I have been working with total joint replacement clients for a decade at this point and it has always baffled me at why total knee replacement rehab is always so much more difficult than total hip replacement.
How come after 3 months total hip replacement patients are back playing golf while so many total knee replacement patients are still trying to sleep without pain or even walk normally?
Recently I had an epiphany…it was our fault! The medical community as a whole is setting you up for failure when it comes to rehabbing your knee…here’s an example…
I recently had a client who came to see me 3 months after he had his knee replaced because it still was not straight, was painful to walk and sleep and he couldn’t do anything the surgeon had told him he would be able to do at 3 months.
He had done EVERYTHING he was asked to during rehab by his therapist and the doctor from the time he woke up from surgery, to the in-home therapy and eventually through the outpatient rehab setting. He was frustrated.
There was a common issue everyone was having…they all pushed as hard as they could but couldn’t get his knee straight. When pushing didn’t work and caused more pain, they pushed some more.
When pushing more didn’t work, the Surgeon ordered the Extensionator (a crutch that they tie your leg into and then pump air into a blood pressure cuff using the machine to push your knee down) to get the job done. It didn’t work.
Now he was frustrated and after hearing how he had been taken care of during the past 3 months I was angry!
He was in terrible pain every therapy session and then it would take 36 hours for his knee to recover afterwards.
To deal with the pain, his therapist and surgeon told him to ICE ICE BABY!
They did this, of course, despite all the mountains of research and evidence telling us that icing makes it worse!
In studies of clients who ice vs don’t ice, the ones who ice report better outcomes in the immediate 72 hours, but MUCH WORSE outcomes 6 months later. They have more fibrotic tissue and lower levels of function (they also are probably still icing!).
The question I had when I met this client for the first time is the same one any intelligent human would have…why isn’t pushing it working?
Why isn’t it going straight when the surgeon was able to get it completely straight in surgery?
And most loudly in my head…why the hell were they all still trying to push when it clearly wasn’t working?
With the definition of insanity being to try the same approach and expect different results, I decided to listen to the intelligence of understanding pain and take a different approach.
Pain is a response the body has to give us a warning to stop something that the brain is perceiving as detrimental or dangerous to us. Unfortunately, sometimes the brain perceives something as dangerous and we feel pain when it actually is not dangerous. While the brain as good intentions…sometimes this actually makes things worse.
For the past 3 months, the therapists and surgeon had been pushing and pushing on this knee with the patient in a seated position and putting him into tears. The body had learned that when someone put it in that position and started pushing to guard against it because this was a dangerous activity (true or not, this was the brain’s perception and that is ALL that matters). He was not improving and the pain was ridiculous this far out from surgery.
So how do we get the knee straight without pushing relentlessly on it?
The first step is to relax the muscles that have been in a state of constant firing for the past 3 months and get the brain to remember that being relaxed is OK. In this case we used soft tissue massage techniques, dry needling with and without estim and other desensitization techniques to break the pain cycle the client was experiencing.
Once we did this, then all the sudden the client started actually feeling a stretch in the back of the leg (what you’re supposed to feel) instead of terrible knee pain anytime the knee started to go straight.
We also used neuromuscular techniques such as contract relax of the hamstring in a prone position (laying on his stomach) since his body did not think of this position as particularly threatening to it. This gave us an opportunity to work the knee into extension well beyond where it had been in one session without constant guarding going on.
With this different approach and then by having the client pull a sled by walking backwards and try to “push” the ground away (into knee extension) like a cornerback in the NFL when they backpedal, we were able to start having the client actively use his leg through full extension. Again we took an approach that had not been used before. We used an exercise that would not be perceived as dangerous since the mind had no prior experience with it.
Making the transition to actually using the full range of motion in the knee during walking is perhaps the most important piece to the return to normalcy process. Just because the joint passively can get to full extension, doesn’t mean that the brain will actually let you use it during activity.
If we kept pushing on his knee he would NEVER have gotten full range of motion or been able to walk normally every again.
The Surgeon and medical community would have just classified the outcome as “one of those unlucky souls”, just an expected undesirable outcome…oh well, it happens.
The fact of the matter is that the medical community during the first 3 months contributed very directly to the poor outcome for this person but they will never tell you that.
They told him to ice it. Research shows that this increases fibrotic tissue accumulation and delays the inflammatory response which is CRITICAL for any healing to begin.
They told him to push through pain and keep pushing and scared him into thinking he was doing something wrong and if he didn’t get it straight it was his fault. By telling him to keep pushing they were continuing and worsening the pain cycle that he was in.
They were happy to prescribe opioids or other pain medicine and give him more ice but never actually looked at why he was having pain or for a way to break the pain cycle. Instead they created the worst cycle imaginable for a total knee replacement patient.
Push on knee -> Cause heighten pain response ->Push more -> Cause inflammation -> put ice on which increases fibrosis and makes it harder to get it straight next time -> Just start to feel back to where you were ->Repeat
Shocking this doesn’t work.
If you or someone you love has had a knee replacement or is looking to have one done, please share this article with them. The more the people around them that understand what pain actually is and how to overcome it, the better chance at a quick and full recovery they have.
The idea that if your knee won’t go straight, push more, is from decades ago. It didn’t work then and it doesn’t work now.
Protect yourself and your knee…arm yourself with knowledge and understanding of what is really going on and be your own best advocate!