This article in the series is going to speak on how to navigate the first 2.5 to 3.5 weeks post operation. Why was such a random number of weeks you may ask? Sometime between those weeks of your recovery (barring any major setbacks, (and following the info below) you will really start to feel like you’re turning your first corner. The swelling is either almost gone or much more manageable, your pain is under control, likely even with just OTC medications. Even your walking is relatively symmetrically and you’re starting to get an itch to take your new knee out into the world. First however we need to get through weeks 0-2.5 and obviously they are going to be the hardest to overcome. This article will talk only briefly about what your stay will be like in the hospital or other generic tips you can get out of your hospital literature. These articles are about getting you the good stuff. The secret sauce for success. It’s this PTs opinion that if you understand why things are happening as they are, you’ll have a better understanding of how to manage it and overcome it.
The path to success…Pain control, Range of motion (ROM), and walking.
Pain control and swelling: your knee was just put through the gamut, and especially initially you will have significant pain. A part of your body was just aggressively abducted from your body, and then you were sown back up with a new metal knee hammered into its place. Your body is going to respond as though you just had a severe or catastrophic injury to it, because it didn’t know you signed on the dotted line to do this; or that it was done in a methodical way. Skin with nerves, muscles and bone were all cut, and with healing comes swelling.
Swelling response has transmitters in it that will cause a chain of events to occur in your body, some we like and others we could live without. For instance, swelling will put your knee in lock down. Every muscle the swelling touches will tighten to guard the recently “injured” body part, but in the same breath feel weak and painful. Thus, adding significantly to the stiff painful feeling, but also making the muscles irritable or difficult when being asked to work. On top of this, your knee is now doubled in size and may be carrying pounds of extra fluid weight for your new knee to have to lift. Your knee has become a water balloon and now every time you bend your knee, that water is being forced to displace, and this could add to your discomfort. So, your muscles are tight, your leg is a blimp, and you are having say 8/10 pain with any attempt to move your leg. Now in walks your Physical Therapist.
The first thing you very quickly figure out in the hospital is 1: Asking your nurse for your prescription pain medications routinely is paramountly important or the pain will sneak back up on you. If it does flare up it can also take longer to get back under control (if your MD deems them safe of course). 2: The leg feels almost humanly bearable if you just prop it up on a pillow, pack it down with ice and lay in bed watching your favorite talk shows all day. Unfortunately for you, smiling at the end of your bed is a Physical Therapist who, if you heard her correctly just said: “common let’s take your first walk.” That’s when you look at the clock and start thinking I just had my surgery 22 hours ago, did she even read my chart?
As much as it might be much less painful to lay still in bed, this is likely the worst thing you could be doing for yourself. Over the next 2.5 weeks, do you need rest? Yes of course, it’s important for your recovery. Do you need to elevate your leg and ice the knee, yes and in fact the bed is a great place to do that. Unfortunately, if you give into this great feeling, you will also likely be putting yourself at risk for significantly longer recovery time, more pain in the future, contractures as well as other serious complications like bed sores and blood clots. At this moment, you have one job to do; to get moving! This will happen by exercise, stretching, and yes walking. By doing so this PT is going to decrease your swelling through muscle contractions which pumps the fluid out of the area; and we just discussed how unfortunate swelling can be. Improve your range of motion (ROM). Start to initiate quadricep activity, and if you read article one and watched the video there you know why this is important. Lastly by walking right from the get-go we are telling our new knee what is expected of it. Consider your new knee to be like your retirement fund. The earlier you invest in the ideas above, the faster you will see the interest start to accumulate. So compounding gains come from early exercise and walking.
Ok, so I lied slightly. Your PT won’t just throw you into walking (ambulation). They will likely start with an evaluation, and this will include checking your motion and strength. Hopefully they will check both how far you can bend the knee, but also how far they can do it for you. We call this passive range of motion (PROM). Everyone struggles with regaining their motion; however, it may present differently. Typically, you’ll either struggle more so with either regaining what we call extension (straightening) or flexion (bending the knee). If you find yourself in a situation where your knee won’t straighten fully or at least to say 10 degrees of full extension, then read the following closely! This information however is important for everyone. When you are lying in bed you need to make sure your knee is not flexed. This means:
- Do not put a pillow just under your knee letting your heel touch the bed.
- Instead, have your entire leg as straight and elevated as possible. Have your foot higher than your knee. This will also aid in decreasing swelling. You can do this by placing a pillow lengthwise from your knee to your calf or using multiple pillows and your hospital bed controls.
- Do not roll your leg out to the side externally rotating your entire leg and keeping your knee bent.
- Your body is going to find a way to get comfortable (it’s sneaky), and if you can’t straighten your knee it’s going to be very uncomfortable having it out straight (unsupported). One way your body “fixes” this problem is just by rolling the knee and foot out to the side placing the side of your knee on the bed.
- Congratulations, you now not only have a knee issue, but you are going to have hip pain and you’ll likely start walking in this same externally rotated hip position, which puts you on a very bad path. Instead of rolling the leg out, support it like described in the first bullet point, but if your leg is naturally rolling out, the staff can use a wedge pillow or other techniques to attempt to prevent it from happening. Keep your foot and kneecap pointing up toward the ceiling!
If you are struggling with flexion (this is most people) then make sure to keep up with all the pointers described above so extension doesn’t become an issue. Every so often during the day when possible; make sure you are getting the foot down on the ground and bending the knee. Initially, do not linger there for too long (around the time it takes you to eat a meal for instance), but get the knee a quick flexion stretch, and back to elevation. As you get further away from postoperative day 0, you can obviously increase this time more and more as long as your foot is not swelling up. Basically, around the time you are getting out of the hospital, it’s time to start spending a good deal of your day in a recliner, where it’s easy to transition into both positions. Long story short, make sure your knee is getting a good amount of time in both extremes of your range of motion. If your knee is feeling quite painful and stiff, this is your body’s way of asking you to change positions or do the exercises the PT left for you. It helps!
Why might you ask, does your knee struggle to move in the first place? Plus, why is it such a big deal? Just rest now, and once it’s recovered the motion will return too…right?? WRONG. Ultimately there are three major factors that affect your knee ROM. Lucky for you we’ve already spoken about two of these which are swelling and muscle guarding. Unfortunately for the: “rest, wait and see folk”, there is a third more permanent cause which we have to consider. As you move forward from your surgery date the swelling and muscles will calm, but as your body recovers it does so by the use of scar tissue. It’s a completely naturally healing process and this is how your body will “reconnect” the skin, fascia, muscles etc. that were cut through. You see, the body doesn’t regrow skin; instead, it will grow scar tissue. This is why you will always see your incision as a light line down the center of your knee. It’s helpful where you need it. Unfortunately scar tissue grows in haphazard ways. Scar tissue is going to begin to connect layers of tissue that are meant to freely glide along each other allowing your knee to move. Hence causing possibly permanent contracture (limited motion). Luckily for you, if you begin to move these structures early and often the scar tissue does not get the chance to form where it shouldn’t. Hence the saying: “move it or lose it!” This is why your PT is going to ask that you put yourself through some pain when it’s time to stretch.
It’s my opinion that every PT session you have from day 1 until well into outpatient sessions should incorporate some active and passive stretching to the knee BY THE THERAPIST. You will always get a more passive stretch than active, typically by 10 degrees of lag between the two. Hence, if the PT is stretching it, then more unwanted scar tissue is being taken care of. Not all PT’s will do this so make sure to ask for it.
I typically will tell my patients to tolerate what you can, try and relax the muscles in the leg as much as possible. Typically, I try to keep the pain under a 6/10, but more importantly the pain should return to baseline levels about 30 minutes after the session is over. If 6 hours later you are still in a great deal of pain, you likely went too hard that day.
So where should you be when you leave the hospital (typically 48-72 hours post op)? In terms of ROM, this varies greatly. Optimally, you would have at least 0-85 degrees of motion. This means you can straighten fully (0 degrees) and you can almost bend to a right angle (90 degrees). However, if your Therapist tells you your missing 5-10 degrees of extension, or that your flexion is at 75 degrees don’t fret you’re not off target to make great gains. If it’s worse than that, time to hunker down and have a talk with your PT about why things are lagging. By the time you leave Rehab 0-105 or Homecare: 0-110/115. These numbers are for those who had good motion before the operation. If you couldn’t straighten before, you likely won’t now either.
Let’s quickly talk about where your knee will be at the end of this great experience. By the time you’re done with outpatient PT your goal is to shoot from 0-120 to 125 degrees of motion. In comparison your original knee (depending on your body shape) likely bent from 0-135. Your new hardware does not allow this, however. If you can gain 120 degrees of motions this will allow you to do everything you need to do and meet all your goals.
These numbers may all be confusing at this point; however, when you are in the moment will become clearer. Having an idea of where your milestones are gives you an understanding of how you need to progress. Not all Therapists will share this with you.
Alright, we’ve spoken a lot about Theory and expectations, now it’s time to talk about action! Equipped with a new host of knowledge, move on to article 4 and learn how to walk the walk.