New knee? No Problem!

Knee pain is a common complaint seen in physical therapy clinics. Physical therapists will often work on your range of motion and strength to help decrease pain and improve your functional mobility. At times though, going the surgical route may be the best option after exhausting noninvasive options. 

Today’s post is dedicated to giving you more information on a total knee replacement/arthroplasty (TKA) as well as tips and tricks to make the recovery process a little easier before you start and speak with your physical therapist. 

Background

Knee replacements are one of the most popular elective surgeries occurring in the United States, with the American Academy of Orthopaedic Surgeons estimating that nearly one million occur annually. That being said, there are certain things that should occur in order to get the most out of your new knee and get you back to doing the things that you love.

What is a knee?

Working from the inside out, the knee is a hinge joint between the bones of the femur from the upper leg to the tibia in the lower leg and the patella in between. Articular cartilage covers the bones and allows them to glide smoothly in the joint as well as provide nutrients to the bone. 

Between the femur and the tibia are two "shock absorbing" wedges that cushion the joint. These are called your menisci. 

Ligaments are located both between the bones as well as on the side to provide support and stability to the joint. You may hear these referred to as your ACL, PCL, MCL, and LCL. 

All of this is enclosed in the synovial membrane that releases fluid and allows the joint to move smoothly and transport nutrients throughout the joint. 

Causes of knee pain

Many different things can lead to knee pain, and it is often important to look at causes coming from above and below the joint. Weaknesses or mobility limitations in the hips and feet can lead to knee pain, as well as increased “use” at the knee joint. This can lead to “wear and tear” over time and osteoarthritis in the joint. Osteoarthritis is when the cartilage starts to break down and bone spurs develop where there is increased friction. Other ways that arthritis can occur is through rheumatoid arthritis (when the synovial membrane is inflamed leading to cartilage damage), or following a traumatic incident such as a fracture or fall that leads to ligament injuries. 

Why consider a Total Knee Arthroplasty (TKA)?

Surgery should only be recommended after attempting non-invasive measures, such as physical therapy. With knee pain, muscles can be strengthened or lengthened to allow a decrease in pain and a return to a functional life. However, if knee pain is severely limiting your ability to do the things that you love and other methods have not been working, then it may be time to speak with a surgeon or your therapist about what is the best option for you.

What happens during a Total Knee Arthroplasty (TKA)?

There are many great videos that show how a knee replacement can occur. Typically, the damaged cartilage on the bones are removed and smoothed. The new implants are placed on the bone and often the patella is smoothed. Finally, a spacer is placed between the added components to allow smooth gliding. 

What to expect after surgery

Every surgeon has a different protocol of activities that they suggest for a patient to do following surgery. Here are some things that you can ask your surgeon if they commonly use or recommend.

• Continuous passive motion (CPM) Machines: These are used to slowly move the leg and help a patient regain range of motion quicker. Occasionally, the machines are covered through insurance.
• When to start physical therapy: Many surgeons will ask you to start physical therapy within 48 hours following a knee replacement. Speak to yours about when they usually suggest to begin. 
• Swelling, especially following activities, is very common. There are great tips and tricks below to help decrease swelling (ankle pumps are one of my favorite)! 
• At the hospital, a physical therapist and occupational therapist will visit you and help teach you how to get in and out of bed, how to perform daily activities, how to move around with a walker or cane, and how to use a staircase.

Tips and Tricks

Here are some of the suggestions that I tell all of my patients.  

• Prior to surgery make sure you have someone that is around to help you with daily life activities so that you can maximize rest and reduce the risk of falling. 
• Set up your appointment with your Physical therapist ahead of time. Physical therapy is vital in the road to recovery following a total knee replacement. 
• See if your doctor has any exercises or activities that you should be doing before your first outpatient therapy session. 
• Decrease the swelling. The acronym RICE is a great way to help decrease inflammation and swelling in the knee. Swelling is often a cause of pain following surgery as well as slowing progress. Makes sure you rest, apply ice, add compression, and elevate the knee. Use ice for approximately 15-20 minutes at a time, take a break and then come back to it multiple times a day, especially after activity. Also, ankle pumps are amazing!! With your leg resting, gently point your toes and then pull them back towards you so that you are pumping your ankles. 
• Keep the knee straight while resting! This is a HUGE aid in recovery, though it might not be very comfortable! Extension is easy to lose if you are not careful and practicing this. 

Exercises

Here are some exercises that are safe to perform after leaving the hospital and before your first therapy visit. However, check with your surgeon first before you start to do these exercises. Stop any of these exercises if you feel any pain. 

• Quad squeezes  
• Lie on your back with legs extended. 
• Contract the quadricep muscle on the front of your thigh. 
• The leg should be straight and perhaps feel like the knee is pressing down. 
• Hold for 6 seconds then relax. 
• Repeat throughout the day for 5 reps. 
• Hamstring isometric  
• Lie on your back with legs extended. 
• Contract the hamstring muscle on the back of your thigh. 
• It should feel like you are pressing your heel into the ground. Without moving your leg, contract the muscles as if you were pulling your heel towards your buttock 
• Hold for 6 seconds then relax. 
• Repeat throughout the day for 5 reps. 
• Gluteal isometric  
• Lie on your back with legs extended. 
• Contract the gluteal muscles (aka, your buttocks). 
• It should feel like you are pinching a penny with your glute. 
• Hold for 6 seconds then relax. 
• Repeat throughout the day for 5 reps. 
• Ankle pumps  
• Lie on your back with legs extended and possibly elevated.  
• Push your heel away from the body and toes pulled back towards you 
• Push your toes away from your body moving your heel closer to your body 
• Repeat this throughout the day with a minimum of 10 reps each time. 
• This will help to improve blood circulation and should be performed throughout the day. 
• Heel slides  
• This will help to increase range of motion and should be performed gently, or else you may have increased swelling and/or irritation. At the hospital, the goal is to get to 90 degrees. When performing these at home, do not try and push for more than that for the first days following surgery. 
• Place a towel or sock on your foot to help with sliding. 
• Lie on your back with legs extended 
• Flex the hip and new knee, sliding your foot towards you, causing the knee to bend. 
• Gentle hold for 10 seconds. Repeat this 5-10 times throughout the day.

In Conclusion

Recovery is a process, but it is well worth it if you put in the time and dedication to your exercises! Remember, motion is the lotion, and it is important to work on recovery at home and not just in your physical therapy gym! 

Red Flags

Reach out to your surgeon or seek emergency care if you are experiencing shortness of breath, chest pain, severe calf pain, or a fever.  

Author

Alana Hamilton Alana Hamilton is a physical therapist at Advantage Physical Therapy in Falls Church, Virginia. She is a proud Hokie from Virginia Tech with a major in Biology and a minor in psychology and sociology. Following graduation, she immediately got her doctorate in Physical Therapy from Radford University. She is an avid fan of Pilates, running, and hiking. On the weekends, she can be found hanging out with her family and baby as well as doing Spartan races with her old physical therapy classmates and friends. She is a big believer that during rehabilitation, "Motion is the Lotion" and that staying active is key to remaining healthy.