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Total Knee Replacement - Advanced Strategies For Reducing Pain & Increasing Motion
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Oct 29, 2022
Once you have passed the normal healing time after a total knee replacement, continued improvement in range of motion becomes challenging. The strategies discussed in this video are for educational purposes only and should be discussed with your physical therapist or doctor before attempting. These strategies must be modified for your individual limitations.
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So this is my mic. I'm going to try to keep it close, but I'm not sure if I could keep it as close as I need to
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So hey guys, Tony Maritato here, physical therapist. Disclaimer, this is for educational purposes only
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Anybody who's in this group should be seeing a licensed physical therapist. They should be advising them on what they should do and should not do
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They need to follow the directions of their orthopedic surgeon. My goal for today is to share some new concepts that perhaps you're not aware of and ideas
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on how to increase specifically knee flexion once you've kind of passed the traditional
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you know, healing phase. So you had your first two weeks where you kind of went through the roller coaster of
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you know, it was better and then it got really bad and then it started to get better again
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and then you went weeks three, four, five, and six, I usually tell my patients those first six weeks
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are just about healing the damage done during surgery. Surgery is a traumatic event. It's going
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to take a lot to just heal and recover from surgery. Forget the procedure that was even done
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Zero to six weeks, it's just time to get over the acute healing process. From seven to 12 weeks
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you're starting to get back the mobility and the movement and the things that you used to do
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I usually tell my patients, you know, from the three-month mark to the six-month mark
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okay, now we're making some progress. We're doing some stuff. I feel good again. I've got my energy
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back. 12 months is really the time frame that I would typically expect you to say, hey, I forgot
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I even had a knee replacement. Like the knee feels natural, normal. All the little stuff that you
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noticed before is gone and you're just functioning like you normally would. So think of that time
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frame. Obviously for some it's compressed into a much shorter time. For others it's extended
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There is no perfect schedule for healing. Your body is going to do what it needs to do
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You can get in the way or you can let it happen. So don't overdo it. Just kind of listen to your
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body, listen to your medical team. That being said, a lot of clients are having struggles
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with end range flexion. And so I want to talk a little bit about the anatomy of the knee quickly
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and then show you a couple of my favorite techniques to work on end range flexion
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So excuse me, but I'm going to pull up my pant here. So when you think about the structure of
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the knee briefly. We've got the femur that comes down. That's the bone on top. We've got the tibia
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which is the main bone below. The fibula is this little bone out here on the side. One of the
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things that people don't typically think about is that fibula, it has to rotate and move as I move
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my leg. If you go to your non-surgical knee and you put your hand kind of on the outside, you'll
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feel that bony bump. That's the top of the fibula. If you rotate your foot, you'll feel that fibula
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moving around and it kind of rubs against the tibia. And so there's a lot of interaction there
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It wasn't really involved in the knee replacement, but it's going to influence healing. So there's so
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many factors and structures I don't think are adequately explained. And we don't have time to
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do it now, but if you're interested, post a question. So basically, and then of course
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you've got your patella, your kneecap. And think of your kneecap really as a bone that's floating
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inside the patellar tendon or this piece of connective tissue here. So that bone kind of
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sits on top. If my knee's extended, it should be nice and mobile. It should be loose. It moves side
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to side, a little bit up and down. So when I go to bend the knee, let's talk about what actually
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has to happen. When I'm bending the knee, we tend to think of the knee just kind of pivoting. But in
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reality, what happens is this femur, this top bone is round, this bottom bone is kind of cup shaped
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And so if the femur, which is this bone here, just rolled on the cup, it would end up rolling
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off the back, right? So what has to happen is the femur rolls, but it also slides forward as it rolls
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So when I push forward and I push backward, that femur is rolling and sliding
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So I tell a lot of my patients, don't worry so much initially about the movement you see
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the flex and the extend, worry about how much mobility you have inside the joint
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And so just allowing your therapist, because you can't really do it yourself
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to glide this tibia bone posterior back toward your backside will improve flexion as the swelling
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and pain goes away. The flexion is in there, you just can't access it. Conversely, if I work on
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pushing the tibia anterior, it will improve extension because again, the extension is in
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there. You just can't get to it. So all of that being said, how do I improve my mobility once I'm
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kind of past that acute phase? The connective tissue is solidifying, healing, laying down scar
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tissue There you know it like you guys probably have seen these right These are gait This is probably something you wore when you were in the hospital I mean imagine me trying to stretch this There is no way in the world
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This is at least as strong, probably not as strong, as the connective tissue inside the knee
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Think about it. Every time you take a step, your full body weight is going through the connective tissue in all of your joints
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But we're talking about the knee here. So I guarantee the connective tissue, and when I say connective tissue, I'm talking about
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ligaments, tendons, you know, you may have heard of the term fascia, even muscle is made up of
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connective tissue, as well as contractile tissue, but all of that stuff is holding you together
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That's why when you take a step, all of your joints don't just rip apart. And think about
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the person who not just takes a step, but runs and jumps or a person who picks up, you know
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something heavy and carries it. All of that load has to go through this tissue. So you are never
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going to in and of itself in a hard stretch, stretch or lengthen that tissue. So we have to
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find other strategies. And the main strategy is stimulate the body to come in and grow more
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connective tissue. Now, does it happen quickly? Absolutely not. The example I typically give my
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patients is, imagine if you've ever had a callus and compare that to getting a blister
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Let's say it's fall. I get the rake out. I start raking. I don't rake all year, and then I rake
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for two hours in the middle of November. I promise you I'm going to have a bloody, disgust, and swollen
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blister on my hand. Why? Because I did it too fast and too much. Now, conversely
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if I was to just irritate that section gradually, maybe I'm working on pull-ups or an exercise and
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I do a few and I let it go and I do a few more and a few more and a few more and over the course
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of a month or six weeks, I've irritated this enough that my body has laid down more skin cells
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excuse me this is going to be thick hard strong this is what we are trying to do so this it
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basically responds to the same thing i put a stimulus on the connective tissue which in this
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case is going to be a stretch i do a low intensity long duration and we'll explain what that means
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i'm stimulating my body to come to the knee joint to lay down the cells that will grow the connective
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tissue, just like I grew a callus. If I do it too fast, I get a blister. We don't want blisters
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I do it slow. I do it consistent. I grow the length of that connective tissue
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But we're not all such patient patients. And so what are some ways we can kind of speed up the
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process? So I was asked to specifically do a compression wrap video. This is probably way
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longer than you expected, but I figured what the heck I've got the time. So this is an elastic
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compression wrap. It's a knee wrap. Usually athletes will wear them when they're doing
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heavy back squats. It's a lot thicker and stronger than any kind of ace wrap or bandage
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but it obviously has some stretch, not like a gait belt. Let's talk about this for a minute
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This is absolutely one of those things that if you are being assessed by a medical professional
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they can determine if you're appropriate to use this kind of treatment or not
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There's concerns about certainly blood clots. There's concerns about venous return, your veins, varicose vein issues, lots of other things
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But like I said, this is only for education. So what I typically do with my patients, and I'll try to get some real life examples for you later today
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is I would start with the wrap a little bit below the knee
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Depending on where your incision is, you know, most incisions are going to stop right about here
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The wrap is going a little bit lower. I do what's called an anchor wrap. So it's snug. It's not
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compromising blood flow, but it's kind of snug around there. And then what I do is, if you notice
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there's three red lines in the middle of this wrap. I try to do what we call about a 50
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overlay with each wrap. I'm not doing this to provide stability. I'm not doing this to provide
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support. I'm literally doing this to apply equal pressure all the way around the knee joint
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And so once I come up, look, so 50%, 50%, 50%. Once I come up here, now I'm going to tell you
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the concerns before I show you the exercise. The concerns are, yes, this is going to restrict
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blood flow. It's not going to cut it off. It's not a tourniquet, but it is tight. So lymphatic
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drainage and other benefits are going to be compromised. There's a price to pay for everything
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but I'm only leaving this on less than five minutes. Most of the time I do 60 seconds the
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first time we do it. Then I progress to about five minutes. I always check the venous return
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and the blood flow, the capillary refill and the toes. I keep an eye on everything. I make sure the
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client is comfortable, not in pain, maybe a little discomfort. But basically what's happening here is
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assuming you still have swelling, because most of us who still have limited range of motion will
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have swelling The swelling is pressing out on the joint right It like a balloon It pressing out So if I counter that pressure of swelling it kind of lets my brain say hey this isn so bad
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You know, when I wrap most swollen knees and then I unwrap them in four minutes or so
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I usually see about a centimeter decrease in the girth, the swelling, the circumference of the knee itself
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Now it refills, but that gives us 20 minutes that we can get more range of motion through the knee because there's less swelling, right? If my
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knee is swollen and I try to bend it, my knee just feels like it wants to pop open. Nobody is going to
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push through that kind of pain and you shouldn't. So this gives me that sense of security. It allows
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my nervous system to kind of calm down, chill out a little bit, reassess the situation. My brain
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right now is like, oh, this feels snug, but comfortable. I'm not quite sure what's going to
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happen next, right? And so I noticed that this started to creep up. So I'm going to kind of
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readjust these guys. Okay. So the other thing that happens, and the way I explain it is imagine I have
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a water balloon in my hands, or even just a regular balloon, right? Regular round balloon filled with
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air. If I squeeze the circumference of that balloon, what happens to the balloon? It grows
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in length. It separates. So as I squeeze the circumference of the knee joint, I'm separating
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my tibia from my femur. I'm creating a length through that joint, which stimulates the stretch
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within the joint capsule. That stimulation is a low level stimulation, longer duration
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It allows my body to say, hey, we need to lay down some more tissue here, right? We're going
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to build that callus. That's the goal. It also changes sensation in my brain. My brain processes
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information is coming from my knee, right? My knee just went through this massive trauma
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Some crazy orthopedic surgeon, just kidding, cut my knee open, chopped off the ends of the bone
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replaced it with whatever materials they use. And now, you know, the osteoarthritis has been
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handled, but I've got all this other stuff to deal with. So my brain is saying, well, wait
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something is different. I don't know if this is good or bad. Pain is generally an indicator of
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your brain perceiving information saying, hey, red alert, something is wrong. We need to stop
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whatever is happening. And it sends that brain signal down to the tissue. And we can have a
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complete discussion on pain. We have some pain experts in the group already. So that's a
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fascinating topic. But the idea is I'm alternating the sensation and what my brain is used to feeling
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while my brain is a little confused, right? And confusion is important. If I bump my elbow at the
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middle of the night, I rub my elbow. It doesn't change the fact that I bumped it, but that rubbing
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stimulates touch receptors that confuses the brain and allows my brain to feel something other than
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the effects of the bump, okay? Okay, so I'm feeling something different. I'm like
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feels pretty good, feels stable. I feel like I can do something. So now, of course, I can work
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on my range of motion, right? So in this case, you most likely would come close to your available
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end range, but it doesn't have to be your end range. You shouldn't feel massive stretch anywhere
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what happens is as i start to bend because of the compression it increases the the horizontal stretch
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between the tibia and the femur so even though maybe my bend and i can't tell let's just say
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this is like 40 degrees it's the equivalent of moving my heel back to 80 degrees right because
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I'm taking the slack out of the joint. The other thing that I can do here is I can tolerate the
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discomfort a little more. Now, certainly as we bend more, there's going to be more pressure in
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the back of the knee. But again, if I kind of just grab it and shake it, I do these little shakes
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just like that. I didn't bring it with me today, unfortunately, but if I had my rolling pin
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I would use the rolling pin massage. And there's two or three things that's happening here
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So while I'm rolling, I'm thinking about the rolling pin. I'm not thinking about the knee bend
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I'm also feeling that sensation all over my thigh, which is distracting me from the sensation I have
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in the knee. I'm moving the hip. As the hip moves, the femur rotates and the tibia rotates. So I'm
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creating movement deep inside the knee joint that somebody else can't do really for me
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So there's all this stuff that's going on. Certainly, depending on your mobility, I'm going to try and do this without messing up my audio
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But if you imagine I'm in bed, I'm at home, I would lay back
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I'd hold on to the upper thigh. And I just let gravity kind of pull that knee down
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So I'm not pushing it. I'm letting gravity pull it. and I'm letting my upper thigh muscles, which normally kicks the leg straight
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I'm letting those muscles relax to allow that flexion to happen. Now, let's say you're like, Tony, I can't do it
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I can't hold my leg up. We always like to get a little creative in the clinic
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So what we had done at one point, and I'll try to do this real quick because I know I'm running out of time here
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any kind of long strap that you might have something that comfortable I like flat straps because they kind of can come in behind the knee and they don get in the way too much but basically what you would do is you make a version of a sling
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see if we can do this excuse my voice guys um and i'm putting two straps together just because one is never really long enough
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And so imagine I bring this into position. Obviously, I've got way too much
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Okay, so I lay back. My sling, it's over one shoulder and across my back
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I'm back in this position, and I'm totally trying to stay totally relaxed
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I'm just letting that leg dangle, let it hang out. I can look at the ceiling
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I can watch TV. I could do whatever. and with time that foot will get lower and lower but you have to think of other things right when
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I talk about long duration low intensity I'm usually referring to a stretch that could be on
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for I don't know 20 minutes that isn't so painful you can't tolerate it but is uncomfortable enough
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that you can feel it. Now, what happens when I take the wrap off? Immediately, I feel this flush
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The fluid is coming back in. My toes are a little bit warm. I feel more mobility
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And then what I would typically do is I would go back. I would go back into this position
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and just kind of hang out, relax, let that rest. I'm not doing anything. I try to kind of move my
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ankle, just make sure I'm loose. Because a lot of us will be like, we're so nervous and tight
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Just let go dead. Right? And it just hangs down there. Now, can you do it sitting in a tall chair
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Absolutely. I could let my knee just kind of hang down here. That's another way to do it
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If I back up a little more, right? Look at this little bony bump right here. Okay? So when I'm
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forward, that's the bottom, that's the top of my tibia. As I move back and relax, that tibia
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translates forward a little bit more, which would help my extension. It doesn't so much help my
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flexion. So it's one of those things where there's lots of strategies. I could sit here, talk to you
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for hours and just go through, well, if that didn't work, try this. If this didn't work, try that and
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just keep going on and on. There's no right or wrong. You know, nobody has the answer. If somebody
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had the trick, that person would be rich, they'd live on an island, and none of you would have
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these problems. So I'm the first one to say, it's all about trial and error. It's all about
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experimentation. If something doesn't make sense to you, sorry, if something doesn't make sense to
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you, try something else, find a medical team that will listen to you, that will work with you
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and values your opinion, because none of us have any clue what you are feeling. But I do promise
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you, the people that I see work the hardest are usually the people that tend to have the greatest
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challenges. And when you read stories about people who have this amazing range of motion in two
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three, four weeks, they're usually not working that hard. It's just luck of the draw. It's the
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way their body heals. It's the way their body lays down scar tissue. You can't make it better or worse
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It's just the way it is for that person at that time. Had they gone through the procedure a couple
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months later or years later or earlier, it might have been terrible. It might have been a major
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struggle. So don't let your progress be a signal to you of how hard you're working or not. Everybody
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works hard. Nobody gets their knee sliced open and doesn't work hard. So take this video, use it as an
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educational resource. Ask me questions. This is all new to me. I'm just kind of not treating patients
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but putting these videos out there. I want to produce content that you guys are interested
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that you guys are looking for, experiment. Never, ever, ever will I say
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do something that hurts or push through the paint. The most aggressive I will ever get is
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it should be a little uncomfortable, but certainly tolerable. You shouldn't be breathing heavy
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when you're doing these kinds of stretches and mobilizations. You shouldn't be sweating
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You shouldn't be agonizing. It really should be right at that point of discomfort
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Doesn't have to be much more than that because we're doing things in a specific way for a
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specific reason. If you're not sure, go to this basic rule of thumb
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Don't think too much about what it feels like when you're doing it. Think about what you feel like later that night, the next morning
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If you feel worse later or the next morning, you did something wrong
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you did too much, you did too little, you messed something up. If you feel back to baseline
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not better, not worse, or you feel better, keep doing it. I mean, it really is that simple and
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that's the best advice anyone in the profession can give you. Thank you guys for watching. I took
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up way too much of your time. I hope this video was useful. Let me know if you have any questions
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comments, answers, solutions. I'll talk to you guys later
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