Knee Replacement Surgery: When Life Catches Up To You
I’ve led a pretty active lifestyle which at different times has included skiing, hiking, running, competitive swimming (which is not always as low impact as you might think!) and horse back riding, primarily in the equestrian sport of Eventing. Consequently, I have a fair amount of aches, pains and scars to show for it. While I’m not a risk taker by nature, all of these endeavors include a certain amount of risk and injuries are to be expected. Eventually life catches up to you and by age 53 my resume of injuries had taken a toll and were preventing me from doing many of the activities I enjoy. The worst of these injuries involved my knees and I realized it was time to consider a knee replacement in my left knee. Here’s my story of how I got here, what it’s like to undergo a Total Knee Replacement (TKR), how I’ve rehabbed from it and what life is like five months later.
My knee story (or one of them anyway):
When I was 18 and about to start my sophomore year of college, I was invited to go skiing with a group of friends on the glacier of Mt. Hood in my home state of Oregon. I was on a swimming scholarship at Southern Methodist University and was by no means an experienced downhill skier. Most of my experience on skis had been of the Nordic variety, tagging along with my father and sister for long weekend treks on the flatter terrain of Mt. Hood. But skis are skis, right? And what teenager could resist the chance to ski just below the summit of an 11,000 mountain overlooking the beautiful Oregon landscape on a bright, sunny August day with their best high school friends? Never mind the fact that swimmers are by nature and reputation notoriously uncoordinated land mammals and I was by far the least experienced down hiller in the group. It was a day that I would later categorize as “it seemed like a good idea at the time”.
It didn’t take long for the steep and icy terrain to get the better of my unstable body and a tumble quickly turned into a summersault which ended in a full face plant. My left leg was caught awkwardly behind me when my ski did not release and I remember a searing pain in my knee as I desperately tried to reach the binding. The result was a trip down the mountain in a ski patrol toboggan where I spent the remainder of the day with an ice pack nursing my painful knee followed up a few days later with a visit to an orthopedic surgeon and the news that I’d torn my ACL. The surgical technique in those days did not include ACL reconstruction as it does today. Instead they used my Iliotibial Band (IT Band) and a large screw to provide stabilization to the joint. I spent the next eight weeks immobilized in a full leg cast which meant the rehab process took longer and was a lot different than it is today. I did manage to return to school, albeit on crutches and a week late, and was competing again in time for our conference championships that spring. Ah, youth!
Fast forward and my left knee had become very valgus (knock-kneed) and painfully bone-on-bone after thirty years of wear and tear. To make matters worse, in 2017 I broke my right leg in a riding accident which resulted in multiple tibial plateau fractures, compartment syndrome, ACL and meniscus tears and required me to be non-weight bearing on my right leg for several months while it healed. This put additional stress on my already painful left knee. The pain and poor alignment began to affect my gait and I was concerned that it would eventually impact my hip as well. Although it was pretty obvious I would need surgery, this wasn’t possible until I’d sufficiently rehabbed from the surgeries required to fix the damage I’d done to my right knee. Finally in January of 2021 my orthopedic surgeon referred me to a joint replacement specialist who took a look at my left knee and recommended a Total Knee Replacement (TKR). My surgery was scheduled for mid-April which gave me ample time to prepare.
Preparation is Key:
With my history of knee surgeries, I’d learned the advantage of pre-habbing for surgery so I made use of the time before my surgery date working on leg strength and balance in order to make my post-surgery rehab process easier. This was key and I highly recommend to anyone considering knee replacement surgery (or any elective knee surgery) that you work with someone who’s knowledgable about strength and conditioning for knees. I recommend finding a Physical Therapist since you’ll need one post-surgery anyway. However, if you already work with a strength and conditioning coach, personal trainer, or Pilates instructor see if they would be willing to consult with your PT to develop an appropriate pre-hab program for you. The stronger you are going into your TKR, the easier your post-surgical experience will be and the better your rehab outcome. I also strongly encourage you to work on balance as much as strength as this will be crucial to helping you recover and avoiding falls, especially in the early weeks of your recovery. In part 2 of this piece I will detail the exercise program I followed before and after surgery as an example of what you can expect.
Surgery and Initial Recovery:
It’s becoming common now to have knee replacements done on an out-patient basis rather than in-patient and this is something you should discuss with your surgeon as both have pros and cons and the decision will be different for everyone. I opted for in-patient, feeling it was a better choice for me due to my experience with compartment syndrome as well as prior difficulties with anesthesia and pain medications. I had the good fortune to have my TKR done at New England Baptist Hospital, one of the premier orthopedic hospitals in the United States. They do thousands of these every year at NEBH and I can’t say enough about the level of care I received. Although I can’t speak to how the recovery would have gone had I opted for out-patient, I do know others who have taken this route and were quite happy with the results. Personally, I felt more comfortable having a little more time to recover from anesthesia, ensure my pain medications were tolerable and work with a Physical Therapist a few times before being discharged to go home.
The recovery process for a TKR is completely different than any knee surgery I’d experienced previously. First, my leg was wrapped after surgery but I was not in a brace of any kind. Second, after previous surgeries I had some period of either non- or partial-weight bearing post-op but with a TKR you are weight bearing as soon as the nerve block, spinal, and/or anesthesia wear off. Third, you start physical therapy within hours after coming out of surgery. After my nerve block had worn off the therapist had me up and walking with crutches down the hallways of my hospital floor. To my absolute amazement I was actually pretty comfortable! The post-op PT protocol I followed included leg lifts, glute contractions, quad contractions, heel slides and ankle pumps which I started that afternoon. My surgeon wanted me to have 90 degrees of flexion and full extension (0 degrees) by my first post-op visit which was three and a half weeks after my surgery. This seems to be the standard and consequently the primary focus of rehab for the first few weeks is regaining your range of motion. The strengthening exercises you do are really more about getting your muscles to start firing again after surgery and retaining your muscle tone. The real strengthening work comes later on once you’ve started outpatient therapy.
I wasn’t set up with a continuous passive motion machine (CPM) after surgery which is sometimes prescribed in order to work your range of motion. Instead, I was encouraged to do as much as possible on my own by doing heel slides for flexion and quad sets for extension. For those of you familiar with Pilates apparatus, the bed I was in after surgery looked very much like a Cadillac with a frame that went above the bed. I had a sling around my leg which was attached to a strap on a pulley system. This was attached to the frame and allowed me to raise and lower the sling by pulling the strap. This system allowed me to elevate my leg as well as work on knee flexion from my hospital bed. My surgeon stressed the importance of regaining full extension after surgery and I knew from prior surgeries that this can sometimes be more difficult than regaining flexion. One tip I learned was to avoid placing a pillow under my knee which is something people frequently do after knee surgery because it elevates your leg and feels more comfortable on your knee. The problem is that it keeps your knee in a slightly flexed position and inhibits full extension of the joint. To avoid this, I got into the habit of putting a pillow under my ankle and allowing gravity to gently encourage extension. I did this for as long as I could tolerate and as frequently as possible throughout the day. At night, I slept on my back with my leg fully extended and not supported or propped up with pillows or if it was, I made sure it was straight. If you are a side sleeper, this might take some getting used to but it is worthwhile to regain extension more quickly.
Swelling:
I had a lot of swelling after surgery so I really focused the first few weeks on getting the swelling down not only for comfort but to help with joint mobility. To reduce swelling, I used ice packs, alternating 20-30 minutes on and off during the day and as needed for pain at night. Once I was home, I took periodic breaks during the day to lay on the floor with my leg elevated on a chair or ottoman. This enabled me to get my leg up well above my heart and helped to reduce swelling. I tried to do this for at least 20-30 minutes at a time and at least two or three times each day. The swelling gradually went down over several weeks but the joint remained somewhat warm to the touch and slightly swollen for the first three months. Note: I’m now 5 months post-op and it is still slightly warmer to the touch than my other knee but I’m told this is typical and will gradually return to normal.
Risk of Infection:
One of the biggest concerns with TKR is infection and you should discuss the signs with your surgeon and your care team so that you are very aware of what is normal and what isn’t. I was told to contact them immediately if I had any unusual discharge at the incision site, increased pain, tenderness, redness or swelling, persistent fever, shaking or chills. After TKR surgery you are vulnerable to a bacterial infection that starts somewhere in your body, travels through your blood stream and infects your new knee because the body recognizes it as a “foreign object”. To minimize this risk, for at least the first two years after your TKR surgery they recommend prophylactic antibiotics before any procedure that may enable bacteria to enter your blood stream. This includes dental work and I was advised not to have any dental work done for at least three months post-op and to take a preventative antibiotic prior to dental work for two years thereafter. Other conditions that were of concern are things like strep throat, pneumonia, urinary tract infections and tooth abscesses and you should seek immediate medical care if you suspect you have any of these conditions and mention to whoever treats you that you have had a joint replacement.
Pain:
Pain from a TKR will vary person-to-person so your experience may be different than mine but I found the pain to be very tolerable. Admittedly, I’ve experienced a lot with my other knee so my pain scale may be somewhat skewed but I’d rate it the easiest knee surgery I’ve had including ACL surgery.
The first day my pain level was very tolerable and I didn’t experience any real discomfort until about 12 hours after surgery when everything had worn off. At this point my pain spiked to a 7 or 8 (out of 10) on the pain scale which lasted for a few hours before coming down to around a four. After the first night I was able to sleep comfortably through the night throughout my recovery. Once I was home from the hospital I stopped taking any prescription pain meds and was able to control pain with a combination of ice and Tylenol. Even during physical therapy my pain never really got above a 6 or 7 and most of the time it was 2-4 depending on my activity level. My worst pain spikes occurred once I was sufficiently healed and the therapist began to manually push my range of motion, however, even then the pain was not long lasting and was still tolerable.
I did experience a lot of bruising and muscle discomfort, which was not unexpected due to the somewhat brutal nature of the surgery (if you aren’t too squeamish you can find video of TKR surgery on YouTube). Initially I thought the muscle pain was related entirely to the surgery itself and the tourniquet, but eventually I realized that the pain I felt was due to my muscles and tendons being stretched because my leg alignment had been altered. This was especially true on the lateral side with my quad muscles and IT band. Presumably these had shortened over time due to my knock kneed alignment and were now being stretched with my newly straightened leg. To relieve the discomfort I used a handheld percussive massage gun and did A LOT of stretching but it took several weeks for this to improve and 3 months before it went away entirely.
In-Home Physical Therapy (Week 1-3):
My physical therapy continued at home starting the day after I was released from the hospital and I continued at-home visits for three weeks before beginning outpatient therapy. My home PT consisted of twice weekly visits and a program of leg lifts, glute contractions, quad contractions, ankle pumps, standing heel raises, standing lateral leg lifts (hip abduction/adduction), standing knee bends (knee to chest and heel to bottom), stair stretch (using a stair to press into knee flexion), and walking on a level surface as tolerated. In terms of walking, I used a long hallway where I could practice safely, starting out with both crutches for the first week and then using just one crutch for short periods so that by day 10 I was able to walk with one crutch full-time.
My incision was closed using steristrips and wrapped in gauze wound dressing during surgery. Prior to discharge the gauze wrap was removed and the incision and steristrips were covered with a waterproof bandage which made showering easier. The bandage stayed on for the first two weeks while the steristrips were removed at my first post-op visit. I did not have sutures or staples and the incision healed very quickly once the bandage was removed. The incision is 5 1/2 inches long and runs at a slight angle lengthwise along the front of my knee.
Outpatient PT (Week 4 - 16):
Starting outpatient PT was a big milestone, not only because the swelling, pain and bruising were much improved but I was able to progress much faster. I started outpatient during week four and by the end of that week I was able to ditch the crutches all together and begin to incorporate unassisted short walks into my daily rehab routine. My initial PT routine consisted of treatments (manual scar manipulation, Graston technique, and end-range flexion/extension stretching) as well as strengthening exercises. My exercise program included warming up on a stationary bike followed by quad sets, leg lifts (gradually adding ankle weights), side-lying lateral leg lifts (gradually adding ankle weights), bridges, clam shells, heel raises, single leg hip hinge (to improve balance and glute strength) and straight leg kickbacks using a resistance band. By week 6 or 7 post-op we added wall squats, short arc quad sets (gradually increasing ankle weights), and hamstring curls (with light weight or using a resistance band).
We also worked consistently on my gait to correct a slight limp I developed after ditching the crutches. One of the gait drills I did which I found particularly helpful was walking backwards (next to a wall for safety and guidance). This helped to retrain my brain to bend my new knee, pick up my foot properly and then transfer my weight onto that leg as I set it down rather than swinging my leg around as was becoming my habit in order to avoid flexion and full weight bearing. I credit this drill and the use of my Pilates apparatus (more on this below) in helping to improve my gait and lose the limp.
The stationary bike also played an important part in my rehab program as I had access to one at home. Initially I used the bike to improve my range of motion and for the first few weeks biking consisted of 5-10 minute “spin” sessions which were really just pressing the pedal back and forth to work on my knee flexion with the seat set higher than my normal setting. It wasn’t until about week six that I was finally able to turn the pedal all the way around and gradually lower the seat to increase knee flexion. Once I was comfortably able to “spin” I started to use the bike for exercise as well as range of motion. As my rehab progressed I switched from the stationary bike to outdoor walking so I could enjoy the warmer summer weather. Walking allowed me to work flexion and extension as I continued to improve my gait. I’m a big fan of walking as a form of exercise and I think it is very underrated. It’s SO good for you! Not only is it great for your balance and posture (i.e., vertical alignment), it feels good to be upright and getting extension through your hips if you sit a lot which is often the case as you recover from surgery.
Over time my therapist added exercises to my program including the use of a raised slant board (to gain quad strength and increase my confidence going down stairs) and weight lifting (hex bar dead lifts). What I’ve outlined above was the basic program I followed throughout my outpatient rehab and lasted through week 16. Note: my rehab program was designed to accommodate my painful right knee and did not include exercises requiring flexion in both knees like with squats or lunges, therefore it might not be entirely reflective of a program for someone who’s non-surgical knee is healthy.
Pilates for Physical Therapy:
As a Pilates instructor I know the power of Pilates to aid in rehab and I’ve used it many times myself before to recover from knee surgeries. After my TKR, I started doing a few simple mat exercises from my hospital bed including the Hundred w/ legs down, Half Roll Back, Roll Up, Spine Stretch Forward and Saw (check out my tutorials on Facebook, Instagram or Vimeo if you need coaching on any of these exercises). After I was discharged from the hospital I practiced a daily routine of mat exercises, keeping it pretty basic at first and making modifications as necessary. If ever you need a reason to start a regular Pilates practice, recovering from a leg injury or any surgery for that matter will prove why Pilates is so essential! The simple act of getting out of bed, rising from a chair or getting up from or down to the floor is a serious struggle if you don’t have the core strength, mobility and balance to accomplish these tasks with one limb out of commission. Try getting down to the floor and back up on one leg or without using your hands while you’re healthy and you’ll see what I mean! Pilates makes simple daily tasks easier when you’re healthy but it is a lifesaver when you’re injured.
Around week five, I started using my Pilates Chair to do the leg exercise called “Footwork” (in parallel foot position on one spring) and immediately noticed improvement in my gait. I attribute this to the way in which the chair helps you work the range of motion in your knees in an active way with the “push-pull” action of the springs. I found it to be a much better way to work on flexion than doing stair stretches or trying to pull my heel to my bottom. This led me to create a morning Pilates routine using several different Pilates apparatus. This routine consisted of:
1) 8 -10 reps each position on the foot corrector
2) 8-10 heel raises/tendon stretch on the 2x4
3) 8-10 reps each position of Footwork on my Chair (using a light spring setting which I gradually increased over time).
This was a game changer for me in terms of my strength and confidence. Walking got easier and I increased my daily walks from 1/2 mile at a time to a mile or more. By week 8 I was walking 2 miles at one time and began repeating that twice a day so that by week 10 I was walking between 4-5 miles a day.
Post-PT:
I was released by my surgeon to return to full activities at the three month mark post-surgery. I am now five months post-surgery and I’m able to do all of the activities I was doing prior to my TKR with a few modifications still for flexion (my flexion is about 120 degrees currently compared to 135 prior to surgery). My knee is slowly starting to feel “normal” and the sensation around the incision is returning. I’ve recently been comfortable enough to start kneeling on both knees again and with sufficient padding I can even kneel on one knee at a time which has allowed me to add other exercises into my routine (including the Pilates exercise Kneeling Side Kicks). Although I wouldn’t say I’m back to where I was pre-surgery in terms of strength or flexion, I continue to make progress. It’s surprising to me how much more comfortable my knee is already which makes progress easier to achieve.
I’ve also returned to a regular Pilates Reformer practice and I found I’m able to do most of the exercises with a few requiring modifications either to spring or gear settings to reduce knee flexion or tension on the joint. My other knee continues to be painful which is unrelated to my TKR but requires similar modifications. The Reformer exercises I’m not doing right now include: Swan on the Long Box with feet on the foot bar (requires too much flexion), Semi-Circle (excessive knee flexion), the Twist part of Snake and Twist (strength) and Star (strength and torque). In side exercises I notice weakness laterally and this can feel like too much torque on the knee so I’m careful in a side plank position (as in Star on the Reformer or Side Bend on the mat). Once I’ve strengthened sufficiently to do this easily on the mat then I’ll start working it back into my Reformer practice. I’m grateful that Pilates gives you so many options to meet you where you are and help you strengthen in a safe way! I’m modifying most of the exercises requiring knee flexion (like Footwork, Stomach Massage, Mermaid, Knee Stretches). For these I use lighter springs and/or change the gear setting to minimize the degree of knee flexion (some Reformers allow you to lower the foot bar instead of changing gears). I’m also very careful with the standing spilt exercises until I regain my strength and balance and I modify them either by not rising up fully or using a Gondola pole to steady myself.
Horses and Returning to the Saddle:
Sadly, I am not back to riding yet but this isn’t related to my TKR. After my riding accident a few years ago in which I shattered my tibial plateau, I was forced to take a long hiatus while I got that injury sorted out and healed. Unfortunately it has been a much longer break than I anticipated as the extent of my original injury wasn’t fully apparent for some time and has required multiple surgeries since my initial accident. I’m hopeful that a return to riding will be in my future sometime this year.
As for returning to the saddle post-TKR, I think riding is definitely possible five months out under the right circumstances and with a reliable horse who you know well. The advice I’d give to any rider facing a TKR is this:
do as much pre-hab strengthening as possible
work diligently and consistently through your physical therapy as you rehab
find a safe and reliable equine partner
work with a professional horse trainer (even if you are one) to help you when you are ready to return
and most importantly, don’t push yourself to return too soon!
Listen to your body and make the decision to return when you feel confident. For some people this might be as early as 3 months while others will take a little longer. For the majority of us, 4-5 months is probably a reasonable target but don’t commit it to stone! Be willing to adjust your timetable if you need more time. As every horse person knows, life with horses can be dangerous and you need to weigh the risks and make a prudent decision based on your situation and your comfort level.
Part 2/My Pre-hab and Rehab Exercise Program:
In Part 2, I’ll detail my Prehab and Rehab exercise program for Total Knee Replacement. I’ll summarize my timeline and the exercises I followed to give you an idea of what worked for me and what you might expect if you are considering a TKR. This is NOT intended as medical advice and you should consult with your doctor and physical therapist to create a program to address your needs and specific health conditions.
