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About the author:
Hi, my name is Anthony (Tony) Maritato, PT. I am a licensed physical therapist and owner of Total Therapy Solutions. I have specialized in helping clients recover from total knee replacement surgery since 2002 and have created this video to help YOU.
Total Therapy Solutions
5900 Long Meadow Dr
Middletown, OH 45005
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0:00
And I was trying to figure out if I was live a second ago or not
0:03
Anyway, so this patient, let me restart. This patient is not new to me
0:09
I had treated him historically for other conditions, but he's new for this condition
0:16
He had a total knee replacement approximately six weeks ago. He was recovering well, but challenged when it came to range of motion and pain
0:26
he really really really struggled with pain and I know so many of you watching are dealing with
0:33
pain limitations pain restriction and that that in and of itself is an entire discussion that
0:42
would take hours to get through but I want to share this gentleman's experience I'm going to
0:48
try to share as much of his situation as I can without violating his privacy he's certainly given
0:54
me permission to share a lot. So I appreciate that. But you know, what's interesting about him
1:01
so I treat a lot of patients after knee replacements every single day. And I see
1:05
everything across the spectrum. You know, I've shared this, I see people who had a knee replacement
1:11
and they just breeze through it, you would never even know I've got a gentleman right now
1:16
He did amazing. He is, you know, five weeks post op, hey, Linda. And you would have no idea he ever
1:24
had a procedure done. I've seen other patients that just struggle at every single crossroads
1:30
and they have challenges all along the way. So the gentleman I'm seeing shortly, I'm looking out
1:36
the window just to make sure he doesn't come while I'm talking. He's been dealing with some
1:41
significant pain. Now, not having seen him immediately following surgery, all I could go
1:48
by was the reports. I talked to his wife and I talked to other caregivers. Hello, thanks for
1:53
joining. And I hear pain. And so when I hear pain, I think, well, the incision and, you know
2:00
stuff inside the knee, because so often we as clinicians just kind of jump to that conclusion
2:08
But when I saw him yesterday, so he had a manipulation under anesthesia about 9am, 10am
2:15
yesterday. I saw him in my clinic about 11, 1130, something like that, like literally within an hour
2:22
I think they left the surgical center and came straight here. He was unable to get out of the
2:29
car. He required some assistance. So I helped him. We got out of the car together. I walked with him
2:36
using his walker. He could barely load weight through the extremity. Hey, Sheldon, thank you
2:43
for coming on. And it was really challenging. But once we got in the clinic, so we get in the
2:49
clinic, we get in a chair, I shared some video of the experience yesterday. What I realized for him
2:55
was his pain was not really coming from the knee. His pain was coming from the musculature around
3:02
the knee, from the back of the knee, the thigh muscles, the quadricep muscles, the gastrocnemius
3:07
the calf muscle. He had virtually zero pain in the knee. But as such, when we, when I would try
3:18
to manipulate or mobilize the knee, yeah, so Air Force, congratulations, thank you for your service
3:26
is saying that all of his pain was at the quad There are so many components and potential sources of information that generate pain that we have to speak a new language We can just say the knee anymore or even the leg
3:42
The leg could be 100 different structures within the leg. So I want to encourage you guys, all of you, that when you're talking about the experience
3:51
that you're having, try the best you can. Like I ask my patients all the time and I tell them, I'm like, look, I understand
3:59
understand this is a hard question to ask, but I need to know as a therapist, do you feel, do you
4:05
the patient, feel your pain is coming from the skin, the muscles, the nerve, the blood vessels
4:12
the bone, the connective tissue that surrounds the muscle? I'm going to treat those tissues
4:17
differently, and it's going to change the way I approach your rehab. If I believe
4:24
if we determine that your pain is coming more from a muscular tissue, then it's coming from
4:32
the actual bone, you know, and the incision pain might be different than the nerve pain that you're
4:39
feeling. Yesterday in the group, or maybe this morning, sometime in the group, you know, a member
4:45
in our Facebook group talked about that feeling of a strap that just runs right around the thigh
4:52
muscle. And historically, I've talked about how the surgeons, some surgeons will use a tourniquet
4:57
and the tourniquet will create tissue damage that will persist for months after surgery if it isn't
5:04
adequately addressed. And the patient that I'm going to see here in a couple minutes
5:09
I believe a lot of his pain is generated from what the tissue damage he experienced at the
5:17
thigh and a calf. And I'll give you a reason why I feel this way. So as I was moving his leg into
5:23
extension, right? Extension is straightening the leg. This is a common scenario. So I grasped the
5:32
back of his knee, the calf. I start to move. Immediately he jumps. He jumps so quickly that I
5:39
knew it wasn't really, it wasn't thought, like it wasn't planned. You know, it's just a reaction
5:46
It's like a reflex. I hit your funny bone and you reflexively respond. So for him, he reflexively
5:54
jumped. And I said, are you okay? And he said, yeah, it's okay. I was just anticipating the pain
5:59
But then as we got toward the end available range of extension, now zero is full extension for this
6:05
gentleman. He was at about 27. As we're getting to the end of extension, I would expect from a
6:14
mechanical perspective that he would experience discomfort and pain in the back of the knee because
6:19
as the knee is going straight, we're stretching the back of the knee. Now, some patients will have
6:24
a Baker cyst in the back of the knee. Some patients will have some connective tissue
6:29
Hey, Irish. And he didn't. All of the pain he was experiencing going into extension was coming in on
6:37
the inside medial lower portion of the knee. So there's a peasant, cerime, bursa in there and a
6:44
couple other structures in there. But that pain was inconsistent with what I was expecting from
6:51
a biomechanical perspective. So then I have to start looking at other things, you know, and that's
6:56
where there's not a lot of muscle where he was experiencing the pain. I'm not stretching the
7:02
connective tissue when we say scar tissue the scar tissue wasn being stretched in that area where he was experiencing pain moving into this extended position So all of these things are coming into play
7:16
And I guarantee your therapist is thinking about this stuff. There is no therapist who's just
7:21
blindly pushing and pulling and doing things. They might not verbalize it to you. And that's
7:27
why I want to kind of share this experience with you. But I know they're thinking about it. So
7:32
anyway, so moving it to extension, feels pain, pains, anterior, anterior medial, um, below the
7:39
joint line. And so, you know, we're thinking about it. And if you guys watched the video yesterday
7:45
I gave him a little wheel, a little roller and he massaged it and it desensitized. Now that's a huge
7:52
sign to me to say, okay, we're dealing with sensitivity. We're not dealing with something
7:59
that's dangerous. You know, all of you watching right now, 18 of you, wow, thank you so much for
8:04
joining. You can, you're the only one who can understand and determine the difference between
8:12
pain that's associated with danger and pain that's just there for pain's sake. You know
8:18
pain is a protective mechanism. Pain keeps us alive. Pain is the ultimate motivator our bodies
8:24
have to make us move or to make us stop moving. And so as he was using the roller, he was able to
8:31
desensitize that area a little bit, reduce the alarm, and we were able to get a little more
8:37
extension. But as is the case, and I'm sure you guys have experienced this, okay, so we got extension
8:44
a little better range of motion, we did a little exercise then in the new range of motion
8:48
And I guarantee 20 minutes, 30 minutes later, it's dipping back up, right
8:53
You've probably experienced that. You loosen up your knee. I see him pulling in
8:58
I'm going to wrap this up in just two minutes. You loosen up your joint. You get increases in range of motion
9:04
20, 30 minutes, it's tight back to where it was. Why does that happen
9:09
Because we're making chemical changes. So gentle range of motion, not extreme high load, high forces
9:17
gentle range of motion. Oh, three months ago, still don't have full extension. You're in a
9:24
popular crowd, David. There's a lot of people who are struggling with this. And I'll talk more about
9:29
this as the week goes on. But anyway, you loosen up the knee with gentle exercise, relatively
9:36
pain-free exercise. That changes the chemistry. That change in chemistry allows you to gain range
9:44
of motion. We've reduced some of the inflammation because there's something called a myokine
9:49
A myokine is a protein produced internally in the body. If you think of a steroid injection
9:55
our bodies produce those same chemicals naturally. They don't last as long, but they're free
10:02
right? And so I always try to explain to my patients who are dealing with that situation
10:07
where you do a little movement, it feels great. You do too much movement, it feels worse. You
10:12
don't do enough movement, it feels worse. It's because we're changing the chemistry locally in
10:18
the joint. And that's what we want. I would rather most of my clients do less, less intensity
10:27
but maybe more frequent sessions. In the ideal world, in the perfect scenario
10:34
you would be getting a full night sleep We know that interrupted sleep raises blood sugar levels we know that interrupted sleep increases sensitivity to pain It increases the stress hormones Sleep is by far the number one factor that gets in the way of
10:53
tissue healing and recovery. So getting adequate light early in the morning, light into the eyes
10:59
getting adequate light in the evening. I'll share some videos of, I'm not a sleep specialist
11:04
but I'll share some videos of physicians and educators who are. Because if you can not master
11:12
just improve your sleep, your rehab experience is going to improve tenfold. If you're a person
11:22
sitting there being like, Tony, I'm lucky to get four hours of sleep. And before surgery
11:27
I was lucky to get six. Again, you're in a popular position. There's a lot of patients
11:33
dealing with that. But I want you to understand, my PT says I'm doing good, but I don't feel like
11:39
I'm... I guarantee, if you don't feel like you're doing enough, you're probably doing too much
11:48
It's the truth. I've been in this 20 years. I've had a lot of experience. I've met a lot of
11:53
fortunate people. I've never met somebody who told me they feel like they're not doing enough
12:01
who actually wasn't doing enough. 16 weeks, still struggling with the bend
12:09
I'm going to keep sharing ideas. I'm going to do my best. But I promise you, if there was a solution
12:16
you wouldn't be struggling with your range of motion and the solution would be out there
12:20
There just isn't a solution for these kinds of problems. So let me wrap this up because I got to get out there
12:27
and help my patient get in the clinic. uh sleep is a huge factor in recovery do anything you can to improve your sleep medicated sleep it's
12:38
not sorry i got cut off medicated sleep isn't really sleep so i'll take it over no sleep but
12:48
do any research every video you can on sleep sleep quality sleep hygiene uh if you feel like you're
12:57
not doing enough, you could very well be doing too much. It's just a classic sign of somebody
13:02
who's doing too much. Your body needs to recover as long as you're moving, as long as you're active
13:09
and on your feet a couple of times an hour and doing stuff. If you're sitting, okay, here's the
13:16
deal. If you're sitting in a recliner for eight hours and not getting up, you're not doing enough
13:21
That that's, that's my criteria of not doing enough. But most of you are making trips to the bathroom, making trips to the kitchen, you're getting food, you're checking the mail, right? A trip to the mailbox is awesome. Like, reward yourself for that. Remember, they cut your leg off, they chopped off the bones, and then they sewed it all back together, right? Give yourself a break
13:48
If you don't give yourself a break, how can you expect anybody else to? Just give yourself a break
13:55
Relish the accomplishments you've had. And I'm going to get out there
14:00
So guys, thank you all, 20 of you. Thank you all so much for jumping on this live
14:06
Feel free to share your comments below. I'll get through the comments the rest of the day
14:10
And I hope you guys have an amazing weekend. I'll keep you posted on how this case goes because I know a lot of you are struggling
14:16
with range of motion. And I'll talk to you all
#Health Conditions
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