Continued from the previous page.
WEEK 1
I'm going to give a rather detailed summary of how I felt, what activities I
could do, any problems I had, and my physical therapy regime for
each of the first five weeks after surgery.
I hope some of the information will be helpful if someone who reads this is facing a total knee replacement.
Otherwise, it'll probably be pretty boring!
Everyone recovers differently so YMMV. I am ahead of the curve, at least
as of the time I'm writing this five weeks after surgery, because of the
surgeon's expertise and my own fitness and motivation to get back to my
favorite activities as soon as possible.
I'm not trying to brag about how fast I was able to reach various goals;
I'm just documenting what I was able to do so other athletic types can see
perhaps that their own recovery might be faster than the norm. I'll also
give a timeline for some recovery "milestones" that some of my
medical team shared with me and/or are listed on the sheets of information
my doctor's office provides each patient.
Swelling and bruising:
Just so you know, if you get a knee replaced your surgery leg and foot will swell
up and you'll have some major bruising that gets worse before it gets better.
My leg didn't look so terrible yet on Day 2:
Not much swelling or bruising yet on Day 2.
That's an Aquacel bandage
over the incision; I could take a shower
two days after surgery.
Sitting on the patio on Day 2;
I wore an Ace bandage wrap
most of the time for at least a week for
compression.
On the 5th day I was instructed to take the Aquacel bandage
off. At that point, the incision was healed enough -- with the SteriStrips
still holding it -- to continue to take showers but not tub baths
(no swimming, either).
By then my whole leg was more swollen and bruised. The swelling peaked in the
2nd week because I was on my feet more then. I wore shorts at home but
when I went out to walk or shop, I wore long pants so I didn't freak
anyone out.
The bruising in my toes,
the last place to clear up, wasn't completely gone until the
4th week.
Day 5: beginning of technicolor
bruising; the swelling got worse, too.
Day 5 after I removed the Aquacel bandage;
I kept the SteriStrips on for several days until
they eventually fell off. The bloody spot
is a blister that formed under the bandage.
The middle part of the incision was already healing nicely but the two
ends, apparently where some sutures are tied inside, were bumpy. Five weeks
later, they've mostly smoothed out.
Pain level:
The first five days were great for me -- until the nerve
blocks and "pain cocktail" the doctor put inside my knee wore
off. Then I began having more pain at night while trying to sleep and
during the daytime when I was doing my PT exercises.
At that point I had to increase the amount of pain medication I
was taking, which was discouraging.
I was given prescriptions for two pain meds, Hydrocodone and Tramadol.
Both are narcotics but Tramadol is a relatively tame version thereof.
I was hoping not to need either one because 1) I don't like the side
effects of codeine or its derivatives and 2) I don't want to risk
getting addicted to any opioid (it's a national epidemic right now).
I took only two of the Hydrocodone w/ Tylenol pills the first week and
swear I'll never take another one again because of the nausea (no vomiting),
racing heart rate, and dizziness. I'd rather be in some pain than take
that stuff. I'd already told the PA I was allergic to codeine-type
products but it seems to be the default narcotic that this practice
prescribes (Jim was later prescribed it for his arm/hand surgery, too,
with another Ortho Atlanta doctor).
Tramadol I can handle; I've taken it occasionally for
knee pain for several years but only one at a time, days or
weeks apart -- never five or six a day.
I took Tramadol every four or five hours for several days after the
nerve block and joint "cocktail" wore off, then began tapering until
I was off it completely by the end of five weeks. I needed it more
during the day than night, especially to relieve any pain when I was
doing my PT exercises at home or before going to out-patient PT.
Between Tramadol pills I've been taking a prescription NSAID
that I'm trying for the first time (Diclofenac) and acetaminophen, or just
generic ibuprofen.
Physical therapy & activity level:
A knee replacement causes enough shock to the body to make even a
physically fit person tired for a few days or more.
I'm a lousy nap-taker but I tried to take at least one nap every day
the first week and spent a lot of time sitting on our comfy couch with
my legs elevated as high as was comfortable with a couple throw pillows on
the ottoman.
Elevation is critical for blood flow and the prevention
of blood clots in both legs after a knee replacement. That and frequent
icing of the traumatized knee are important for several weeks.
Over the first weekend, after my in-home therapy evaluation, I did the
recommended dozen or so exercises recommended by the hospital PT and
the home therapy company owner two or three times a day. It was
time-consuming but necessary. Besides, I wasn't supposed to do a
whole lot more except sit with my leg elevated anyway.
A female physical therapist with the same in-home therapy company came
back on Day 4 and Day 7 for two more 45-minute sessions with me.
When she came to the door on Day 4, a Monday, I was standing there to
let her in using no walker or cane. The previous day I realized I could
walk just as well without either aid as with them, and it
was a lot more convenient without. I didn't use the walker or cane any
more after that, even to go to the bathroom across the hallway during
the night (we have several solar night-lights around the house so I
could see just fine).
The therapist looked at me and joked, "Where's the patient??"
(She probably says that to all of her patients to make them feel better.)
I laughed and said I didn't plan to be an average therapy
client, so let's get to work!
That session we mostly ran through
the initial twelve exercises so she could take some measurements and see
that I was doing them correctly. She advised me to focus the first two weeks on
balance and gentle stretching to extend my range of motion, then work more on strength.
Why be normal??
Ultra runners aren't "normal" in a lot of ways. They push themselves farther both
physically and mentally than most other people do. That's why so few
people even attempt to run 100 miles in under 30 hours or do
cross-continent journey runs or bike rides.
Even though I haven't run an ultra marathon in eight years or
run/hiked the whole Appalachian Trail in twelve years, I am
still wired the same as I always was. I still like to challenge myself.
Why should my recovery from surgery be any different?
I can't run but I can still
climb 14,000+ foot mountain -- and hope to continue after getting both
knees replaced.
This view of Mt. Massive is from the summit of Mt. Elbert, CO's highest
peak. (9-5-16)
The next quote is for comparison from the "Commonly Asked Questions"
papers Dr. Schmidt's office provides knee replacement patients
re: using a walker and cane after surgery:
"Every patient heals from surgery at a different pace. Most of
you will use a walker or crutches to begin with and then switch to a
cane. You will gradually improve your ability to get around and most
people will function without any assistive devices by 6-8 weeks."
Six to eight weeks?? I ditched 'em in three days! (I realize I may
not be able to do that the next time.)
I knew how quickly Jim progressed from his partial knee replacement and
our neighbor Gail had told me that her recovery from her TKA went faster
than the average, too. I figured if these physically active folks did that
well, I should, too.
I wasn't in competition with Jim or anyone else. I wasn't trying to set any
recovery records or impress Dr. Schmidt. I was just very motivated because
I wanted to get back out walking, hiking, cycling, kayaking, and gardening
again as soon as possible!
I'm wired to move my body as much as possible, not sit or lie down for any
length of time except to sleep.
The evening of Day 5 we had our last of four puppy training classes with Holly.
I went to watch what was going on while Jim did all of her handling during class.
The trainer and two other pet parents were surprised to even see me there, let
alone enjoying myself and not using a walker or cane.
Sitting (or standing) knee flexion (L, bending back
as far as possible), and prolonged
knee flexion (R) get easier each week; my end goal
was at least 120 degrees passive bend.
More than once during my early recovery I had a
little concern that maybe I was doing too much, too soon, based
on feedback from other people who have had knee replacements or know
someone well who's had one.
Fortunately, I've gotten some very positive
feedback from Jim and my medical team.
The nurse at Piedmont Fayette Hospital who conducted the "joint class"
called me on Day 6 to see how I was doing. We talked for about 15
minutes about my experience at the hospital and recovery at home.
She assured me that as long as I'm not causing more pain, I'm doing
everything right. She said most of Dr. Schmidt's patients recover faster
than the norm because of the techniques he uses, and I should just
ignore admonitions from patients and friends/relatives of patients
who've had surgery with anyone else.
Not only are the physicians' skills different, but also every patient
recovers at a different rate based on many variables. Since I'm athletic
and fit and highly motivated to get back to (my) normal as fast as
possible, it's natural that I'd be ahead of the curve.
Ready for out-patient physical therapy:
My home therapist was also very positive and reassuring.
On Day 7, my last day of home therapy, she added some new range of motion
(ROM) and balance exercises to my list: marching with my knees as high as
comfortable, heel raises, mini squats, swinging my legs out to the side while standing,
walking sideways and backwards -- carefully -- in the house.
I was able to practice all of them correctly while she watched and
gave instructions.
Heel raises (L) help build calf strength and
balance; mini-squats (R)
help build up the quads and ROM for more advanced
exercises later on.
She also took me outside to walk a little ways up and down our hilly street
(I hadn't done any recreational walking yet except in our back yard), go up and
down the curb (our only "step" until I realized we have a fireplace
hearth with a 6" rise I can use), get up and down from a chair holding on
with my hands if necessary, and other practical, real-life movements.
She said I was more than ready for out-patient PT and riding a
stationary bike -- on Day 7.
She was very pleased with my progress and said I'd accomplished in one week
what some patients can't do in home therapy in three weeks. She also said I
was doing as well as a 39-year-old man who had the same surgery the same day
I did (I don't know who he is, so I guess it wasn't a breach of confidentiality).
My home PT order was written for up to three weeks but even
before surgery I told the care coordinator that I wanted to go to out-patient
therapy after one week so I could use stairs (we have no stair steps at home)
and a stationary bike (didn't have one of those at that time, either, or a gym membership).
Jim got on a stationary bike in PT a week after surgery and felt
like it really helped him recover faster. I also read that cycling indoors
and other
aggressive exercises can help total knee
replacement patients recover faster, so I assumed it was standard, current
practice in physical therapy.
WEEK 2
I was mighty disappointed when I got to out-patient physical therapy on Day 8 and
my new therapist didn't want me on a stationary bike or doing stair steps yet.
He gave me a thorough range of motion (ROM) and strength (resistance)
evaluation that day and we set the therapy goals I needed to accomplish
in order to do the amount of walking and cycling I want to resume in a
few weeks or months -- zero degrees full leg extension (measured
under the surgery knee) and 120 degree passive (without assistance) knee
bend -- as well as successfully completing various balance and
strength/resistance tests.
Gluteal sets (above L), quad sets (above R), done
lying down or sitting, and
long arc quad sets (below) all help with the
goal of zero degree leg extension.
He was surprised to learn that I did only a week of home PT because he
said I was already at the stage strength-wise and flexibility-wise of
patients who've been doing home therapy for two or three weeks --
the same thing the female home therapist had already told me.
Despite that acknowledgement, my out-patient therapist wanted me to just continue with the same ROM
exercises the physical therapist at the hospital had given me, as well as the additional balance
tasks the home therapist had added -- but no cycling indoors until I could
bend the surgery leg more.
Although I was at zero extension (the goal), my passive bend was "only"
100 degrees that afternoon. The morning before, in my last home
therapy session, it was 105 degrees passive, which is better. It took me
a little while to realize why I'd regressed. (More about that shortly.)
The only new thing he added to my lengthening list of exercises to do at
home was to hold some of them longer in the extended positions and bring
them back slower to build eccentric strength.
I was glad he gave me at least a little something new to add to the routine
so I'd feel like I was making some progress.
Here's a lesson I learned the hard way:
Keep this in mind if/when you have knee replacement surgery.
As I mentioned, I was at 100 degrees passive bend (without assistance) the afternoon
of my 1st out-patient PT session on Day 8.
The home therapist had measured me at 105 degrees the previous morning, which is better.
The difference?
I had more swelling and less range of motion when I had PT sessions
in the afternoon versus the morning because I'd been up on my feet
longer! The swelling was always less in the morning after lying in bed for 8-9 hours.
I learned real fast that I needed to schedule my PT sessions for the morning when
possible. (The exercises I did at home were always easier in the morning, too.)
I could tell my range of motion and strength had improved before the next
session with this therapist on Day 12. Still, he didn't want to let me on the
recumbent stationary bike or do more than one step up and down in PT. Although
my knee bend that day measured his original goal of 105 degrees passive
bend for the bike, he upped the ante to 115 degrees.
The only new exercise I got on Day 12 was stepping up and down in various ways
on a 6" step. I was able to simulate the exercise at home on our brick hearth
(there are no stairs or other steps in our house).
After two sessions with this therapist I was frustrated. I didn't feel like he
was giving me enough "homework" to
challenge me or to improve on what I'd already accomplished.
That's when I started to add more reps and slightly increase the difficulty
of some of the exercises in other ways. I've been in PT before and I could figure
out how to make them a little more challenging. I was careful to do it gradually
so my knee didn't hurt.
That was the caveat two nurses and two physical therapists had given me:
If/when it hurts, stop.
The idea is to gradually stretch out the
muscles, not tear them -- and keep at it every day so they don't heal
too short during those critical first weeks.
I did two other things at that point -- called the home physical
therapist to ask her advice re: whether I was doing too much too soon, and ordered a nice, quiet hydraulic
resistance trainer we can use with our own bikes in the house!
I've had a bike trainer before but somewhere along the way, had sold it. We don't
belong to a gym so I felt like that was one good way to make further progress.
It will also be handy for both Jim and me during bad weather when we don't want to ride
outside. (Jim also used it with his bike after his hand/arm surgery in
November before he was able to ride outside.)
It took several days to get here so I wasn't using the trainer until the end of
Week 3.
Endurance athletes are outliers:
My home physical therapist is older and has had more experience than the younger therapist I had
in out-patient therapy. She's learned over time that "one size doesn't fit
all." She tailors exercises to her clients' abilities and seems to
agree with the study I referenced earlier about more aggressive therapy
leading to better, faster outcomes for knee replacement patients.
I felt like my out-patient therapist was just going by the book for what he thought
a 68-year-old woman was capable of doing, not someone as athletic as I am.
The home therapist said he may have certain restrictions from his practice or perhaps had a mishap
previously with another patient who did too much too soon.
It really helped to get some encouragement and reassurance from her. Even though
I was ahead of the curve in recovery for an average older patient -- an
outlier -- my progress was "normal" for me after a lifetime of endurance
activity.
I wish she did out-patient physical therapy but she just does in-home.
I'll ask for her again for the initial in-home therapy when I get my second knee
replacement in December.
Straight leg raises lying down
(L) and long arc quads sitting up (R) to strengthen the quads
increased in difficulty first
by holding them longer, then using 5-10 lb. weights later on.
Swelling and bruising:
My leg and foot were the most swollen and bruised during the 2nd week because
I was on my feet more and spending less time with my leg elevated.
Both mentally and physically, sitting still for any length of time was
the hardest part of recovery for me.
I continued to ice it several times a day but the swelling only went down 1)
overnight after lying in bed for 8-9 hours, and 2) after lying in our bed for
30-40 minutes each afternoon with my heel resting high on our padded headboard
and using my hands to massage the excess fluids from my feet down toward my core.
Pain management:
Although I had more swelling I was able to reduce the number of Tramadol pills I
took the 2nd week to about three a day, alternating with the prescription NSAID Diclofenac,
acetaminophen, and/or ibuprofen as needed. I wasn't using those while taking Tramadol
until Dr. Schmidt told me they were OK as I was weaning off the opioid.
My knee didn't really hurt during the night unless I tried to lie on
my side -- ouch! I still woke
up every one or two hours to move it, either in bed with ankle pumps and heel slides or
just getting out of bed and walking to and from the bathroom.
I continued sleeping in the spare bedroom so I could move anytime I needed to and not
disturb Jim.
Other activities:
During the 2nd week I was preparing meals again, doing some housework, weeding/watering
in the yard, and going into WalMart, Sam's Club, Home Depot, etc. to shop.
I also began walking our hilly bike paths and streets near home, gradually increasing
the time and distance to at least half a mile a day outside, plus the distance I walked
in our house, yard, and shopping in big box stores.
On Day 11 I had my first follow-up appointment with Dr. Schmidt. He ordered X-rays
(see below for before-and-afters), checked my range of motion, asked questions about my
recovery, and answered every question Jim and I had (he's very good about that).
Left knee before and after surgery, front view
Left knee before and after surgery, side view
(Any time I needed a reminder why my knee hurt, all I had to do was look at those x-rays!!)
Dr. Schmidt gave me the go-ahead to drive since this was my left leg and Tramadol
isn't a heavy narcotic. I loved that freedom but had to get into and out of the front
seat of the Odyssey carefully the first few days.
After a couple weeks my ROM had improved enough that I didn't even have to think about
how I was getting in and out of our car; the truck was a little
harder because it's higher off the ground.
The doc was pleased with my progress after just eleven days and four PT sessions but
reiterated that he wanted me to wait at least three months before having surgery on the
other knee. That disappointed me but I continued working hard on my exercises at
home and in out-patient PT because I had other important goals for activities I wanted
to resume ASAP.
Continued on the next (and final) page: recovery during
Weeks 3 to 5, when I "graduated" from out-patient physical therapy
Happy trails,
Sue
"Runtrails & Company" - Sue Norwood, Jim O'Neil,
Cody, Casey, and Holly-pup
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© 2017 Sue Norwood and Jim O'Neil