Friday Q&A: Pain After a Total Knee Replacement

Q: I have had a TKR (total knee replacement) in March this year (5 months ago). I still have pain and swelling in the repaired knee, mainly on the outer side and behind the knee. Is there any yoga exercise recommended to stabilize the knee and make it healthy?

A: I am sorry to read that your Total Knee Replacement (TKR) has not resolved all the issues you hoped it would have accomplished. Literature review states that 90% of all patients are pain free after six months, but sometimes the recovery period can take a full 12 months. Ten percent of TKR patients are not pain free within this time period.

Pain is a symptom of an underlying problem. The cause of the pain needs to be thoroughly addressed by the surgeon who performed your surgery. My advice would be to return to him and have him perform a complete exam, including diagnostic studies (X-ray, CT scan, blood work) to rule out any underlying infection and to ascertain the alignment of the knee prosthesis.

The other thing you might consider is a complete orthopedic examination by a physical therapist who is skilled with post-operative TKR rehabilitation, especially someone who can evaluate the biomechanical basis of your knee pain and look completely at your legs, hips, pelvis, back and how you move in space. A wonderful resource for you to check out is called Bridgebuilders to Awareness in Healthcare, a group of yogi rehabilitation professionals who blend traditional physical therapy and other rehabilitation disciplines with the practice and application of yoga in a therapeutic context to assist you in your journey back to wellness.

It is very common for the TKR to correct the arthritic cause of pain but if the patella is not tracking well and is not aligned within the patellar groove, then the imbalance when the quadriceps tendon contracts to straighten your knee will be extremely irritating. So if you are doing straight leg raises with or without weights, long arc quadriceps sets, or any other quadriceps strengthening exercises, the first thing you can do is stop anything that causes knee pain when the knee muscles are contracting. After you and your surgeon rule out any underlying pathology or prosthesis problems, you also may want to try to figure out how your current pain is different from your old pain. If you had knee issues similar to the ones you are having now then it is definitely important for you to see a rehabilitation professional.

If you are currently in a yoga class or have a home yoga practice, you really need to pay strict attention to the alignment of your hips, knees and feet as well as attention to how you move into and out of poses. You might want to stop all standing poses for now and instead work on passive inversions like Legs Up the Wall pose (Viparita Karani) or Chair Shoulderstand to see if you can mechanically drain some  of the edema. If the edema and swelling is under the knee cap, you could ask your surgeon if he will aspirate the fluid, and if he agrees, it might not be a bad idea to ask him to culture it to make sure there is no infection lurking in the joint.

I am sorry that I can’t give you a specific "yoga exercise" for stability because I can’t see your body and how it moves. But if you are feeling that your knee is unstable, this is a sure sign that the leg is weak and it is unable to balance on itself. Please be patient and be a good detective. If your surgeon's assessments all come back negative, that is a good conclusion because you will know you can work on the specific issues at hand. With diligence and compassion for your knee, it will hopefully progress and allow you to resume the activities that are important for you.

—Shari

Knee Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s previous post Arthritis of the Knee and Yoga about what the next step might be when your own self-care management techniques are not as effective and your quality of life is severely impacted. So I thought I would you give some background about the elective procedure total knee replacement and why you might elect to have it done. Professionally, I see a lot of total knee replacements in my work as a home health physical therapist, and I also have yoga students who come to my class either after the procedure or beforehand as they are preparing themselves for the surgery.

Although many people will never need surgery for arthritis of the knee, if you have severe joint damage, extreme pain that isn’t helped by other treatments, or very limited motion as a result of the condition, knee replacement surgery may be necessary. So if the arthritis pain in your knee worsens, and the exercise that once helped you feel better has become unbearable, your doctor may recommend a total knee replacement (TKR). Surgery for osteoarthritis can provide several benefits, including :

• improved movement
• pain relief
• improved joint alignment

When you research the procedure, you will discover there are gender-specific knees, which are knee replacement models designed for women, and dozens of other options, too, including different materials, sizes and models from a variety of manufacturers. How do you choose? Generally, you don’t. Surgeons typically determine which implant they’ll use when they are in the operating room and actually looking at the structure and size of your bones.

X-Rays of Knee Replacements (from Wikimedia)

Prior to surgery, however, you should have an informed conversation with the doctor about your options so you can ask good questions about why a particular model might be chosen, and determine if you’re comfortable with the doctor’s approach and experience or whether you’d like a second opinion.

When only a portion of your knee has severe arthritic wear and tear symptoms, as confirmed by diagnostic testing as well as subjective complaints, you may be recommended to undergo a “partial or unicompartmental knee replacement.” This may be recommended because it helps to straighten up the joint, which has changed its position as a result of osteoarthritis. Partial knee replacement can be more effective and durable if appropriate and are less invasive. Recovery time is less because there is less surgical trauma.When the entire knee joint is replaced that is called a total knee replacement, and the ends of the femur, top of the tibia and often the patella (knee cap) are fully replaced.

When you are ready to return to your yoga class, you should take time to talk with your teacher about your knee replacement. I will routinely ask these students a series of questions:

1.    How long ago was the surgery?
2.    Are you still in pain?
3.    Are you still in physical therapy?
4.    Do you have any hip or back pain (either before or after the knee replacement)?
5.    How much mobility do you currently have? Can you get up and down from the floor?
6.    Do you have arthritis in any other joints?

So be prepared to provide your teacher with this information. Knee range of motion will vary widely both in a recent post-operative knee as well as a knee replacement that is over one year old. A lot depends on how much motion you lost prior to the surgery and how hard you worked postoperatively. The answer to the question “Can you get up and down from the floor?” is important because it tells the teacher a lot about a student’s flexibility and strength. Knee flexion will vary considerably, but I have never seen a knee replacement with 155 degrees flexion nor have I ever seen someone able to do a deep squat. Whether this just happens to be my student demographic or not, I don’t know.

When resuming yoga practice, alignment is a big deal with knee replacements because post operatively you want to avoid torque forces through the joint because that affects cement in the joint. “Closed chain activities,” where your weight is shifted with your foot remaining on the floor,” where your foot is lifted off of the floor with subsequent weight bearing will affect the joint differently. For standing poses, I teach students with recent knee replacements to pick their feet up and then replace and position as opposed to pivoting to change directions. Down the road, you can introduce pivoting if it doesn’t cause pain or discomfort. Liberal usage of props; walls, chairs, blocks will assist the student in not over-doing too quickly.

Strengthening all of the muscles that cross the knee joint as well as secondary stabilizers is also important. This means front, back and side leg muscles. Attention to hip alignment and strength also translates to protection of the knee replacement. Kneeling is problematic but not necessarily injurious to the new knee. Finally, pay attention to the feet—where is the weight on the foot? A lot of individuals who suffer from arthritic hips and knees have feet that need some tender loving attention. Baxter in his prior posts talked about feet (see Your Feet on My Mind), and I agree that where the body meets the ground and how we stack up from there is crucial in protecting our joints for longevity, especially when we become bionic.

I would like to add that lot depends on your pre-surgical state of health. If you have been active up till the day of the surgery then your recovery time will take about three months till you feel like you have integrated the new knee into your body. This is a rough estimate, but it seems about right for a traditional total knee replacement. Minimally invasive and partial knee replacements have less trauma, so healing and function comes more quickly. For those individuals who have lost a lot of mobility and have developed severe range of motion loss and significant loss of muscle strength, the recovery time will be more arduous because of all the structural as well as cardiac changes.

Finally I want to emphasize this: talk to your surgeon before and after surgery to know what your particular limitations and precautions may be, and remember to share them with your yoga teacher. Remember this is an invasive surgical procedure and everyone heals in a different manner. Be kind to yourself and remember that with a lot of hard work you will regain function and improve the quality of your life. This the reason why you decided to undergo this surgical option in the first place.