Total Knee Replacement: Don’t skip these steps.
Tommy Conway - Chartered Physiotherapist and Director - OneHEALTH
Total knee replacements that give trouble leave clues! Over years of treating total knee replacements that seem unsuccessful or which still give clients issues I have come up with a step by step approach to make sure you have a successful surgery and recovery. By the way you won’t be out of pain in six weeks, and walking isn’t how you recover so read on!
Step 1: See a physio before you get the operation
This is the most important step. You need to have a real estimation of how long your recovery will take and your physiotherapist will guide you with this. Not all knee replacements are the same and not all people have the same day jobs and recovery time. I have two clients currently recovering from total knee replacements who are the same age, same weight, same occupation but different have recovery times. One has decided to take 3 months off to recover, the other has taken 6 weeks. Both of these clients got different strategies to optimize their recovery. They needed different plans before they got the operation, you need to know what you are letting yourself in for.
Step 2: Control swelling
It should be your number one focus because it will dictate the weight of your leg, the range of motion at your knee and the pain levels. Too often I see clients 9 months post total knee replacement who have a knee full of fluid and wonder why they still limp or can’t get to 90 degrees knee bending. Look at it this way your knee needs space to move and if that space is occupied by fluid, it can’t move. The swelling will also cause the skin to stretch, this stretching of the skin leaves opportunity for swelling. It gives the swelling somewhere to move into even six months after the operation, that’s why you need step 4.
Step 3: Exercise vs Hands on
Both are important and should be utilised but at different stages of the rehabilitation. When I start rehabilitation of a total knee replacement, I want to see my clients once a week for 8 weeks. This allows me to do hands-on techniques, like massage, scar tissue work, and mobilisations to reduce swelling, increase range of motion and get the joint moving back as it should. This is vitally important because at this stage of the rehabilitation your knee is swollen and painful, which limits your ability to do exercises. After the 8 week period I usually progress my clients to in house yoga or pilates classes so they can continue their rehabilitation monitored by a physiotherapist. This stage is less hands on based because the swelling should be gone and the knee range of motion should be achieved. Put simply, if you are only doing exercises in the first 8 weeks you are giving yourself less chance of success and the same goes for after 8 weeks if you are doing nothing but hands-on you have a less chance of success. Everything has its place but at the right time and not one is greater than the other.
Step 4: Walking is not rehabilitation. Strength training is!
Total knee replacements that give trouble leave clues! One of the most common scenarios I see with clients who deem their operation was not successful is they believe walking is the only thing they need to do to recover and they stick to the same exercise sheet they were given first week post operation. Sometimes it’s a person's own belief that walking alone is the answer. In their mind they get past the first 6 weeks of exercises and then get out and walk, or unfortunately sometimes it’s the instruction they have been given. In reality you do not use your knee joint a lot in walking, walking is a hip and ankle dominant movement. The knee has a role to play but that is not the activity that I would use alone to rehabilitate a total knee replacement. The second issue is following the exercises you are given on week 1 for 6 months. These exercises are designed to restore range of motion but have little carry over to daily life. They are not challenging enough and usually are done in lying or sitting. You need to do exercises with your feet on the ground, in standing and ones that imitate knee dominant activities like lifting objects from off the ground and going up and down the stairs.
Strength training causes skin to get tensioned. Have you ever seen the modern intercounty star, do they look like they have loose skin? No, they have skin that is tensioned, toned through strength training. The looser the skin as outlined above the more potential for recurring swelling. You need to strength train to finish the rehabilitation, to tone the skin, to stop the swelling re occurring 9 months after the operation. To make this operation worth the time, you need to put effort into step 4, you need to seal the deal.
In conclusion, my clients that follow this process have huge success with their total knee replacements. Then at times I take on clients 6-9 months post surgery that are still struggling to use the “new knee” they were given. That struggle if not resolved will lead to further struggles. I have seen clients 6 years total knee replacement, no longer complaining of the knee that “was never right” but now of a bigger problem. This bigger problem can often be the spine and unfortunately we can’t replace that! I know it might be hard for you at home reading this to join the dots on how a knee could affect a spine but just try and think of the knee as part of an orchestra, if it’s timing is off, the orchestra’s timing is off. I hope you take from this that there are clear steps to help you recover from a total knee replacement. There can be no shortcuts and remember failing to plan is planning to fail, please take step 1.