Once you have decided to have your knee replaced, there are a series of decisions that you will need to make to include:
- Identifying your surgeon
- Choosing the hospital where you will have the surgery
- Choosing the Post-rehab facility where you will spend 6-10 days after you are discharged from the hospital
- Identifying the physical therapist that you will use for your long term physical therapy
Now each one of these decisions is the most important one at its time. You want the best surgeon when you are having the surgery. You want to be in the best hospital for reduced post operable infections when you are recovering. You want to have the best physical therapist while you are rehabbing because they are going to be the one that kick-starts you on your way to recovery. This blog article will focus on the last decision!
A Comment About This Blog
This blog is about my experience and what I have picked up from talking to others about their experience in going through the same process. Some physical therapists may disagree with some of my statements as to the role I provide to the patient versus the physical therapist, others may feel that their practice model is the only one that works, etc. I was a patient and I am not a doctor or physical therapist! So these views are views from my perspective and may not reflect the opinion(s) of my surgeon or physical therapists.
I expect some will want to correct my viewpoints. That is the nice thing about this blog it is mine. If you are planning on having a total knee replacement discuss the issues I raise with your surgeon, your hospital, your rehab clinic and the physical therapist you select and come up with your own game plan. As you go through the process, don’t be afraid to make changes.
Once the surgery is over and you are out of any dangers from the effects of the surgery, the physical therapist will be the one you will rely on to get you back on your feet. I have seen several physical therapists over the years for various muscle pulls and strains. All my experiences have been positive!!!!! But, you have to believe and trust in the physical therapist you will be working with. So if you don’t have one, don’t be afraid to ask friends, your surgeon, the hospital for a reference and then interview them at their office. Get comfortable with them because you will be seeing them for quite a while and you are entrusting a major part of your recovery to them.
The Necessity For Physical Therapy Following Total Knee Replacement
One of the major problems that you will face post-total knee surgery replacement is the immense damage done to the muscles around your knee by the surgery which is one of the reasons that this type of surgery is classified as major surgery. In 2-3 hours, the surgeon is going to destroy the muscle relationships you had prior to the surgery. Once these relationships have been destroyed by the surgery, all of the muscles surrounding the new knee will tighten and become shortened and scar tissue will build up and solidify to further restrict movement. The result of the surgery is that you cannot bend or straighten your leg properly both of which impede your movement.
Issues with the Bend in the Knee
Prior to surgery most people may have a knee bend angle of around 125 degrees. When you get through surgery, you may be in the high 70’s to low 80’s. Many surgeons will make the target goal for a comeback to be between 115 to 120 degrees. Only those who really put in an all out effort will get back to 120 and above. Stories I have heard is that most get back to between 105 to 115 degrees. To go down stairs comfortably or bicycle you will need to be near 115 degrees. For those who don’t progress into the low 100’s in a reasonable period of time, they may require a manipulation which involves the surgeon bending your knee (you will be under anesthesia) to snap the scar tissue that will have hardened to a point of preventing further bending. Bend in your knee can come back for a period of up to two years after the surgery.
Issues with Straightening the Leg
For many who have total knee replacement, there is an accompanying issue that relates to being able to straighten the leg. As part of the surgery, the underside of the knee will become bowed upward such that the leg will not lie straight. If the leg is not straightened, further complications may arise related to walking, body alignment, etc. Various muscle stretching exercises will be required to get the leg to lie straight.
Therefore, the focus of knee replacement physical therapy is to get the leg to both bend properly and to be straightened so that you can have a productive life doing whatever you want to do. You and your physical therapist’s job – is to stretch the muscles and prevent the scar tissue from solidifying to a point that you can resume whatever you consider to be a “normal life”. While doing this you will re-train you muscles how to work as a group again.
Total Knee Replacement Results in Pain in the Rehab Process
You will be told about it by the surgeon, you will be told about it by friends or associates who may have went through similar surgery, the hospital will tell you about it and if you have visited a physical therapist they will tell you about it. What is the “it”? The “it” is pain, major pain not minor pain and lots of it over a prolonged period of time. I should note that the source of and the composition of the pain will change over time. In the first 1-4 weeks the pain will be directly related to the healing from the surgery. After the surgical pain has ebbed, the remaining pain will be that related to stretching the muscles to get the bend back and the knee straightened. For the most part, the rehabbing pain will be high during the stretch and be gone as soon as the stretch is finished.
Controlling the Pain Following Knee Surgery
Immediately following the surgery, the surgical pain will be held in abeyance by the anesthesia which will wear off 2-3 hours after the event. For the next day you may be on morphine which you can control with a pump in limits set at the hospital that is automatically injected into you. But, the hospital will want to get you off drugs like morphine as soon as possible. The next set of drugs will be Hydrocodone or Oxycodone or similar drugs until the surgical pain is gone. After this point you will use some over-the-counter pain killer when you go to physical therapy. For a 1-2 month period following the surgery, you will be on some blood thinner such as Coumadin to minimize the formation of clots from the surgery. During this period, you may be limited in what pain killers you can take as they may enhance blood thinning. Once off of the blood thinner medication, you will have a broader range to choose from.
Some surgeons may keep you on Hydrocodone or Oxycodone during physical therapy as a means to mitigate the pain encountered in physical therapy but, there are negative consequences to long term use of these drugs. These drugs can affect your ability to focus and doing your own driving to and from physical therapy sessions is asking for an accident while taking these drugs. If you are working, taking strong pain medicines may also affect your work performance. These drugs taken for a long time can lead to dependency and addiction.
However, my experience and that of others is that there really is not an effective pain regimen to deal with the immediate pain that you will experience in physically therapy. The pain medicines will assist you after physical therapy with residual pain but not that directly related to the actual knee stretching or leg straightening therapy. So you may have to “suck it up” especially if you are driving yourself to physical therapy.
Responsibility For Getting Your Leg and Knee Back Into Shape
Making Time for Physical Therapy
During your physical therapy period, you will attend 2-3 sessions a week each lasting 30-50 minutes over 3-6 months or longer. What you may not be told is that you will need to spend at least 30-60 minutes a day stretching the muscles on your own. When you add the travel time to and from the physical therapist’s office, you could be spending 2-3 hours several days a week on your therapy. You don’t have an alternative, you must find the time. If you have to go back to work during your physical therapy period, you must work with your employer to make sure that they understand the time you will need away from the work office. If you don’t put in the time, you may not get the mobility that you want.
Your Role Versus The Physical Therapist For Your Recovery
The bend and leg straightening mobility can be improved for a period up to 2 years following the surgery. You must understand that the motivation and responsibility for you achieving whatever mobility you want to achieve is yours and no one else’s. The role of the physical therapist is to assist you to achieve your mobility goal. I kept pushing mine by constantly asking them each week for a new exercise to do at home. Let them know that you are aggressive. If they don’t go their part, they don’t suffer you do. So be in control of your treatment!
Every couple of weeks, you should have a discussion with your therapist as to your progress. Physical Therapists have charts that chart how the average patient should progress. Based on your surgery and the way your body heals, you may not be average or you may be average. If you are not satisfied with your progress, you need to take control and discuss the issue with your surgeon or discuss the possibility of switching therapists.
The amount of physical therapy sessions may be limited by your healthcare provider and after their completion you may have some more bend or straightening to go to get to your mobility goal. You will have to recognize that either you will have to pay for the physical therapist out of your own pocket or any further movement will be accomplished solely by your own efforts at home.
Physical Therapy Process
There are three potential physical therapist groups that you may be involved with;
1. The first will be the hospital therapist who will be responsible for getting you up and walking around the first couple of days after therapy. During this period of time, the surgeon may have ordered a CPM unit which is a device that you place your leg into and it will electronically move the knee joint for you while you lie in bed. You may be on this device 2-3 times a day for as much as 2 hours each time. The purpose of the device is keep the knee joint mobile, to prevent the formation of scar tissue and to gently begin the muscle stretching process.
2. After discharge from the hospital, you will typically enter a rehab clinic which is responsible for your bodily improvement after surgery to the point that you are capable of going home and functioning which means climbing and going down stairs and doing other tasks that you may have to do on your own once home. The physical therapists will typically meet with you 1 to 2 times a day to stretch your knee, get you walking with a walker (a walker is preferred over crutches), and perform other strengthening and balancing exercises necessary to your recovery. Your surgeon, may also have ordered the CPM for your use while in the rehab clinic.
3. After your discharge from the rehab clinic, you may see a personal physical therapist of your own choosing who will work with you from this point forward. This therapist will be the one that you will get the most leg gain from. Initially, they will examine you and create a treatment plan for you given your state when you come to them. Their role is to get you back on your feet doing what you want to do with your involved assistance. They will be responsible for doing all the initial stretching, straightening and muscle strengthening to the point that you can participate and eventually take over. They will use different types of stretches and exercises varying in their intensity based on your ability to absorb the pain.
You could decide to use the rehab clinic for your continuing physical therapy but most of those I have talked to have used the three different physical therapy groups.
Choosing a physical therapist is a crucial decision as it may dictate your knee and leg mobility one year later and for the rest of your life. Given the importance of this decision, let’s discuss some of the criteria that are important in selecting the appropriate physical therapist.
Licensed Physical Therapist
Rule number one is make sure that your physical therapist is licensed in your state, has had appropriate training and has sufficient experience working with total knee replacement patients. Today, almost all accredited college physical therapy programs require 3 years of post graduate training in physical therapy. You can check with your State government to make sure that the therapist you have chosen is licensed and qualified.
Since your knee is one of only two you will have, make sure that the physical therapist has the appropriate experience to work on you. If you do not have prior experience with the physical therapist, ask them for references of others who they have worked with. Typically, your doctor may suggest one or two therapists that former patients have had a successful experience with. Alternatively, your hospital may have total knee surgery replacement orientation classes and they may also suggest some physical therapists or you may have some friends who have had the same procedure and had a successful physical therapy experience. So if you have had no prior experience with a physical therapist lean on these resources to find the one for you.
Physical Therapy Practices
There appears to be two models as to how physical therapists conduct their practice. One model is where you receive dedicated care from the physical therapist from the time that you are at their office until you leave. The second model is one in which you share the time of the physical therapist among other patients who are there concurrently with you. The first tends to cost more, the second less. I have used both and found that early in my therapy I preferred the first and later the second. Why the difference?
Early in physical therapy following your knee surgery, there will be several issues that you will have to address concurrently to include: getting the bend back in your knee, having to have your leg straightened so that it can lie flat, retraining the muscles around your knee to work together again, building back muscle strength, and learning how to walk independently again. As you go through time after surgery, a good physical therapist will have reduced your issues down to your bend and straightening.
In a physical therapy session there is only so much stretching that you can endure and be safely given in a therapeutic manner. The recovery process is a process of stretching muscle, it tightens a little bit, you stretch them a little more, they tighten again but not back to the same point you had before the last stretch, you stretch further, etc, etc. It is a process that occurs over a time period which will differ for everyone. So when working with a physical therapist who is devoted to you for your appointment, they will work in other muscle strengthening and balancing techniques in between stretching. I found that this helped for about 4-6 weeks until I was walking on my own without the use of a walker or cane. After that, the added exercises were of little added value.
After two months, I switched to a physical therapist who shared his time with patients and found that the rest period I had between the stretches actually helped me to relax and deal with the next set of stretches.
The point is that when you are considering a physical therapist, ask them about how they run their sessions and whether you receive sole care while you are there or do you share their time. Incidentally, the cost for the physical therapist who shares their time should be less than the one who provides sole care. What you want is the best physical therapist to get you back on your feet. If the best physical therapist shares their time, they may be the best bet despite your inclination to choose one who gives their sole time during the session.
Issues in Attending Physical Therapy
Getting there. Attending physical therapy sessions can be a problem. Until your knee has sufficient strength to operate a motor vehicle, you will not be able to drive yourself for 4-6 weeks after the surgery. That means that you will need a ride 2-3 times a week to get back and forth between your home and physical therapist office. So another consideration in selecting a physical therapist maybe the distance of their office from your home.
Out of pocket cost. Cost may be another issue that can affect your decision. The physical therapist you may want may not be a part of your current provider’s network. As a result if you decide to still utilize them, you may have higher co-pays or may have to pay for the full cost yourself. Even if covered by your provider, their may be a cap on the number of sessions that you can attend within a plan year, and any over the cap you may have to pay for by yourself.
Waiting time. If you have had prior experience with a physical therapist, you may have a track record as to whether they start appointments on time and finish on time. This can be an issue if you have to travel any distance to their office or are taking off from work to attend sessions. An appointment could end up taking up most of the morning or afternoon from the time you leave your location until you return.
Aggressiveness. To get you back on your feet as soon as practicable, you need to determine whether you wish to work with a therapist who will aggressively push your stretching despite the wails or wincing that you do. While in the clinic, I had one who would release the stretch as soon as I grimaced. I later had another who had a sign above his desk that was entitled Dr. Pain which was lovingly given by his patients. He would stretch to where he thought your therapeutic level was and would not be swayed by your grimacing. Physical therapists have told me that a good physical therapist can sense the limit of pain a person can take and I believe them. If you don’t have someone who will push you and they back off at the first onset of your pain, they may not be doing you a service in the long run.
Comfort level. Your physical therapist is going to see you at your weakest moments. You need to be comfortable with the person you will be working with, therefore, if you have not worked with the physical therapist before, go to their office and interview them prior to your surgery.
Getting Appointments. A good physical therapist will be in demand and as such getting appointments that can fit your schedule (given your driving limitations) can be at times problematic. Therefore, as soon as practicable, schedule appointments for 4-6 weeks out. This way you will not have to deal with the issue. Most physical therapists will not take appointments until after the surgery.
Progress. If you, your surgeon, or your physical therapist do not feel you are making sufficient progress, discuss it with them. Decide what needs to be changed and change it even if it means changing your physical therapist. But, before you change physical therapists, make sure you understand why you are making the change and make sure that the appropriate change behavior occurs with the new regimen. As time passes and you are not making the appropriate progress, time becomes your enemy.
Helpful Hints
If you have leg straightening issues, you can order a board that straps to your leg. Initially, your leg will be strapped down as tightly as you can take. As time progresses, you keep tightening the straps to stretch the muscles to make your leg lie flat. Once you have accomplished a position close to flatness on the board, you will then put a towel under your ankle to raise it further off the board and then resume the tightening process to get the leg to be equally straight as your other leg. You will do this for about 10 minutes 1-2 times a day increasing the ratcheting on the straps every 2-3 minutes.
Get yourself some leg weights to help strengthen your leg. These waits can wrap around your leg. You will need these to increase the weight on your leg muscles as you go through various exercises. These should range in the area of 1-5 lbs for most. I actually went up to 10 lbs. You also may need some yoga straps to do some hamstring stretches. I use an old 2-3 inch wide leather belt it works just as well.
Create a space in your home for you to do your exercises that is yours. I had the belt, weights, an exercise mat, several sized balls, a stationary bicycle, etc. So I converted a TV rec room into my personal gym area.
Create an exercise list for each day of the week. This list will vary depending on the day. On days when you have physical therapy you may do less because of the impact of the therapy. Some muscles will need time to respond to exercise and you cannot work them each day. The big muscles to be worked on will be the quadriceps and you can only do so much a day with them. So sit down with your therapist and work out your weekly schedule. It is also important to be religious in doing the exercises, so get into a daily routine of doing them each day at a certain time. If you live with a particular someone, get them involved if you need assistance.
Whenever you are sitting at a movie, being in a passenger in a car, or watching TV, pull your ankle back and stretch into the knee and hold it for a minute. Release and do again for another 5-10 times. Do this twice a day that you do not have physical therapy. The goal is to increase your bend each time.
I was on a stationary bicycle within a week after surgery. My seat position was 3 times higher than my normal height prior to surgery. As time passed, I moved the seat down until it reached my normal height. Each time I moved the seat down, I kept my foot for my repaired knee forward of the pedal by about 2-3 inches. I then started moving it back to the same level as the other foot. When they were level, I lowered the seat. You will experience pain each time that your repaired knee rises to the top of the pedal arc until you are comfortable with that seat height. Do not try bicycling outside until your physical therapist approves it, or that you are experiencing absolutely no pain at the seat level you will be using. Having a huge surge of pain, while cycling down a street might put you on the ground in front of a car, so don’t put yourself in this position. Once you are ready to try an outside bike ride do it on a bicycle path with no cars on it to check yourself out.
My Continuing Result
It has been 11 months since my surgery. Today, I am walking 4-5 miles every other day. Every other day, I bike for 1-1 1/2 hours at a decent level at about 14-15 miles per hour. Each day, I also due 6-7 leg exercises. About 1-2 times a day when I am sitting in front of a computer or watching TV, I do 5-6 1 minute hard stretches. I am up over 115 degrees of bend and going for the 120’s. It has not been easy, but it has been worth the time. Have a good result!!!
