Bob's Arthrofibrosis story

[rjs1956]

Update April 12 2007 - I had my second PT session today.  The knee is a bit less swollen and the tissues are a bit softer.  The therapist cranked on my leg and was able to get it to 62 degrees of flexion.  The pain kicks in at 55 degrees so it was a painful session.  This is an improvement from the first session when she could only bend it to 40 degrees.  I asked how can you tell when the pain is too much?  She replied we will know if it swells worse tommorrow.  I was recalling what I had read from another poster about working in the "pain-free zone".  With the pain I have been feeling trying to push to greater ROM I have no idea what that means but it sure sounds good.  The pain under my patella is pretty sharp and often intense.  I would compare it to the pain felt when the dentist drills too deep in a tooth although not that intense.  Fortunatly I only feel that pain when I bend my knee past 55 degrees.  So I can stand, walk and do most of my PT routine with no pain.

[rjs1956]

Update April 13 2007 4 days post-LOA.  I took 2 hydrocodone's and wired up my knee with the tens unit which is supposed to interfere with pain sensation and I eventually got the CPM machine up to 90 degrees.  Very little pain but a lot of stiffness.  Needless to say 90 degrees on a CPM with a relaxed leg does not translate to 90 degrees on my own using muscles.  I am beginning to see how important the softness of the surrounding tissues are to ROM.  After my 90 degree success during my PT routine I noticed the tendons above and below me knee as well as the patella were noticeably softer and more pliable.  On the other hand my quad muscles continue to be real sore, I think increasingly so.  The soreness is similar to having really overworked them but it is from the scar tissue removal so I suspect the soreness will last for several more days.  The only problem with it is it makes walking without crutches a real pain .  It takes a lot of little tiny baby steps to warm up each time.  Also the straight leg raises out front are hard to do with the sore muscles.  The swelling continues to slowly go down and my knee is only barely warmer than my good knee which is a good indication of no new scar tissue growth.

[rjs1956]

Update April 14, 2007 5 days post-op.  Today was a day my knee told me to take it easy.  It felt a bit irritated from the push to 90 degrees yesterday.  When I went to bed last night it was already feeling irritated so I wore the PolarCare with the CPM last night.  Today I kept the upper range of the CPM only in the 50's and even that gave me small painful twinges.  The knee felt warmer and somewhat more swollen.  By the afternoon I did feel strong enough to go for my daily walk around the hotel in the parking lot.  Nice to get some fresh air. Still walking very very slowly.  Hopefully tomorrow will be better.

[rjs1956]

Update April 15, 2007 - Not much to report.  The irritation from pushing to 90 on the CPM on Friday is a bit less.  Flexion on the CPM is back below 60.  Also found full extension not as easy to achieve.  Therapy is like the stock market.  Walking on crutches so I can do partial weight bearing to reduce irritation.  Still a lot of soreness in the muscles above the knee.  The soreness every day seems to be in a different spot.  I am wondering if the soreness is from pushing the leg to max flexion at the end of the LOA operation.  If so I am wondering if it would have been better not to have pushed it that far.  It certainly answers the question if 100% flexion was possible but since I can't achieve anything close to that now and I'm left with all this muscle soreness day after day was it worth it?  I might have been better off now if that full flexion had not been done.  PT tommorrow morning (Monday) and OS visit the next day.  I am going to ask doctor Folk if they have ever tried a mini manipulation under local anestesia; a shot of lydacain under the kneecap to numb the knee just before a PT session which would allow the therapist to push the flexion more than it is typically pushed.  I am taking pain meds to basically achieve the same thing.  The problem is the pain meds don't stop the sharp pain.

[rjs1956]

Update April 16, 2007 day 7 post-op.  PT session today.  No ROM gain - 62 degrees at the point YOUCH butt-off-the-table pain under the patella.  PT noticed that the fat pad at the bottom of the knee is the least pliable portion of the knee so she really focused on massaging that area.  I had not noticed it but now I will massage that area as well.  I was focussing on the center of the fat pad where the patella tendon is.  I have also been noticing how flexing the leg when it is behind me; the back leg toe push off when walking, or the back leg on the bicycle, is a more limited flex than when the leg is out in front.  There must be a mechanical reason.  I am so looking forward to the day when I can pedal the bicycle all the way around.  Meeting with doctor Folk tommorow.

[Jaci]

Hello Bob,

It's normal to have different degrees of flex depending on the position of your leg/ knee. I did a series of 'experiments' with my good leg-- lying on my stomach, standing, lying on my back, doing wall-slides, lying on my side, and so forth-- that confirmed the differences. Remember too that internal swelling can effect ROM.

Are you using a recumbent bike or an up-right bike at PT? I found the recumbent bike easier when I had really limited ROM. I would just get on the bike and rock back and forth. However, Dr. S had me stop using the bike at one point because my knee was swollen and inflamed. Finding the balance between doing enough and doing too much is one of the most difficult aspects of rehabing from scar tissue surgery. Sometimes the best thing you can do is go back to basics-- wallslides, patella mobes, quad sets, gentle stretches.

I thought of something that might help the quad muscle pain-- Lidoderm patches, they are 5% lidocaine and you'll need an Rx for them. You wear the patches for 12 hours then remove for 12 hours before applying new patches. You can use up to 3 at a time and you can cut them into smaller pieces to fit the area. I've used them a lot and found them very helpful.

Good luck with your appt. with Dr. Folk.

Take care,

Jaci
 

[rjs1956]

Thanks for the input Jaci.  The patches sound great.  For me the muscle pain is just annoying and is not slowing down my therapy (except for the straight leg raises - ouch) or effecting my ROM.  My main stumbling block is the sharp pain under the kneecap when I hit about 60 degrees.  I am going to ask Dr. Folk if we can try a MULA - manipulation under local anestesia.  I want to try a lidocaine shot under the petella to numb it and then try and bend it.  I can push into stiffness and tight muscles but the sharp pain is a show-stopper.  I wonder if the patches you mentioned can deliver enough lidocaine to numb my kneecap.  If so that would be a great solution; slap a patch on the kneecap, wait until the numbness sets in and crank the ROM.

I was using an upright bike at PT.  I have a small bike trainer "Magne-Trainer" in my room that I can use sitting in a chair or sitting on the floor.  The pedal action is very smooth.

[rjs1956]

Update April 17, 2007 8 days post-op - Met with doctor Folk today.  He was not at all concerned with my flexion limit at 60 degrees 1 week after surgery.  He said the sharp pain under the patella at my flexion limit is due to the tightness of my patellar tendons and the surrounding tissues in the knee.  That tightness is exerting a lot of extra force on the patella causing it to grind with a lot more friction than a healthy knee.  He said in the operating room when he had my leg fully flexed my knee was entirely white as the tissues were so stretched the blood could not flow.  Ha also said the muscle soreness from that stretching takes a good two weeks to go away. He said I should expect to see a noticeable improvement at two weeks post-op give or take 3 days as the tissues soften up.  I got the distinct impression that there would be no real benefit at this stage to try and endure a lot of sharp pain to increase the flexion by pushing my current limits.  I should expect flexion gains at that two-week mark.  However it is important to keep up the current level of PT by continuing to use the CPM ("motion is lotion"), and the floor exercises as all of that will encourage the tissue softening.  He gave me a prescription for Celebrex to accelerate the reduction in swelling.  I told him my idea for a manipulation under local anestesia (MULA) and he said sometimes they do that but not until at least 6 weeks post-op.  My knee is still a bit warm so the healing process is still underway so anything excessive would be counterproductive at this point.

I asked him again about what my knee looked like inside and he said the two quarter-sized lesions where the patella and femur condyle had worn each other down deep into the bone level had been healed over with fibrocartilage.  I will have to ask him next visit if that can mature into normal cartilage and if that new cartilage will extend the mileage for my knee.

[rjs1956]

Update april 18, 2007 9 days post-op.  I find spending so much time on the CPM machine my extension takes a lot longer to achieve during my floor PT.   I find at this stage that walking without crutches is hard for a couple of reasons; the muscle soreness is the prime reason.  Secondary is the tug of war between the flexion training the CPM provides and the extension I work so hard to achieve on the floor.  Walking requres a blend of the two which is hard when the muscles hurt.  It is easier to just extend the leg, lock it, get the muscles clenched and just leave it that way.  But that produces poor gate.  Walking requires alternating the extension and flex, tightining and relaxing the muscles.   I look forward to the two-week mark when I can expect the muscle soreness to subside.

[Janet]

Okay, here goes. Originally I tore my quad tendon and had an open repair (5/1999). After that, I was immobilized, so no one was surprised that I developed scar tissue problems. At six months post-op, I had a MUA and arthroscropy (10/1999). At that point, it worked hard on flexion with my PT and after three months, I was at about 115. I never had extension problems. But I was complaining about how my knee felt and the pain with walking and everyday living. My OS told me to be patient. By the time I ran out of patience, I got a second opinion from a knee specialist. This was about in September 2000, so quite a bit of time had passed with my OS talking “patience.” By then I was back to 90 and my x-rays showed patella baja and infrapatellar contracture. I went back to PT and again gained the 115, but my quads wouldn't strengthen no matter what we did. I was still in pain and felt disabled with my daily activities. That OS did a LR and removed tons and tons of scar tissue from my knee (5/2001). Again, PT helped but not much, so she sent me to a PT who specializes in gait. I worked with him for six months, but had little improvement. That OS finally threw up her hands, saying she'd never seen anything like it and that it didn't make sense. She suggested I see Dr. Wojtys or Dr. Noyes. Since I live close to Ann Arbor where Dr. Wojtys is, I made an appointment with him. He looked at the MRI I brought with me and knew right away there was more scar tissue around the patella tendon that was causing problems. I understand now that one sign was that I had full extension while non-weight bearing. But as soon as I stoop up, I could not get full extension so I walked with a bent knee. I also had a patellar defect (in the articular cartilage), so he said we wouldn't know for six-eight months if taking the scar tissue out would help. I decided to go ahead with the surgery (6/2002). He removed a “huge ball” (his words) scar tissue from the patella tendon and did a little “clean up” on the back of the patella. The recovery was long and hard, and he was right that it took about eight months of the “special arthrofibrosis PT” to see any improvement because my quads were so weak. That surgery was the last I needed for scar tissue. But the damage was already done. In November 2006, I had a TKR because of the patella damage. My medial and lateral compartments were fine, but the patella was awful. At the beginning of the recovery, I did fine. But by two weeks post-op I could feel the scar tissue forming and it was extremely painful. I had a MUA at five weeks, and haven’t had any problems with ROM since.

Sorry that was so long! I’ll only add one thing. While I had functional flexion of 115 to 120 before my TKR, I couldn’t use that flexion. It hurt to have my knee bent because of the patellar defect. Now I can sit with my knee bent without pain. And my gait is improving as I relearn how to walk correctly after eight years of limping.

Janet

[rjs1956]

Janet, all I can say is dang!

[rjs1956]

Update April 19, 2007 10 days post-op.  PT session today.  We really focused on deep massaging the upper and lower pateller tendons as they are really tight.  Max flexion today was 47 - pathetic.  I'm not going to get flexion gains until these tissues soften up.  Good news is the muscle soreness is quite a bit less, more in the deep part of the muscle now.

[Janet]

Sorry, I see I put my post in the wrong place! It was so long, I decided to type it in Word and copy and paste it here. I knew I was answering your question, but I ended up putting it under your post instead of where you asked me in another thread about scar tissue forming. Do you want me to move it so it makes more sense posted with your question?

Keep working at your flexion. The trick is to find the place where you are stretching, but not too much. If you work too hard, it can cause more trauma, and cause more scar tissue to form. Bend as far as you can comfortably, then just a little further...hold for a few seconds, then release and repeat.

Is your knee warm?  Are you still swollen? That will definitely inhibit your ROM. Keep icing and elevating....knee above the heart, ankle above the knee. In fact, after my TKR, the doctor said to try to elevate to a 90 degree angle. I couldn't make a "tower" that high, but I got it close!

Janet

[rjs1956]

Update April 20, 2007 11 days post-op.  Please feel free to move your post Janet.  I am doing two things to work on flexion; spending a lot of time at the start of my floor routine deep massaging the tendons and surrounding tissue above and below the kneecap as well as pushing the kneecap itself side to side and up and down, and using the CPM gradually adding degrees as the knee stretches.  Typically I start the CPM at 45 and notch it up 1 or 2 degrees at a time after about 5 cycles or when my knee feels pretty good at the extreme.  As a result after a few hours I can get it up to the mid 60's.  At one point during PT when the therapist was working on flexion my leg was hanging off the end of the table and my knee was bent about 60 degrees and she asked "Are you holding it up?".  I don't think I was. I may be wrong but I felt relaxed.  The darn thing is so tight I think it was holding itself up.  Last week, with a lot of pain meds, I got the CPM up to 90 but the next day my knee felt overworked so I backed off.

To me my knee does not feel warm but doctor Folk said it felt warm to him when I saw him 7 days post-op.  That is why he said not to worry about flexion gains.  I started taking celebrex 4 days ago and the swelling is down quite a bit. 

[rjs1956]

Update April 21, 2007 12 days post-op.  I went to the arts festival in downtown Greenville using both crutches so I could stay on my feet for a prolonged period.  The Reedy River Bridge park is a spectacular walk.  I was out for about 2 hours and I felt pretty good.  When I went to bed I wore the DynaSplint extension brace cranked up to 12 instead of the CPM machine.  I woke up every hour from small pains as it excerted its force.  Annoying but not show-stopping pain.  I have noticed that the muscles that promote full extension are not firing very well.  If I lay my good leg's thigh on a low support, about 4-5 inches high, with my knee bend on the edge and allow my heel to rest on the floor, I can raise the bottom part of my good leg off the floor extending straight.  I can really feel the muscles, or tendons, right above my knee doing some work.  If I try the same thing with my bad knee, I cant fully extend it.  I get it about 60% of the way up.  But for the past few days I have added that excersize to my floor PT at home and the muscles appear to be getting stonger and I can raise it a bit farther and stronger each day.  It feels like the same muscles when I press the back of my leg into the floor to get full extension but it highlights the ones that feel like the ones responsible for extension when walking.  I will show it to the therapist tommorow and get her opinion.

Update April 22, 2007 13 days post-op.  I attended the Seacoast church service today.  It is the church Chris Sligh from American Idol attends.  He normally leads the worship service I gather but he was at the White House in Washington DC for some reason this weekend.  I'm sure I will get a chance to see him play and sing.  The music was outstanding. I play bass guitar at my church in Atlanta so I appreciate good sound.  I am in the CPM machine now and I have it up to 77 degrees.  I am still feeling some pain under the patella at 55 degrees but it is less than last week so I am assuming that means my tissues are softening up a bit.  As long as I keep my leg relaxed I don't feel much pain but as soon as I try and bend it much using my muscles - like a simple hamstring flex raising my heel behind me - the pain appears real fast.