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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