously and then suddenly today my swelling and stiffness increased. It actually feels like I have an invisible ace bandage stretched around my knee! I've continued with my stretching exercises and am actually even holding a stretch longer... but this stiffness continues. Is this temporary or should I be concerned about some longer lasting effect? Thank you so much for your reply.

1/14/2019 09:46:28 pm

Your experience is not unique. It is common for patients to feel that recovery is quite easy for the first few days following surgery and then feel that their progress becomes much more difficult. This is so common, in fact, that we tell our patients to expect the second week to be less pleasant than the first.

There is an inflammatory cascade that happens when your body is traumatized. Surgery causes injury to the body. This injury induces an inflammatory cascade. It takes your body a while to mount this inflammatory response. In general, I would expect this inflammatory cascade to peak around 10-14 days postoperatively.

Additionally, as your body begins to heal, tissue planes begin trying to "stick together." This early scar tissue makes stretching more challenging.

It is crucial not to discontinue stretching during this time. The mistake is to let the pain suggest you are doing something inappropriate. You only have a few weeks to regain a functional range of motion, and each day that goes by allows the scar tissue to become more robust. This means that delaying stretching only makes subsequent stretching attempts more difficult.

Do your very best to relax mentally and physically during stretching sessions. While you do not need to use high forces during stretching, it is usually better to extend the duration of stretching and to add multiple sessions throughout the day. Additionally, the use of ice can help reduce some pain and inflammation. If your surgeon allows it, anti-inflammatory pills can also be helpful during this time.

Once you have achieved a functional knee range of motion, and the inflammatory phase of the healing process is behind you, your knee will feel better and better, and should ultimately become pain-free.

Reba Pierce link

1/17/2019 04:59:12 pm

I am 10 weeks post-op TKA. My flexion has varied of late from 125 to 127 with passive assistance. I have maintained a slight degree of swelling which my PT assures me is not impeding my progress. However, my walking has been consistently sub-par and in the last few days I've developed the that band that so many people have referened. I was very interested in your information about stretching, which my PT hasn't instructed me to do. Since reading your blog, I've been doing prolonged stretching for a couple of days and plan to continue. At times it seems to be helping, but I wonder if I've gotten to this information too late in my recovery and will need more aggressive treatment by my surgeon.

1/17/2019 08:39:12 pm

If you have achieved 127 degrees of flexion and have full extension, you should be in great shape. I would expect an excellent result. At this point I would recommend simply maintaining the range of motion you have achieved, and allow the inflammation to subside gradually as your knee heals. Patience is key. There is no reason for you to be anxious at this point, the hard work is behind you. At this point I would expect your knee to gradually settle down and feel better and better as months go by.

Melissa C

5/11/2019 08:15:47 am

I cannot even imagine 127 degrees! Wow!! I am 10 days post op and have struggled to get to 70 degrees. I simply cannot believe how extremely tight the knee is, already. I have read through all of the emails and will continue to work at holding the flex position for a longer period of time. Thanks for all of the information!!

5/12/2019 11:02:30 am

@Melissa C

In the first couple of weeks following total knee replacement, concentrate on reducing inflammation. Ice, anti-inflammatory medication, slow/sustained stretching.

Try to relax as much as possible during the stretch, keep the anxiety level low. Remember, you have 6 weeks to get a functional range of motion back. Stretch multiple times per day, for longer and longer periods of time.

Even a couple degrees of progress per day will give you an excellent range of motion.

Phyl

1/23/2019 01:29:33 am

I am a 70 year old female 7 weeks out from TKR. I had my right knee replaced in 2017 and now my left knee Dec 2018. I have that tight band that has been spoken about on here and only 90 flexion so far, it was stuck at 78 for 3 weeks. I’ve just started doing the longer stretches you recommended and already I can feel the difference. I think my Physio will be pleasantly surprised at my progress so far. I was too frightened to “push it” as I thought I would break something. Thank you for your suggestions they do help!
PS... I am only taking Osteo Panadol and Celebrex and have been since my op as I had adverse reactions to all other meds..even though I was on them for the other knee, I must admit I feel better without the stronger ones.

1/25/2019 10:49:30 am

It definitely sounds like you got off to a bit of a slow start. 90 degrees always seems to be a "sticky spot" with regard to range of motion.

If you have not done so already, check out the videos I posted using a yoga band to help stretch beyond 90 degrees of flexion.

At this stage following surgery you will really need to be persistent with long duration stretching to regain functional range of motion.

If you are still stuck around 90 degrees of motion at 7 weeks, I would strongly recommend discussing possible manipulation under anesthesia with your surgeon. This usually helps you get back on track with your range of motion.

The trouble is, most patients are unable to achieve much improvement in range of motion on their own beyond 6-8 weeks from surgery. A manipulation not only rapidly advances this range of motion, but buys the patient a few more weeks to make further gains in motion.

Beyond 8 weeks, if range of motion is inadequate, additional improvement usually requires an invasive procedure (arthroscopic lysis of adhesions prior to manipulation.) This obviously entails additional risk and ideally is avoided.

Cheryl

1/23/2019 11:29:05 am

I had my first total knee replacement on 11/14/18 and the second one in 12/26/18. The first one was a breeze - the second one, not so much. Four weeks post surgery, I am having trouble even reaching 110 range of motion. My incision is healed yet, the sensitivity is nearly unbearable. I can’t tolerate even a light cloth touching it. I do the stretching exercises as recommended and still have therapy twice weekly. At the last visit, the therapist found an area that was extremely sore, to the right and back of my knee. He suggested I have damage to a tendon and recommended self massage. Could this be a barrier to healing?

1/25/2019 10:41:41 am

Every patient has a somewhat different experience when rehabilitating a joint replacement. A subsequent joint replacement can even feel different to the same patient. In my opinion, 110 degrees at 4 weeks is fine. I would recommend continuing to stretch for long periods of time as I recommend elsewhere in this website. The longer the better. I would expect another degree or 2 of improved range of motion for another couple of weeks time. That should allow you to regain at least 120 degrees of motion. This should be more than adequate for all desired activities.

Touching and massaging the knee along with ice should help reduce the hypersensitivity. Anti-inflammatory medication (oral or topical) can also be helpful, but I would discuss this with your surgeon. If there is a point-tender spot that does not improve with time, I recommend discussing this with your surgeon.

Kevin

1/23/2019 08:17:06 pm

Dr. Gorczynski:

I am six weeks out from left TKR. 63yo male in excellent health. 5-11, 158 pounds. I came out of surgery well. PT initiated very aggressive therapy. I was 120 degrees flexion at 2 weeks and 130 degrees at 3 weeks, with less than 1 degree from straight. Still pushing both. PT has had me doing athletic therapies like running up and down stairs, body weight squats, wall sits, static and walking lunges and other drills. I have been riding a stationary bike for 30 minutes and have walked for 40 minutes. I have not used an assistive device since Day 10. However, I have also developed swelling above the kneecap and along the lateral side of the knee. It is always stiff and painful at this point. I have been pushing through it in PT and gym training of my own, which has included low-weight single leg presses. But it is becoming problematic. Feels like a tourniquet across the top of my knee. Very tight. While my gains in PT and gym have continued, I'm actually going backward in daily life. I am taking no meds. Sleep is problematic. Concentration level at work is low because of the pain. I saw my surgeon at 6 weeks and he was thrilled and said the swelling will subside. Implant looks good. But I am worried. The question is: Did I do too much? And what is the cost?

1/25/2019 10:35:38 am

It is very easy to become a bit impatient when rehabilitating after total joint replacement. It is important to understand that the healing process truly takes at least a year(and perhaps even longer) to be complete.

Swelling indicates inflammation. Some inflammation is expected and unavoidable after surgical trauma. Overuse also may cause inflammation.

My recommendation is: maintain your knee range of motion. Reduce the repetitive and higher impact exercises. Let your knee calm down.

As long as your knee range of motion is adequate, time will take care of everything else. When you are feeling better, and a few weeks have elapsed, gentle strengthening can be resumed. I would focus on hip and core strength. It is really too soon to be aggressively strengthening the muscles about your knee.

My sense from your message is that there will be no long-term consequence from the overuse your knee was subjected to. Let it calm down, and then gradually advance activities. Remember, this is a long-term process. Your patience will be rewarded.

Karen

2/9/2019 02:37:55 pm

Hey Doc,
I had bilateral TKR’s last April. I have good range of motion and am finally walking well. ROM 125 in each. No real pain but stiffness on the knee surface, best described in your diagram as “purple”. I am happy to have straight legs, ability to stand for longer periods of time and to have ROM that allows for me to ride a bike. However stairs are still with discomfort due to this tightness? Scar tissue? How do I expedite or stretch this area? I have tried massage & shock wave therapy. Any ideas?

2/9/2019 08:03:19 pm

The purple in the diagram above represents the tissue plane between the skin/fat in the front of the knee and the kneecap (patella). These tissues must slide relative to each other to allow normal knee flexion. That being said, your 125 degrees of flexion suggests well done rehabilitation, and I doubt your range of motion is interfering with stairs.

The tissues around your entire knee are usually thickened a bit after surgery (permanently) as there is normal scarring expected. Long-term, this generally does not cause any significant discomfort.

Difficulty on stairs, particularly in the front of the knee often suggests hip weakness. Another common complaint associated with this is aching pain in the front of the knee with prolonged flexion (for example in a movie theater or back seat of a car.)

Thankfully, there are a few simple exercises that usually make a tremendous difference. I have an entire blog posting focused on this:

https://www.yourorthomd.com/orthopedic-knowledge/anterior-knee-pain

Melisa Brubaker

2/9/2019 03:10:27 pm

I am 61 yrs young, I had both Osteo knees replaced using Conformis, 6 months ago 8/9/18..Before hand I started exersizing, riding a bike, & swimming to get in better shape before surgery..I had excellent exstension after surgery, everything went well, but my right knee more often that not is super tight at times, feels like a tight band around the knee, and up into my inner area & front of leg..like a pulling..I have continued with exer. 3 x a wk for 30 minutes, & I walk 15 to 30 min. every day on my treadmill as well as 15 min 3x a wk on my bike..Also my scar is darker on this knee..My left knee feels great other than a little stiffness if I sit too long..Can u suggest anything I might try? I also eat healthy to try and improve..I rarely do steps there are none in my home..could that be it? tks so very much!

2/9/2019 07:56:38 pm

From your comment, I presume both knees were done under the same anesthetic. Thus, both scars should have similar appearance. While I would expect continual improvement for up to an entire year or more from surgery, it is strange that your knees feel so different. If this is significantly irritating to you, it is worth discussing this with your surgeon to see if he/she recalls any differences intra-operatively, or if there is any soft tissue balance or range of motion difference between your knees. If your range of motion is not symmetric, I would focus on long duration stretching in an attempt to equalize and maximize your motion bilaterally.

Melisa

2/11/2019 12:35:11 pm

Thank-you!

Miriam

2/9/2019 09:26:03 pm

My knee is so stiff and 8 weeks after surgery what can I do to help this. I stretch every day with no relief.

2/9/2019 10:03:14 pm

If you are not happy with your range of motion at 8 weeks postoperatively, you could be a candidate for manipulation under anesthesia. I consider this a way to "catch-up" to where you should be at this point. It is important not to delay. I usually perform this when needed at 6 weeks post-op. Much beyond this, the scar tissue has become too robust to make much gain...in this situation an arthroscopic procedure needs to be performed first to cut the scar tissue prior to manipulation. Obviously, an invasive procedure is much less desirable than a simple manipulation. Therefore....call your surgeon this week to discuss manipulation ASAP.

Here is a link to an article I wrote on this topic.

https://www.yourorthomd.com/orthopedic-knowledge/manipulation-under-anesthesia

Shearon link

2/10/2019 05:41:59 am

I had right knee replaced jan 15 2018. I have had pain on left side of that knee since. Had arthroscopic sept 7 to break up scar tissue and bend. I was able to bend to 121 after that surgery but with great pain. My pain is worse and range of motion is too. I still go to gym twice a week. It usually takes me a few days to get over my work out which is not that strenuous. I did not have much pain prior to surgery unless I had to walk great distances (shopping, yard work). I have had a nerve block and nerve ablation (very painful). So far no relief. What do I do now? Live in pain with a stiff knee? Not what I planned when I retired. I am 69 and in great physical shape except for the knee. My mental state is suffering too.

2/10/2019 11:47:54 am

A stiff knee can be very frustrating- both to patients and to surgeons. Assuming the knee was properly balanced during surgery, a stiff knee suggests inadequate rehabilitation (stretching) in the early postoperative period. Once stiff, regaining normal motion without pain is very difficult. That is why I suggest the key is to regain full functional range of motion within the first 6 weeks postoperatively.

Once stiff, pain is a common complaint.

It is very important NOT to avoid stretching because of pain.

If your knee range of motion is inadequate for normal desired activities, and your pain level is unacceptable at this point, it is important to ensure your prosthesis is appropriately placed (all angles and rotation are correct), and that there is no evidence of infection.

It is possible (although far from ideal) to undergo revision knee replacement surgery under these circumstances. Clearly this entails risk. Most concerning is the risk of infection. Revision surgery is most predictable if the underlying problem can be clearly identified. If the problem is poorly positioned prosthetic components, this can be fixed. If no cause can be identified, then it is crucial to make up your mind that early rehabilitation will be done differently next time....regardless of pain level.

Long duration stretching is absolutely mandatory.

I would also plan on using a static stretching brace like a JAS (Joint Active System) brace to help facilitate extended progressive stretching.

https://jointactivesystems.com/products/jas-sps-knee/

I have found such braces quite helpful over the years. I would discuss this with your surgeon. In fact, I would obtain one of these (or similar) braces and use it diligently for several months before proceeding surgically. The long periods of time spent at the endpoint of motion will usually allow progressive range of motion improvement. Even if you do not achieve significant gains, you are training your self to endure the discomfort for long period of times and getting in the habit of stretching every day without any days off. This will be very helpful should you eventually decide to undergo revision surgery.

To summarize:

1- Ensure your prosthesis is implanted correctly. A second opinion is always reasonable. Additional imaging is often necessary.

2- Rule out infection.

3- Train your body to endure long duration stretching.

4- Consider the use of static bracing to help stretch for long durations.

5- Stretch every day for months prior to considering surgery.

6- If surgery is ultimately deemed necessary, make sure you stretch adequately immediately and consistently following surgery, every day, until your knee is cool, calm, and functional.

2/10/2019 11:55:25 am

The reason I focus so much on long duration stretching is that your tissues are viscoelastic. That means they will yield to long duration tension.

https://www.yourorthomd.com/orthopedic-knowledge/viscoelasticity

Early after surgery, no scar tissue has been able to develop. Stiffness at this point is due to the pain and swelling of acute inflammation. Nothing is physically blocking range of motion.

As weeks go by, actual scar tissue devleops between tissue planes and the undersurface of the quadricep tendon scars down to the anterior femur just above the knee. As this occurs, actual physical resistance to motion occurs.

Scar tissue starts out wispy and weak. It is easily stretched. This tissue becomes more robust with time, and ultimately quite rigid. The farther a patient gets from surgery, the more challenging it is to rehabilitate.

I can not emphasize this enough: the time to regain range of motion is immediately after surgery. A functional range of motion needs to be obtained by 6 -8 weeks from surgery. Beyond this time, more aggressive/invasive management is usually necessary.

Miriam Lunk

2/14/2019 08:07:34 pm

I am 8 weeks out of total knee replacement. Rangeof motion is 127 . But I am in more pain and tne knee feels stiffer. I stretch every day. What can help this.

2/27/2019 09:53:22 pm

Time, ice, anti-inflammatory medication, continued stretching, and patience.

I would expect you to "turn the corner" soon, and begin feeling better. If this does not happen in the next couple of weeks, I recommend you discuss this with your surgeon.

Remember, assuming your surgery was properly performed, and you have properly rehabilitated it, you are expected to improve for an entire year.

Nancy B

2/19/2019 12:01:54 am

I am 12 weeks post op after a patella fracture. I was in an immobilizer for the first 4 weeks. My rom was only 60 degrees at 5 weeks of PT so I had an MUA. It is now 2 weeks after the MUA and I am at 90 degrees. Do you think it is possible with your suggestions for stretching along with intensive PT to keep improving the rom or is it too late to have much of a change now? I really want to know the truth but no one seems to know the answer.

2/27/2019 09:57:07 pm

After an injury like you had, treated as yours was, I think you should expect progress with regard to range of motion for many months to come. Slow, steady, prolonged stretches are the best way to improve your range of motion. It is important do stretch as often as possible, for as long as possible, every day. Check out my article on use of a yoga strap to help.

https://www.yourorthomd.com/orthopedic-knowledge/another-way-to-stretch-your-knee-replacement

3/3/2019 11:59:21 pm

Thank you for your reply and for a wonderful, caring website. It has helped me a lot. I am improving with your suggestions of stretches and am now at 118 degrees 3 wks after MUA and PT 5x wk. It has been a long and painful road so far. Could you tell me what I should expect going forward? How long it will take and what I can hope my knee to get back to? Besides the pain, the not knowing is really messing with my emotions.

3/4/2019 07:10:41 am

I am pleased to hear that this website has been helpful to you.

You are clearly working very hard and consistently to rehabilitate your knee. This effort should pay dividends for you long-term.

It is somewhat difficult to predict precisely how any individual will ultimately do, however, in general, and if you continue your consistent efforts, I would expect your knee range of motion to gradually increase over the next several months, and your pain to gradually improve for up to an entire year. This prolonged course reflects the inflammatory process that occurs following trauma (surgical or accidental). Unfortunately, you might permanently lose some deep flexion, but you have already regained a good functional arc of motion. Over the very long-term, a patella fracture increases the risk of developing arthritis in the knee joint. This is because the cartilage coating the undersurface of the patella was also injured when the bone was broken. Overall, it appears you have healed nicely, and are now on the right track to regaining acceptable knee function. I predict your knee will serve you well for a long time in spite of the injury. Best of luck to you!

Nancy

2/27/2019 01:25:23 am

I had tkr right knee in July 2017, no problems with the surgery, not much pain through any of it. Went back to work as a florist in 3 months. Lots of standing, lifting, bending, walking, heavy work. Still no pain but just in the last few months the swelling is horrible. I come from work and can hardly walk. My surgeon took x rays and everything looked good, my flexion is good and my bend is 120. I need to have my left knee done soon but not sure if I want to go ahead with it if my right knee is so swollen all the time. Wondering why the stiffness and swelling is getting worse. Thank you for any comments.

2/27/2019 10:05:09 pm

Swelling without trauma in a knee replacement that had been functioning properly is concerning.

If it is getting worse, it is important to be evaluated by an orthopedic surgeon. If the x-rays look good (as you reported), I would recommend some blood work (CBC, ESR, CRP). These labs are useful to help rule out infection. I would also consider lab work to rule out tick borne illness (Lyme, Ehrlichiosis, etc.) It is also important to make sure your knee is properly balanced (that there is no instability). This is done by history (feeling unstable or giving out) and by physical examination loose side to side or front to back when stressed by your surgeon. Lastly, adverse reaction or allergy to materials should be considered and evaluated.

I agree with your plan to wait on the next knee replacement until the problem with your first knee has been figured out and resolved.

Brenda

3/15/2019 07:30:50 pm

Hello,
I had a TKR of my right knee on 11/20/18. I have been in PT ever since. The fist 3 weeks were torture sessions in which I cried every tim, 5 days a week. Then the dr sent me to a PT he uses for a month. My range of motion was only 105. Dr said he wants to do an MUA. I’m trying to avoid that. I have been at a different PT now since 2/15/19. My ROM is 114, but it is very painful to bend it to that degree. The knee isn’t as stiff as in the beginning, but it is still difficult to flatten it due to a lot of pain behind my knee. I am in PT 4 days a week and just started going to a massage therapist last week. She works on the whole leg for an hour to soften the tissue and relax the muscles. I have no pain after her therapy which is great for several hours. Then the pain behind the knee recurs and bending is difficult. Do you think I should have the MUA? I’m nervous and discouraged.

5/12/2019 10:56:51 am

My experience is that manipulation needs to be done within 8 weeks of surgery. Beyond this point the soft tissue contractors/scar tissue will not yield to a reasonable force.

If range of motion is unacceptable beyond 3 months from surgery arthroscopic lysis of adhesions (cutting of scar tissue) must be done prior to manipulation.

Neil Coleman

4/6/2019 05:53:31 pm

I am 66 yrs old , and I am fit and active . I had TKR 11 months ago , for arthritus . After 6months I had 0 deg. ext and 95deg .flex , and was making good progress . I was playing social doubles tennis , but not quite able to road bike . Generally feeling positive , back at gym and doing regular stretching exercises . 8 months post.op , I had discomfort in knee , with swelling and heat . Had to ease off on physical activity . Weight bearing after sitting was a problem , as well as a very clicky knee . I revisited my surgeon who x-rayed and declared the new joint "pristine " but suggested there had been some tissue damage , and keep up the exercise . My Physio has given me specific quad strengthening work , and I am currently using your excellent "flexing with strap" regime to increase my flex to about 100deg . I also have regular massage , and have been taking low dose antiflam medication.
After 11 months , while I don't have pain , my knee is often clicky and wobbly after sitting or lying . I now limp more , and find activities harder I am concerned with my reversal of progress . While I am doing everything I can do to recover my knee health , can you tell me if it possible to "overdo" these exercises ? , or suggest any thing else that may help? Your blog is extremely helpful , I wish my surgeon and physiotherapist had explained TKR as well as you do .

5/12/2019 11:13:01 am

It sounds like you have a bit less range of motion than would be ideal for your desired level of activity.

The wobbly sensation you describe accompanied with difficult flexion could suggest slight soft tissue imbalance in extension relative to flexion.

Some total knees will loosen up with time, and in the absence of pain do not require treatment.

In my opinion, simply stretching harder or for for longer durations is unlikely to help at this point.

I would consider getting a second opinion on your knee. While an x-ray might be "pristine",the soft tissue balance may not be ideal.

In your case, your knee may be improved by regaining deeper flexion. This unfortunately would likely involve an arthroscopic lysis of adhesions and manipulation. If there is instability in extension and tightness in flexion, this would require revision surgery at this point.

Denise link

4/30/2019 06:00:54 pm

Surgery for complete left knee replacement March 6, 2019. The first 2 weeks I did the recommended physio at home. After the two weeks I started physio up to the day before I saw my surgeon at 7 weeks. I’ve been to pt 12 times. Very and extremely painful every time. Since the fourth week I have felt a piercing hook on the left side every step I make, preventing me from doing them properly. As a result, it makes me afraid of what i will feel when my foot touch the floor.
Surgeon was happy with the X-rays. Bend 90/95, flex minus 7.
I describe that as a large “cup hook”. It is excruciating. I read the comments and recommendations. But none addressed mine.
I’m looking forward to your reply.

4/30/2019 08:29:41 pm

I am sorry, I do not understand what is meany by a "cup hook." If you can clarify this in other words, perhaps I can help.

Much of this website has been focused on helping patients avoid knee stiffness following surgery. This is crucial to a good knee replacement result.

Unfortunately, when a total knee replacement is allowed to get stiff in the early post-operative period, the usual result is pain. The mistake most patients make at this time is to do less stretching because it hurts. The best thing to do is to do long duration stretching, more times per day. Using ice on the uncomfortable soft tissues and being generous with anti-inflammatory and pain medication is also appropriate.

6/26/2019 08:03:15 am

10 months post total knee replacement. I have at least 115 bend and completely straight leg but I still have an awful tight feeling across the top of my knee when walking. I'm hoping it will wear off in time??

7/22/2019 08:31:52 pm

Following total knee replacement, your body will lay down new, thicker scar tissue. This may feel stiff for a long time. Although this tissue will always be present, it should gradually loosen up for a long time. Additionally, the lateral aspect of the knee (outside aspect) is often partly numb, this can feel abnormal, some may describe this as "stiff." With the range of motion you have achieved, I would expect you to feel better and better as months go by.

7/17/2019 11:00:31 pm

Hi Dr G, I am still recovering from a patella fracture on Nov 2018.
I will always be grateful for your suggestion of long duration stretching. I was stuck at 60 degrees and had to get a MUA. It was terrifying. My ROM is great now, almost the same as my NON OP knee. At around 140 degrees! I still do the stretching everyday.
There is still some swelling, stiffness and pain though. I wonder if this may be due to having the MUA late at 10 weeks post op??

Now I am going to have surgery in 2 weeks to remove the metal and am hoping that this will help to fix these problems and that I will eventually feel better.
My questions are:
Re this surgery,
1. do I risk to get that “rare” stiffness again that doesn’t usually happen to others?
2. How soon can you usually do the long duration stretches after this surgery? I’m so scared to start it all over again. It really was a nightmare.
3. Is this surgery recovery going to be as painful as the original surgery recovery?

Also, can you suggest some ways to increase my quad size/strength? My quad is still looking scrawny.

Thank you for your help!

7/22/2019 08:39:30 pm

Outstanding job on regaining motion! Unfortunately, after a fracture, your knee may never feel perfect. It is common to find the hardware used to repair the fracture irritating, and I would expect improvement in symptoms once this is removed.

Assuming your fracture is solidly healed, I would begin range of motion exercises immediately, certainly once the wound has healed.

I highly doubt you will experience significant stiffness after this procedure, and now that you are an expert on regaining motion, I think this should seem relatively easy to you.

I would recommend avoiding open chain quadricep strengthening exercises (open chain is where your ankle swings through an arc). The most common example of this is the leg extension machine. This should be avoided. This is particularly important with your history of patellar fracture. Doing single leg squats is an excellent way to build your leg strength in a physiologically normal way. It is also important to build your hip strength.

Please check out my article on anterior knee pain for a demonstration on how to build up your hips.

https://www.yourorthomd.com/orthopedic-knowledge/anterior-knee-pain

Best of luck with your procedure, I am sure you will do very well.

9/1/2019 06:25:54 pm

Hi Dr G
I have really good relief with the hardware out (2 wks ago) ROM is still good too. I have a quick question re your advice on avoiding doing “open chain quad exercises”. I definitely have avoided using the leg extension machine at the gym but is a “long arc quad exercise” the same thing? (Gentle, no weight)
If so, how long should I avoid this move? Indefinitely?
PS: just a reminder, I had a patella fracture 9 mo ago

9/1/2019 11:26:13 pm

I am glad to hear you are feeling well. I think doing unweighted long arc quad exercises is fine to help regain full, active extension. I would definitely not recommend adding weight to this exercise though, as it could rapidly become irritating to your patella. And yes, I would recommend avoiding open chain strengthening forever. Single leg squat/leg press are better ways to strengthen.

Deborah L Domenici link

9/2/2019 03:47:04 am

I broke my knee June 10th-fell on tile. Only hurt initially. I never had any swelling or mobility issue the 1st week. Was doing everything I normally do-including mowing my lawn with zero pain or problems. All my problems started when I fnd out I broke my knee 1 week later. And i only fnd this out. Because my GP sugg. I have it x-ray since i had broke a toe 10 days prior-and was going to Ortho to have that X-rayd. Found out broke my Patella. but Orthopedist sd it was in a good place. But if I would continue to bend it. I could possibly end up needing surgery. Since it should stay straight for 6 weeks to heal. ALL MY PROBLEMS started with the immobilization. I had horrible calf, ankle, and foot swelling. i got numbness, and my leg felt like glue was poured in there. This went on for 6 weeks. I was so uncomfortable -I called ask-a nurse 2 nights. I was told to go to ER.Since calf swelling could be blood clot. Waited till Monday-told my GP this. He tells me i don't have a blood clot. I sd how do you know. He says " I'm a Dr?" He agreed on my request to let me have ultrasound referral. Where blood clot was ruled out. But this continued. And 2 weeks later when I called Orthopedist upset.They recommended another Ultrasound. Where blood clot ruled out agn. Nothing else was ever suggested from my Orthopedist or GP for these symptoms. The immobilizer came off July 28-6 weeks from June 17th. 6 weeks of hell. When it came off- i asked the Orthopedist. " Is this swelling going to go away?" He says maybe? I had 2 physical therapy sessions. But I couldn't get more than 95 degree bend in the end. Due to my calf and behind knee swelling. Another P therapist told me I wouldn't till I got rid of the edema. So-here i am now-more than 1 month from immobilizer off. I am able to get enough rom to ride my recumbant road bike now-but that's it. And I've only ridden it 3x for about 10 min-because when i get off-10 min later-my lower leg feels worse than ever-stiff cement like. Numbness comes and goes. My ankle when I try to move it-feels like I'm trying to move burnt skin. A lot of the swelling has gone. But I still have some. I can't lift my right foot off the floor more than about 10 inches. And I can't safely walk my 2 big dogs. I'm not walking totally normal by any means. I have taught aerobics a good part of my life. And I happen to be very flxible. My left foot-at 65-I can still put to my mouth. And bend back and touch my butt easily. My right foot now. I can get facing a wall. I'm 1/2 way to the butt-that is a lot of lost rom. And I feel horrible-between the 3 symptoms. Do you suggest-static stretches for me also? I use the neighbors pool. And when i 1st get there. My calf is hard as a rock. I'm able to get fluidity to it in about 10 min. But after the 50- 60 min I'm there moving. As soon as I get home-20 min later-It's BACK-the stiffness. Tuesday I have an appointment with a chiropractor for a compression boot session. And last week I had the grad-forget correct spelling technique done by him. Not so sure that was a good thing. Felt fine agn for 15 min-stiffness back 15-20 min later. And the procedure painful. Common sense tells me pressing on my leg with a stainless steel instrument-to get fluid moving-may not be the best method. So- I need advice. I'm getting very depressed about all this, I feel half crippled from a simple break that required no surgery. Chiropractor sd i should have been offered massage during this 6 weeks of immobilization-to keep fluids moving. And I'm wondering if a brace that allowed minimal movement rather than none. Would have been much more common sensical. Now my patella is healed -But I'm half crippled?

9/16/2019 08:19:44 pm

Rehabilitation after a fracture can be frustrating. I would expect progress for an entire year of more following a patella fracture. Nonoperative treatment of a patella fracture does require immobilization. Now that you are healed, it is important to have patience and persistence. You should be stretching progressively every day. The stretching I recommend on this website for patients following total knee replacement will work for you as well.

Here is a shortcut to several articles explaining how to stretch in the most effective ways possible.

https://www.yourorthomd.com/orthopedic-knowledge/category/rehabilitation

Verna Lister

9/16/2019 08:44:50 am

I had a TKR on Aug 15, 2019. Prior to TKR I had only a maximum of 93 degrees flexon due to prior injuries. Total tears in 1988 to ACL and i 2009 PCL..some Medal lateral damage, After 4 weeks post op of have about 80 degrees flexon, extension seems OK. What should I expect by 6 weeks and what should I do for stretching?

Christopher Gorczynski link

9/16/2019 08:09:02 pm

In my opinion, you are a bit behind schedule in regaining your range of motion. My experience suggests it is very unlikely for patients to predictably regain much flexion beyond 6 weeks from surgery. I recommend long duration, slow steady stretching, as often as possible, for as long as possible.

In my practice, if a patient does not achieve a functional range of motion (0-110 degrees or so) by 6 weeks postoperatively, I recommend a manipulation under anesthesia.

The majority of articles that appear on the following link will provide further guidance.

https://www.yourorthomd.com/orthopedic-knowledge/category/rehabilitation

Close follow-up with your surgeon is crucial over the next few weeks to make sure you end up with a functional knee

9/30/2019 09:08:29 pm

I have been doing to prolonged stretches and making more progress. But to add further information for your consideration. My knee flexon was a maximum 0f 93 degrees for more than 4.5 years prior to surgery..so how would this change the rom by 6 weeks? Would further ROM and more weeks bring a more acceptable ie 115 degrees? I am seeing surgeon Wed. I will advise him of my progress. Any further incites to why I am experiencing lack of rom to date? I have done stretches and PT every day?

9/30/2019 09:16:59 pm

Poor range of motion prior to surgery definitely correlates with a more challenging rehabilitation process after surgery. This is in spite of the surgeon regaining full, unrestricted, range of motion at the time of surgery. It appears you are now around 6 weeks from surgery. In my practice, if you are still stuck around 90 degrees at this stage, I would recommend undergoing manipulation under anesthesia. This usually makes a huge difference for patients.

Here is an article I wrote about this procedure.

https://www.yourorthomd.com/orthopedic-knowledge/manipulation-under-anesthesia

Patrick Shipley

10/3/2019 12:58:07 am

Hello,
I am a 54 yr old male professional bowler, at had my total knee replacement June 4, 2019 on my left knee which is my sliding leg. After seven weeks of physical therapy, I had a Manipulation Under Anesthesia on August 22nd due to be stuck at 75 degrees of flexion. Physical therapy has been tough. The day of my Manipulation procedure, I went directly to PT and was 90 degrees, then PT two straight every day ended September 6th. I am now back to two sessions a week and am at 103 degrees at 17 weeks. I have my 6 week post op appointment from my Manipulation procedure next Monday Oct 7th. I’m afraid I’m stuck now at 103 degrees. The last 3 PT sessions have been the same. I bought myself a recumbent bike about week 5 and am able to peddle completely forward and backwards and moving my seat up gradually, but only to the point that I just can’t do it anymore.
I’ve been seeing on these posts about the tight band that goes completely around the knee. I have that and it’s like a 2-3 inch band. Also, I want to add, when I am trying to get my flexion, the back of the knee hurts, like a squishing feeling.
I have returned to work at 8 weeks, and also started bowling again as of last week and half. My surgeon and therapist told me to get back out on the lanes as part of my therapy, so I did just that. I bowled league last week which was 16 weeks post op, and shit 225-214-183, better than I expected, but my knee bend is still stiff during my slide.
What should I expect from my doctors visit at my 6 week post op appointment from Manipulation procedure? They mention at my 2week appointment, that there is an option of arthroscopy to remove scar tissue, but I really don’t want to go backwards.

Thank you very and input. I need some encouraging words right now.

Patrick

10/7/2019 08:22:38 pm

Hopefully you are trying to stretch the way I recommend in this article. My experience with stiff knees really suggests that short, rapid stretches are ineffective. Check out the article I wrote on viscoelasticity.

https://www.yourorthomd.com/orthopedic-knowledge/viscoelasticity

It is important to find a way that allows you to hold the deep flexion stretch, WHILE RELAXING YOUR MUSCLES.

This is the crucial point, and a mistake I commonly see. You must completely relax your quadricep muscles to effectively stretch. This means not supporting your body weight.

The use of a non-elastic yoga strap is very effective.

https://www.yourorthomd.com/orthopedic-knowledge/another-way-to-stretch-your-knee-replacement

You can also discuss a prescription static stretching brace with your surgeon. I don't think you will gain much from this style of brace at this point as your motion is really not bad enough.

I would recommend working for several months on long duration static stretching before considering arthroscopic lysis of adhesions. This is for several reasons: that procedure really isn't any different or more effective if done now, or in the future, it involves risk of infection, it is no guarantee of improved results, it is much better to train yourself to be able to stretch appropriately now, and (most importantly) if your are stretching properly on a daily basis, you very well may not need any additional procedures.

10/3/2019 01:38:09 am

I’m sorry, I had my weeks messed up. My Manipulation procedure was on August 22nd which was 11 weeks from my total knee replacement surgery June 4th, 2019.

Brenda Solomon

10/6/2019 05:12:50 pm

I had knee replacement surgery three months ago. My range of motion is good 126. I have completed PT. Now I use my stationary bike daily and try taking long walks. But my knee can still feel very stiff some days especially after standing or walking for long stretches. Does this stiffness eventually go away? Is there something else I should be doing? Everyone says it takes awhile. They told me that Medicare will not pay for more PT.

10/7/2019 08:08:34 pm

From my perspective you are doing great for this stage. While every patient has a somewhat unique experience following knee replacement surgery, I would expect stiffness to gradually improve for a whole year. At this stage I recommend progressively resuming your desired activities. It is ok to use ice if the knee gets swollen or sore. Be confident that the way your knee feels at 3 months is far from the final product. Congratulations on your excellent early rehabilitation.

Amy T Lake

3/10/2020 04:30:35 pm

I had total knee oct. 2016 and then may 2017. It is now 2020 they still hurt when I stand 4 or more hours. Is this normal? Can they still swell even though the parts aren't bone? Some days they feel as big as boulders in the inside, but can't tell on the outside. I work 40 hrs a week medical assistant. I had them rechecked and had to pay big money for all the x rays but I'm still not convinced.

3/11/2020 10:21:55 pm

It is not normal for total knee replacements to hurt as you describe. I can take a while for a patient to recover enough to stand for several hours at a time. If your knees swell, it is not the metal prosthesis or bone that is bigger, it is extra fluid contained within the knee joint. This fluid is made by the synovial tissue inside the knee. This is living tissue. I usually remove most of this tissue at the time of surgery, but not all surgeons do. Some patients will have recurrent swelling after knee replacement. This does require some investigation beyond simple X-rays if the swelling and discomfort are significant. Sometimes blood work is necessary. Sometimes additional radiographic testing is needed. Perhaps you should consider a second opinion if you are not satisfied with the explanation you were given by your surgeon.

Michael Treloar link

10/10/2019 10:32:10 am

Keep up the great work! Thank you so much for sharing a great posts.

10/14/2019 06:17:47 pm

It is my pleasure! I am glad to hear that you enjoy this website.

Jim

10/12/2019 03:45:01 pm

I had bilateral tkr sept 5/19 and found your question and answers very helpful, thank you so much for doing this.

10/14/2019 06:16:16 pm

I am glad to hear you find this site helpful, thank you for the feedback!

Christine

10/18/2019 02:17:44 pm

I had a total knee replacement over 4 years ago and had very little pain and recovered very quickly. The only slight issue was a small area of tightness on the outside of my leg just above my knee

A couple of weeks ago I went out wearing a pair of slip on shoes which had heavy soles and were quite loose. At the end of the day I felt a great deal of discomfort in the muscles around my knee and although there has been a slight improvement. It seems that shoes which have supportive, flexible soles cause discomfortaround my knee. Is there a reason for this.

10/28/2019 07:20:51 pm

It sounds like the combination of heavy shoes that fit loosely probably required more energy to walk. I would recommend supportive, properly fitting shoewear.

Abinesh Jegatheesan

11/19/2019 10:23:36 am

Hey I had broke my lateral femoral condyle in a freak accident in April. After the internal fixation procedure I struggled a lot with my range of motion and my knee became extremely stiff and it was recommended that I undergo arthroscopic treatment to remove the scar tissue. I had that done last week on November 8th. Ever since I have been on my CPM machine, consistently doing my post op exercises, going to PT, but there hasn’t been much change in my ROM. My knee is still quite swollen, but I’m still quite discouraged with my progress so far. Is there anything I can do to improve my ROM?

Terry

11/22/2019 02:47:47 pm

I am a 65 year old female who had a total knee replacement 3 weeks and 3 days ago. My flexion is 115 and the leg lies flat. I have the tight band sensation people are talking about. I am incredibly thankful I found your information and will begin the stretching exercises, holding the leg for some time, rather than seconds. Your information has given me peace of mind that I am doing okay, and has answered SO many questions I’ve had. I sincerely cannot thank you enough for taking the time to answer so many questions. Thank you.

11/22/2019 11:04:58 pm

I am glad you find this website helpful. It sounds like your total knee rehabilitation is right on track - your range of motion is perfect for this stage.

Keep up the good work!

joyce stein

12/26/2019 02:13:38 pm

I am 5 and 1/2 months out from total knee replacement. I have good range of motion. Can't do stairs due to clunking and pain behind knee. I go to the gym every other day for strengthening exercises and recumbent bike. Can go upstairs fine no pain. Catching young clunking going downstairs. Mild clunking when I walk. Can minimize it if I keep my glutes tight while walking. He does get irritated from all this clunking. Wondering if there is any exercises that would minimize this. My Doctor says he could replace the plastic in my prosthesis with a different kind if I'm still having a lot of trouble in 3 months.

1/11/2020 10:22:53 am

This probably deserves an entire article, but I will attempt to answer your question briefly here. A total knee replacement is a mechanical device made of hard materials (metal and plastic). A variety of motions are possible between these components. Because the materials are hard, mechanical sensations are common and often quite normal and anticipated. A properly balanced knee will not have major catching and clunking, however. Severe clunking can indicate synovial tissue becoming caught between components, ligament imbalance, or mechanical debris caught between the moving prosthetic components. Exercises are not likely going to help. The fact that your surgeon suggested a polyethylene plastic exchange suggests that he/she is concerned about ligament instability. I would also suggest getting a second opinion from another surgeon before committing to a revision surgery.

Jason Hancock

1/16/2020 07:36:23 pm

I'm a 47 year old man and I'm 9 days post op. I am really struggling like most with flexion and I'm currently at 90° my physiotherapist is making me go a little beyond what I can handle pain wise with her help and holding only 5 seconds. My progress seems to be creeping along and feel like this is brutality! Lol. My question is, when you say to hold these exercises longer using minutes instead of seconds, do I have to be at a point of almost agony when I hold? Or can it be a bit less so I can prolong the exercise? As I'm typing this I'm thinking the answer may be obvious! Thank you!!

1/17/2020 10:46:34 am

This is a very common question. The problem is that when you force range of motion for just a few seconds, your tight muscles will spasm and even the biggest, strongest physical therapist in the world will be unable to move your knee. Particularly at 9 days, there has not been enough healing yet to create any significant "scar tissue" that physical therapists love to talk about.

The resistance at this point is almost entirely muscular. If we put you under anesthesia at this point (so your muscles could not fight back) it would take minimal force to bend your knee so that your heel touches your buttocks.

So- this is why I recommend slow, gentle, long duration stretching. We need to convince your muscles to relax, and to fatigue them a bit so they will relax and actually let your knee bend. It is only at this point that the tissue planes will begin to slide/deform which is actually what gets your knee moving better. Most people will not see much progress with a few seconds of over-pressure.

If you are struggling with range of motion, I recommend significantly extending the duration of stretch. It should be uncomfortable, but does not have to be horrendously painful at this stage in your recovery.

To take the pressure off a bit...having achieved a 90 degree arc of motion at 9 days postop at age 47 is actually just fine, and if you continue working on motion on a daily basis, I would expect you to easily regain a 120+ degree arc by 6 weeks. Just keep with the stretching and try to relax your muscles as much as possible while doing so.

1/17/2020 12:07:23 pm

Thank you so much for your quick response! My my therapist just left and I have achieved 97° which is a 7° improvement in 2 days. I definitely see that the morning PT is easier than the afternoon which I assume is because of less swelling and pain due to 8-10 hrs of rest. Thanks again.

Cami Gorsky link

1/25/2020 08:34:39 pm

I had my R TKR on June 5th 2019 and at 6 weeks was bending great, don't know the degree, but about half way up my thigh. I had my L TKR on Aug 5th and bending was the same. I was cut loose from PT that was done at home. I am 60 years old. I was a 5 day a week tennis player and am in good shape, not overweight and wondered why it has become so still.Seemed to be doing great but my R knee started getting stiff. I've tried ride the recumbent bike, but I know it's not bending as well as it should. I seem to be able to rotate but my right ankle is bending funny to accommodate the rotation. Now, on the Right side I can only bend it to the top of my calf. The Left (second surgery) still bends like it's supposed to. I can straighten them both flat. I called my ortho office and it's taking 3 weeks to get in for a appt. They both click when I walk. I have no problem walking. Just the Right bending. I've been trying to work with it but it's really not budging much at all. I've tried soaking in epsom salts and then stretching but I can't tell that it's helped at all. It's quite frustrating. I had rotator cuff repair in Dec of 2018 to repair 3 tears and it healed quite well without any scar tissue. Do you have any idea why the first surgery has adhesion's? I would appreciate any advice. Thank you so much, Cami Gorsky

2/1/2020 12:59:51 pm

Unfortunately, I do not have enough information to answer the question (why your right knee got stiff after "bending great" at 6 weeks.) I agree that this is not typical. Usually once rehabilitated, a normal knee replacement is expected to easily maintain functional range of motion for decades without having to constantly dedicate time to stretching.

I agree with your plan. It is crucial to have an orthopedic surgeon check out your knee. Anytime the function of a joint replacement deteriorates, it requires evaluation by an orthopedic surgeon.

Gordon Fitzsimmons

1/31/2020 07:37:47 pm

Hi, I am pleased to have found your site and have spent time tonight reading through the posts and answers/advice given. I am particularly interested in the references to "tight", "tight band". I am 9 months post tkr on my right leg and 6 on my right. Of the two, my right has been more of a success to date. I have had a fair bit of I believe soft tissue issues with my right knee/leg . Thankfully this is settling down a bit. I have good ROM and straight legs; I followed my PT program and was discharged from my sessions and returned to work after a few months. What concerns me is this tightness/stiffness above both knees (lower quad/quad tendon). I can walk on the flat and go up hills (with slight awareness of it), use my excercise bike also, however walking down gradients/slopes is a problem. I feel I have to take baby steps due to this tight band/concrete band feeling above my knee. I have even at times gone down slopes sideways as it's much easier. My daughter thinks it's equivalent to a woman walking down hill in high heels. I feel I'm going to fall face down at times. I'm currently trying to take longer strides , but the tightness persists. Is this the scar tissue you refer to ? If so will this go away/settle down given more time ...I'm approaching 1 yr post op in April. I continue to do excercises given to me by my PT back last summer. I will try the longer stretches you mention. Thanks in advance for any advice on this.

2/1/2020 12:53:22 pm

You do not specify your range of motion, other than "good." I assume this to mean 120 degrees or so. I think your difficulty going down slopes is more likely due to relative leg weakness and should improve with time and strengthening of your hips, quadriceps, and hamstrings. There are some technical issues with regard to knee replacement design that can make them somewhat less forgiving going down hill. It is very important to work on strengthening to help you with this. This being said, I recommend that everyone avoid open chain quadriceps exercises (quadriceps extension machine) and instead focus on squats, lunges, etc. I hope this helps you.

2/3/2020 03:42:42 pm

Thanks for allowing and responding to my post. Your advice is much appreciated .

Julie High

2/7/2020 09:39:01 pm

Hi. I am a 60y/o female post LTKR December 18, 2019. Two weeks post-op my ROM was 117/0 and 125/0 at 6 weeks. I've had extreme nerve pain that stings, burns and becomes achey. That started about week 3 and I was told that sensitivity was normal and would go away. I started doing desensitization and the nerve pain was starting to subside at around 5 weeks.. I saw my surgeon at 6 weeks, 5 days and everything looked good. Prosthesis fit was good, x-ray looked good. I discussed the desensitizing with my Dr. and how the nerve pain was starting to subside. We also talked about using Palmer's cocoa butter over the incision site and massaging to break up scar tissue. I did that with his go ahead and I don't know if I massaged too deep but something has changed. I feel stiffness, like a band is being held over my knee. I have almost constant nerve pain, whereas before it only occurred late evening. I also feel a cord shape (vein?) palpable under the skin that extends mid-knee horizontally to the lateral side of my leg that ends at the bend. I've been actively involved in my PT before surgery and post-operatively without any issues. I was unable to complete full reps of my exercises yesterday because of the pain. Today I went for therapy and my PT did light massage, some light exercises and gentle movement of my knee. I'm so frustrated because everything seemed good, with the exception of the nerve pain which was actually resolving until I massaged my scar with the cocoa butter. It seems like it was a simple thing to do. Now I'm concerned that something has gone wrong. This new pain is excruciating and wearing me down. Thank you for your time.

2/8/2020 06:29:17 pm

I think you are only experiencing the normal thickening of the soft tissues around the knee as the healing process progresses. Scar tissue tends to toughen and contract over time. Ice, massage, stretching and (most importantly) time should take care of most of the sensitivity and tightness. As always, if there has been significant deterioration in your knee's appearance and/or function- have your surgeon check it out in person. Excruciating pain is not typical for this stage in your rehab.

Lindsay

2/21/2020 08:56:14 pm

Hi there. I'm a 29 year old female, and I broke the distal head of my femur within my left knee playing soccer 11 years ago which appears to have healed nicely without surgery. Years later, I had increasing pain and last year an orthopedic surgeon found that I had significant wear and tear on the inside of that patella with some bone loss. About 10 weeks ago, I had a osteochondral allograft transplant from a donor placed onto the kneecap. PT was terrible after that due to a combination of problems (bad post-op pain that started PT off for about 5 days, a physical therapist who was too aggressive and never did the type of PT you've talked about on here, and the possibility that I scar quickly). Anyways, I could only get about 70 degree flexion with no progress for four weeks. So I had to have scar tissue removal surgery at 9 weeks (9 days ago) and my surgeon said I had extensive adhesions all over the place that were virtually "cementing" my knee down. He got 135 degree flexion during manual manipulation under anesthesia. After this surgery, my surgeon wanted 90 degrees flexion 3 days post-op, but I could only get about 40 and apparently my patella was already very stiff at that time. Right now on my CPM and at physical therapy, I can get to about 65 degrees with a lot of tension and pain. And my kneecap feels more stiff than last week. My thigh muscle and perhaps tendons/ligaments above my knee are insanely tight and feel so much pain when stretched. I have done well to learn to relax during PT and I'm even on valium and opioids to try to continue to relax these muscles. I know I could bend my knee more if these muscles would stop being so tight. They hardly feel like muscle anymore. And while I simply try to bend my knee outside of an actual PT session, these muscles are like tightropes and the knee bends maybe 15 degrees.

Sorry, this became long, And I suppose my questions are 1) I've been doing everything my doctor and PT has told me to and I'm otherwise very healthy and still young, why might I seem to be doing so poorly with rehab? 2) What can I do about my thigh muscles/tissues that are so tight and painful? My PT just says I need to keep practicing relaxation techniques and massage it.

Thank you so much for reading my long post, and your reply!

3/6/2020 02:34:30 pm

Unfortunately, I am unable to state why, exactly, you have become so stiff. It does happen sometimes. It is called arthrofibrosis. Some patients have a very difficult time relaxing into the stretch. If the response to pain is clenching the muscles, then stretching becomes very frustrating. The best thing to do is to be very gentle with the stretching, but to hold the stretches for a very long time. This allows the muscles to fatigue, and relax. Use some pain medication and ice or heat while stretching. Try to distract yourself during the stretch. Stretch for hours everyday, with no days off. Your hard work will pay off.

Mita Vyas

3/2/2020 02:37:26 pm

Hi Doc,
I have TKR about 5 months a go. My bend is about 120 to 125. I would like to increase it to 135 (I had 140+ before surgery). Is it possible after 5 months? I do exercises for bending and stretching but it increases the stiffness a lot. Should I continue to exercise or be happy with what I have .

Thanks
Mita

3/6/2020 02:26:11 pm

It is possible to improve your range of motion for up to a year from surgery. This will take dedicated time and effort on your part. I would argue that 125 degrees of flexion is an excellent result, and should allow you to do just about anything necessary for a happy life. If there is a particular reason you need more flexion, then keep stretching, but if it is simply to get a "better" number, then I think you may have more pleasant things to do with your time.

Tonya

3/6/2020 04:41:50 am

Hello,

I had left knee replacement surgery January 17, 2020. I've been going to therapy and am now able to stretch to 105 degrees. I'm still having some pain, but still do stretches in therapy and at home, but I still cannot get past 105. Doctor suggested manipulation under anesthesia or try to see if continued stretching will help down the road. I'm afraid of more surgery because when I had the knee replacement, the doctors could not wake me up for 12 hours after surgery and I experienced a stroke during surgery. I'm doing good with the 105 degrees but of course want more. I'm not able to fully straighten or bend my leg. Also, starting a couple of weeks ago, I now have that tight band feeling at the top of my knee cap along the length of my scar. What should I do? Do you think that I can eventually get my leg to a complete bend or completely straighten it out as time goes by? I definitely will try holding my stretches longer. Thank you.

3/6/2020 02:23:04 pm

I understand your reluctance to undergo more surgery. A manipulation is generally done using only IV sedation, and no incision is made. This usually must be done within 6-8 weeks of surgery for a reasonable chance of success.

Diligent stretching as I recommend may get you another 5-10 degrees at this stage, but I doubt it will ever be considered "normal." You don't state how far from full extension you are now. Manipulation will not generally help extension. The best bet there is long duration extension stretching.

3/8/2020 09:06:13 am

Thank you so much for responding!

Bill

3/25/2020 09:00:00 pm

Stats - Age 67 , TKR Oct 15 , MUA Dec 16 , Current ROM 90 (95) . Can you explain why it was necessary to perform MUA before week 8 vs your thinking of Long Duration Stretching even after a MUA has been completed . I thought that after week 8 or 9 the contras had formed and the only way to remove scar tissue was more surgery ?

3/25/2020 10:49:08 pm

After surgery scar tissue begins forming. This scar tissue becomes more robust over time. Early range of motion exercises are very important to regain a functional range of motion before this scar tissue becomes so dense that it will not yield to stretching exercises. Within 6-8 weeks this scar tissue can be gradually elongated by stretching it. It is dose dependent- meaning the longer the stretch is held, the more effective it will be.

After undergoing a manipulation procedure, this scar tissue is disrupted. The surgeon basically forces your knee to bend beyond the point the scar tissue allows. This requires anesthesia because the procedure hurts, and it relaxes your muscles which normally resist stretching when it is unpleasant.

Because manipulation disrupts the scar tissue, you now have a few more weeks to improve your range of motion.

Since you only had 90 degrees of flexion at 8 weeks, if you had not undergone that procedure, then it is unlikely you would have regained a functional range of motion. If you decided that a 90 degree arc of motion was unacceptable much beyond 8 weeks, then the scar tissue would have gotten so dense and strong that manipulation would require too much force to be effective- this could result in a fracture or injury to the extensor mechanism in your leg. This is why I do not recommend manipulation beyond 6-8 weeks, without first performing a lysis of adhesions arthroscopically. Here we cut the scar tissue and then manipulate.

I hope this clarifies things a bit.

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Stiff knee replacement

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