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Viscoelasticity

5/20/2016

26 Comments

 
Biologic tissues are viscoelastic. That means their stretchiness changes depending on how hard they are stretched.  We can take advantage of this characteristic when we are rehabilitating a stiff joint. This becomes very important with certain medical problems. Specifically: total knee replacement and frozen shoulder. This concept is generally helpful in orthopedic rehabilitation and I take advantage of it whenever applicable. 

Think of silly putty.  When slowly stretched it can be drawn out into a long strand, but when pulled aggressively it will snap and break in two.  This is an extreme example of viscoelasticity. 

Your tissues are similar.  While extreme force stretching can cause tissue to tear, this is generally far beyond any amount of stretching a patient can do, even with a physical therapist. A manipulation under anesthesia is a maneuver performed by a surgeon to rapidly regain motion in a particular joint that has become stiff. Tissues tear, and inflammation results. This is the most extreme example of a high force, low duration stretch. It is best to avoid this type of intervention if possible. It is preferable for a patient to spend the time necessary to recover joint range of motion using a long duration, low force stretch. It will result in less inflammation and less pain. 

Shoulders and knees commonly become stiff. Total knee rehabilitation requires stretching to regain range of motion after surgery. Stretching is required to speed up the recovery of a frozen shoulder. When attempting to regain range of motion patients are often told to stretch for 10-15 seconds and then relax. Over and over. Sometimes this is effective. Sometimes it is not. There is significant genetic variation with regard to tissue strength and inflammatory response, and significant psychological variation with regard to pain tolerance, and ability to relax while stretching. When a patient has trouble regaining range of motion I try to focus them on long duration, low force stretching. This tends to create less inflammation and is more likely to allow a patient to relax the muscles while stretching. Relaxing is very important because any muscle resistance will prevent gains in range of motion. 
Force vs. Duration Graph showing less inflammation with long duration low force stretchingForce vs. duration stretching. A longer stretch done with less force will create less inflammation.
This sketch depicts how I think about stretching. A high force, brief stretch is more likely to cause inflammation. A gentle prolonged stretch is less likely to create an inflammatory response. The "amount of stretch"  or the total area under the curve depicted by the hash marks could be identical, but my experience suggests the long duration, low force stretching will give a superior result. 

​How do I know this?

When I was a resident, I developed a frozen shoulder and used long duration, low force stretching to cure myself. I have subsequently recommended this technique to countless patients who presented with frozen shoulders that had failed to improve after many weeks of standard physical therapy.  Although occasionally surgical intervention was necessary, the vast majority progressed using this technique and never needed surgery. This technique has become my standard recommendation following total knee replacement and to rehabilitate a frozen shoulder, and has minimized the need for manipulation. 
26 Comments
Deb Catlow
10/24/2020 02:05:58 pm

Hi, I have had 4 new knees, my first replacement was 1990, due to joint not being right had it revised, then again and again.
I have no patella due to a motorbike accident, this accident will have resulted in my painful arthritic knee.
I have spent a fortune on physios and other therapies to improve my range of motion. All to no avail.
I have approx 50% flexion.
I came across your website and what I’ve read has made more sense than anything else. I now do the prolonged stretch and slowly but surely it’s working, think maybe I’ve been stretching for too long a period.
Do you feel that my flexion will continue to improve after all these years ( my last revision was 2 years ago)?
Deb

Reply
Christopher Gorczynski, MD link
10/24/2020 04:30:54 pm

It is always reasonable to try long duration stretching. My expectations would have to be significantly reduced under your circumstances, unfortunately. Your knee has undergone significantly more trauma than that involved with the typical knee replacement. 4 knee replacements in 30 years plus a patellectomy! By 50% flexion, do you mean only 50 degrees of flexion. If so, I would approach this differently. I would recommend arthroscopic lysis of adhesions with manipulation and static bracing with the goal of regaining at least 95 degrees of flexion. I think this is realistic and would make a significant improvement in your quality of life.

Reply
Deborah
11/10/2020 05:29:47 am

Thank you for your reply.
I have been doing the gravity long stretch approach and must say it has worked more than any other approach, your advice really makes sense to me.
Unfortunately under the current covid situation I won't see the consultant till next year, do you think it will be ok for me to suggest to him the arthroscopic lysis of adhesions?
Once I again thank you for your reply

Christopher Gorczynski, MD link
11/26/2020 02:01:53 pm

I think it is totally appropriate to discuss this possible procedure with him. He may or may not think this is appropriate for your specific situation, but patients should always feel comfortable discussing issues like this with their surgeons.

Deborah Catlow
11/10/2020 05:38:57 am

I forgot to mention that yes 50% flexion approximately

Reply
Deb Catlow
12/31/2020 06:35:00 am

Hi, I’ve been stretching for quite a while now, all was going well so I increased my stretching end point for maybe 3 - 4 hours.
Unfortunately I have taken a back step as my knee now feels like I’ve twisted it and I can’t do much with it. Is this because I have kept the end point for too long periods?
If you get an opportunity to reply thank you.
Deb Catlow

Reply
Christopher Gorczynski, MD link
1/4/2021 09:38:59 pm

Looking back at the dates of prior comments, it appears you have been working on this for a couple of months now. Have you made any gains with regard to range of motion? If so, perhaps ease back a bit on the force you are using while stretching. You do not want to give back any of your hard earned gains. The act of stretching to regain substantial range of motion (as you are doing) will result in tissue micro-tearing/stretching. This leads to inflammation and pain. Be generous with ice but persist.

If after all your hard work, you have not made any gains, with how stiff your knee was, I think you should seriously consider arthroscopic lysis of adhesions (if you can get in to see your surgeon at this point.)

Reply
Richard Wilcox
1/4/2021 01:39:34 am

Do you recommend holding a stretch at the first sign of discomfort, or pushing it further to the level where you can't move it further without pain?

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Christopher Gorczynski, MD link
1/4/2021 09:18:50 pm

Discomfort is subjective. Until you achieve your desired range of motion (ideally at least 0-120 degrees) stretching is crucial. You will probably experience some discomfort while doing the stretches properly. The key here is to hold the stretch at that level for a long period of time (minutes). Then instead of relaxing, try to add a little more stretch. Hold, and repeat. Over and over. Ideally you should gain couple of degrees every day.

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Richard Wilcox
1/4/2021 09:44:08 pm

Thanks for the response. I'm just trying to figure out how much discomfort is optimal. Is it best to stop and hold the stretch as soon as I feel a little discomfort in order to minimize an inflammatory response? Or would I get better results if I held the stretch at a point where I experienced higher levels of discomfort?

Christopher Gorczynski, MD link
1/4/2021 10:12:35 pm

Unfortunately, I don't have an exact answer for you. You need to make progress toward your goal range of motion. Mine would be a minimum of 0-120 degrees. You need to stretch adequately (force and duration) to achieve progress. If you are not making progress, you need to increase your stretching. I would focus first on increasing duration of stretch (which results in less inflammation), but, if you are not making progress, you may need to increase the force as well. I think this is the best I can do for you....Good luck!

Edwardfrancis link
1/29/2021 04:01:48 am

My uncle had knee replacement surgery 2 years before. Now he can walk easily.

Reply
Joe Mancini
2/27/2021 07:20:04 pm

Dr. Gorczynski, with the long stretch approach of an hour a day, and the fact that scar tissue solidifies around 6 weeks, would it be safe to maintain your rom if you weaned back on an hour a day? at what point will it be safe to not do the stretching where scar tissue wont be an issue?

Reply
Christopher Gorczynski, MD link
3/12/2021 02:32:45 pm

Once you have achieved an acceptable range of motion for you, it is ok to simply maintain that with a few minutes of stretching each day. As long as you do not experience any deterioration in your motion, that is all you need to do. At that point it is "use it or lose it." In other words, take your joints through a full range of motion each day (even non-replaced joints) otherwise they will get stiff. Once rehabilitated, and the inflammation has subsided, you don't need to dedicate an hour every day to stretching. Just use it and get back to your desired activities.

Reply
Antonese Robertson
3/2/2021 09:13:43 pm

Hi, I lucked up and found your website tHANK YOU LORD!! anyway I had double knee replacement August 17th 2020 and I feel stiff all over my body like a person who goes to a personal trainer for the first time and feels sore the next day . . .Is this normal, I am 58 years old and I don't understand why I'm stiff ALL over as opposed to maybe being sore in my legs . . .but my whole body?! It subsides around 11 am until about 5 or 6, then I start to get stiff again. Can you explain to me what this is from and what I can do to ease the stiffness, I thought about trying BCAA's (since that's what I did when I hired the Personal Trainer (years ago) and was stiff the next day :) Thank you sooo much for this website!!

Reply
Christopher Gorczynski, MD link
3/12/2021 02:28:46 pm

Early after surgery there is a significant inflammatory response that could make your entire body feel sore. At this stage, I would expect that to have passed many months ago. Perhaps you should see your primary care physican/get some blood work to make sure you are not anemic or have a nutritional deficiency. What you describe is not what I would expect at this point.

Reply
Deb Catlow link
3/29/2021 01:03:52 pm

Hi, I’ve seen my consultant today, and I suggested the arthroscopic lysis of adhesions with manipulation, he agrees with this although he said he’s not a fan of static bracing.
Once this has been performed (sometime after June 2021, would your advice be the viscoelasticity exercises on their own to minimise swelling, or combining the viscoelasticy (sitting on edge of chair and letting gravity do the work), with the yoga strap exercises? Thank you if you find time to reply, I think your advice is invaluable.
Regards
Deb Catlow

Reply
Christopher Gorczynski, MD link
4/13/2021 07:46:33 pm

I would do whatever you can to regain as much flexion as possible. Obviously, from reading my website it is clear I recommend long duration stretching. Whatever method allows you to achieve that is correct. Sitting on chair and letting your knee hang will be inadequate if you want to end up with more than 90 degrees of flexion. I show several alternatives in the how to rehab your knee articles. Best of luck to you in June!

Reply
Karla
5/13/2021 06:26:55 pm

I had a total knee replacement on my right knee 2-21-21. I had 2 months of PT. I have 122 ROM bent and can lengthen my leg flat. I have 24/7 swelling, but continue with stretches every day. My surgeon said swelling is normal and could swell 24/7 for a year. Your blog said swelling usually lasts several weeks. My swelling causes pain. The warmth is only below the kneecap now. I don’t see my surgeon for 3 more months. I am concerned. I called the nurse and she said when I come back in 3 months it could still be swollen and to trust my surgeon. Is there any way during therapy I could have messed up my TKR?

Reply
Christopher Gorczynski, MD link
5/13/2021 06:32:13 pm

Swelling is normal and anticipated after surgery. As long as your motion is good (as you report), I would expect gradual improvement for months. The overall circumference of your knee is likely to be a bit larger permanently as scar tissue forms after surgery. I would continue using ice and stretching and allow your body to heal. You should improve for up to an entire year following surgery. As always, if something really doesn't seem right- ask to see your surgeon sooner. They should be there to support you as your recover. From your question- there is no indication PT caused any harm.

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Karla
5/13/2021 06:30:24 pm

I forgot to tell you that I use my ice machine a lot but it doesn’t seem to help. Two minutes later I can’t bend the knee until after a few steps and I can fell it swell immediately. Thx

Reply
Christopher Gorczynski, MD link
5/13/2021 06:38:00 pm

Ice will not immediately make things better, but over time I would expect it to provide an anti-inflammatory effect. It is generally very obvious to me when my patients are using ice frequently as they tend to have less swelling, less bruising, and better range of motion than those that do not use it.

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Tonya
1/16/2022 11:22:21 am

Not sure if this thread is still active, but I am writing in the event it is. I had TKR 11/9/21, right knee, 60yo. Prior to surgery 5/90 and now 9 weeks out I am about 1.5/113 on a good day. I feel I have done all the exercises, stretches, bike riding, etc as given from PT. Is there any hope that I can achieve 0/120 if I gently but consistently keep working at it, or am I fighting a loosing battle at this point. So frustrated.

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Christopher Gorczynski, MD link
1/22/2022 01:20:06 pm

You are not too far from your goal. Long duration stretching may still allow you to obtain a few more degrees of motion. Do these stretches daily, for as long as possible (aim for 30 minutes continuously at the endpoint, 2-3 times daily as a minimum). While it is easy to get frustrated with the situation, time will also help you significantly. Pain will decrease for many months yet to come. Similarly, you should expect to make significant gains in strength, coordination, and endurance for an entire year from surgery.

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Karianne Morrison
2/27/2022 07:45:39 am

Hi, I had my right knee replaced on 12/17/21. There was some lag time for me getting into PT because the therapist got sick. Once in, I followed all instructions at PT and with home exercise. At 8 weeks, I could achieve only 106 degrees of flexion. (0 deg extension) Even with the therapist pushing my leg, which caused intense pain to the point of tears, the best was 106.
The follow-up with my surgeon went as I expected, and I was sent for an MUA the following day, that was 02/17/22. I was told the procedure was successful and was sent to PT that day. At intake, my flexion was down to 80 degrees.
I have therapy 5 days a week now and I am diligently doing my exercises at home. The first couple of days in therapy went well. but on Wed 02/23 i once again hit 106 degrees and I have been stuck there since. Again, when the therapist is pushing on me to try and get past that number, I am in intense pain.
I know therapy will be uncomfortable, but should it be painful to the point of tears and basically me begging them to stop? I'm at a loss as to why I'm stuck at only 106 and very discouraged.
Any insight would be greatly appreciated.

Reply
Christopher Gorczynski, MD link
4/9/2022 07:07:42 pm

I apologize for the delayed response. Hopefully you have turned the corner on your rehab by now. To answer your questions: therapy can be unpleasant, but ideally it should not bring you to tears. It seems the patients that stuggle with rehabilitation have a difficult time relaxing during the stretching exercises. This means you are fighting with your muscles much more than ideal, and creating more inflammation at the same time. While this is an involuntary reaction, it may be accompanied by anxiety/stress, which further compounds the problem. The goal should be slow, but long duration stretching, while trying to compartmentalize the discomfort and minimize anxiety.

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