The REHAB DEPARTMENT => Soft Tissue Healing Problems - Arthrofibrosis => Topic started by: jakev on March 11, 2004, 05:41:08 AM

Title: chronic effusion
Post by: jakev on March 11, 2004, 05:41:08 AM
i am 2 months post-op with a level 2+ or 3 amnt of effusion on lateral side.  ROM is great, but inflammation is horrid.  ice, u-sound, etc all help but this thing is hot as a torch each day and every hour.  my doc is somewhat puzzled, and this inflammation just promotes more scarring.  i have been down this road before, but my knee is re-sticking, and synovial tissue is thick & angry.  this fluid bubble is what makes activity so uncomfortable and even spinning on bike ain't good.  any idea on how many more more weeks before this will tame down if I limit activity, and any new tips to control?  since I am a multi-op guy will this just take longer?  just in the "why did i do this again phase" and need counsel.  thanks, Jake ???
Title: Re: chronic effusion
Post by: SarahSmile on March 11, 2004, 07:03:03 AM

I am in the exact position as you are in... I am just shy of two months post op and have had terrible swelling, heat, redness and pain everyday.

My OS originally told me that I tweaked my synovium and have bleeding in the joint, but he was hoping it would just "go away" so that he wouldn't have to aspirate it... It hasn't gone away yet and I am going to demand him to do something when I see him this upcoming Monday.

If your knee is that swollen, I would ask your OS to aspirate it and get the fluid out! The fluid can definately create scar tissue and it impairs healing. It doesn't seem normal to still be swollen for this long... Call your OS!!!

Good luck to you & hope you feel better soon!

Sarah ;D
Title: Re: chronic effusion
Post by: Heather M. on March 11, 2004, 08:05:14 AM

At this point, my doctor (an arthrofibrosis/scar tissue specialist) says that the most important thing is to get the heat out.  So that usually means backing down to a level of activity that doesn't irritate things.  Unfortunately, as you've learned, sometimes scar tissue can simply create it's own heat and swelling--it becomes a cascade that perpetuates itself, leaving you in pain and worse off after surgery than before.  Sounds like you may have been down that road....

Anyway, as I said, my doctor constantly stresses the need to get the heat out of the joint.  He has a couple of unorthodox methods that really seem to work.   Another scar tissue patient (Laurie) has done the whole routine and had great success.  She put a highly detailed account of her rehab that should be on one of the oldest pages in this section--look it up if you get a chance.  Otherwise, here's the overview:

1. No activity that irritates the knee.  Delayed weight-bearing (I was five-six weeks post-op before the crutches went, and it could have been longer....).  Passive, non-weight-bearing exercises and swelling control measures.  I did wall slides, quad sets, hamstring stretches, and straight leg raises only when the knee was hot.  Otherwise, I did spinning on a bike with no resistance, 5-6 other isometric/strengthening exercises, and patellar mobilizations to keep the kneecap from freezing up.  Swelling control measures at PT:  Jobst (sp?) cuff treatment, phonophoresis, 'milking' massage, interferential e-stim, and cryotherapy.  Most importantly, when I had a flare like you are having, I'd back down on any exercises until I was doing basically the day after surgery type stuff--nothing strenuous.

2.  Cortisone and/or SYNVISC injections to help block the immune response causing the heat and scar tissue production.  This is somewhat controversial, and I wasn't a candidate because I've had previous post-op infections.  He may do this on my next visit.

3.  Long-term, broad spectrum antibiotics on the theory that a low-grade infection is helping produce the heat.

4. Be sure you're not icing for more than 20 minutes in a one hour period, 6-10 times a day.  Any more than that, and you can cause rebound heat.  I've done it--even got a groovy rash from the ice!

5.  Delayed strength training until the heat and swelling are gone.  This could take months.  It takes great patience, and in the meantime you have to focus on keep the kneecap mobile, gaining/maintaining flexion and extension, gently isometrics to prevent wasting, and so forth.

6.  When it's time for strengthening, this too is slow and steady.  Starting with bike, then theraband work, slowly moving up to eliptical trainer, retro treadmill, and swimming.  Hydrotherapy is often strongly recommended.

7.  If all the above fails, then it's time to evaluate what may be going on in the knee.  In my case, I developed patella baja due to scarring and subsequent contracture of the patellar tendon.  This has pulled my kneecap down out of position and caused it to sink into the joint--meaning that I have bone on bone contact.  At this point, even the most gentle exercise (hydrotherapy, walking, even contracting my quad) causes bone-on-bone friction, pain, heat, and swelling.  It's now a truly mechanical problem and may have to be addressed as such.  So you should be sure that you are dealing only with scar tissue, and not any of the potential mechanical problems that can occur as a consequence of arthrofibrosis.

Hope this information helps some.  If your doctor is not a specialist, you may want to find one who sees lots of scar tissue patients.  Recurring arthrofibrosis is a rare problem, one that many OS's see only a few times in their careers.  Where are you located?  You may be near a specialist that someone on the board has visited.

Title: Re: chronic effusion
Post by: jakev on March 11, 2004, 06:22:07 PM
special thanks to both of you:
unfortunately my athletes mindset is problematic here.  I have 'over-iced' and will limit to 20min plan.  I have been pushing the strength rehab a little too much, even though it is minor.  I had a cortizone shot at 10days, helped for 2, but back to same status.  My doc, who has done dozens of these, as Dr.S's protoge does not want to aspirate and did not want to inject at 6wks post-op.  Heather - your notes are well timed, and I will focus on keeping the heat out as my objective.  I just hope that I do not regresss any further, as it looked real promising at 1 week post-op.  Maybe in a week or two I'll have better news, and the heat is chilled.  It is just bizzare when mechanically, things are much improved.  
Title: Re: chronic effusion
Post by: Heather M. on March 11, 2004, 08:04:13 PM

I thought I recognized you--I'm sorry that you experienced the standard arthrofibrosis rehab...doing fabulously well for a week or two, then a slow and steady decline.  I did it, Sarah's there right now, Janet has reported this--we've all been there.  So you've just got to hang in there and work only as fast as your body lets you.

Dr. S. is really, really big on adding one new thing at a time, then evaluating its effect on overall knee health.  Could it be that you added too much, too soon?  At this point, keeping the ROM and patellar mobility you have while reducing the heat is the priority.  Is it possible for you to go back to an immediate post-op status in terms of exercises and activity?  If you were overdoing it, the knee should calm down nicely in a week or so.  I'm talking hard-core, though--back on crutches, nothing but wall slides, patellar mobes, quad sets, and maybe SLR's, off your feet, keeping it elevated most of the time, icing 6-10 times a day, etc.  It will be tough, but the knee *should* respond nicely.  Maybe you could run this by your doctor and see what he thinks?

Another thing to consider is medication support.  I'm not a big fan of oral steroids, but I've taken them twice.  Man, did they knock the heat back like nobody's business.  Unfortunately, you can only do this if you are NOT going to have ANY surgery for the next 6-12 months.  Who can guarantee that?  I ignored this and had two nasty post-op staph for each round with the oral steroids.  Still, they are a powerful weapon in the conservative arsenal and can be very effective if they are used carefully.

As for aspiration, that works primarily if you've got an irritant like blood in there.  But if you only have fluid produced by an overactive immune system, chances are it will come back almost immediately.  Still, if you've never had it done, it may be a good option as well.

Finally, I can't remember what oral anti-inflams you're taking.  For me, Celebrex is the absolute best.  It brings things down to a dull roar, and I really notice a difference if I stop taking it.  However, others respond better to other drugs, so it's often a case of trial and error.

I hope you get through this keeping the ROM and patellar mobility that you've fought so hard for.  If you back down, *hopefully* the knee will respond well.  Even a little strength training too soon can cause a flare.  I was given the go-ahead by Dr. S. to start the x-trainer and stuff, but after a few weeks it became obvious that it was doing more harm than good.  So we stopped.  Same thing with hydrotherapy.  He wants to go in again and clean the knee out, and also see how bad the scar tissue and arthritis are...that way, he'll know better how to recommend that I proceed.  I will admit to being reluctant to do a 'looksy' surgery, even when Dr. S. is the one recommending it.  Our doctors are specialists, but they don't have to walk around post-op on our knees....still, I may hold that in reserve.

Take care.

Title: Re: chronic effusion
Post by: jakev on March 11, 2004, 08:51:57 PM
hard for me to imagine another scope and going through this again after so much, but I find it ironic that Dr.E actually recommended that potential of a looksee again to me someday.  Belive it or not, your post last fall actually played some role in my ultimate deciion to try again with an 'specialist' OS.  I am doing Vioxx and just plain have over done it in terms of activity.  This little bit of dialogue from you is motivating, as I can say that the few moments that the inflamation & fluid is down, the knee feels as good as it has in years.  So therefore, I'll go hard core for a while and see.  I am kind of holding 6 months post-op as my ultimate yardstick.  thanks again so much and best wishes in your process as well.
Title: Re: chronic effusion
Post by: Rosa on March 12, 2004, 01:58:04 PM
Hi Jake,
just thought I'd add my comments...
I've been suffereing from swelling for nearly 5 years now. I've had 2 ops, the second was a partial synovectomy (as a result of removing adhesions and supra patellar plica), along with a lateral release. At the same time, the surgeon took a biopsy. Since then (Sept 2002), the swelling has decreased somewhat, but flares up on certain activities (such as standing about!!!). I have had to give up my running which is very frustrating. I try swimming from time to time, as this doesnt cause any pain, but for 2 days afterwards the knee will become more swollen and stiff. I probably exacerbate it as when I swim, I just cant do the leisurely stuff, I go for it as fast as I can to get that heart rate going! I cant help pushing myself when I exercise, I almost do it subconciously!
Anyway, the constant swelling is worrying me in that it encourages scar tissue and cartilage damage. I have had it aspirated, but the fluid is back within the hour, and have had steroid injections, but when these wear off I have a huge flare up.
The biopsy showed features consistent with rheumatoid arthritis or a seronegative monoarthropathy. I have been treated my a rheumatologist who concluded that I dont have RA (bloods are -ve and show no inflam markers), so it must be the monoarthropathy. I have tried various anti-inflams, the latest I had a bad reaction to, and have refused to take the really strong stuff for RA sufferers. My rheumatologist has said the only way to treat me now is to aspirate and inject a couple of times a year, which I have refused after the last reaction. He also has said it is no point me going back to an OS. I'm wondering if I should as I have reached a dead-end.
I was wondering if you have seen a rheumatologist, as s/he may have some other suggestions.
Also, did you have a complete synovectomy? and if so does this mean it has grown back?
Sorry I dont have any good suggestions for control of your swelling, as nothing seems to work for mine. If you find anything - let me know!
Good luck
Title: Re: chronic effusion
Post by: jakev on March 12, 2004, 06:52:46 PM
Interesting.  I did have a complete synovectomy and this is when my scarring problems began to occur. I have no signs of rheumatoid arthritis, but was tested long ago.  I have no baja like Heather.  No doubt my lateral synovium is thickened again, but like you, swimming can really trigger a response if I flutter kick at all.  Weight bearing is often problematic for me, and the real cause of this fluid & swelling remains elusive. I can only hope that time improves things as the mechanics are much improved.  Like every day, I iced first thing this morning for 20min on way to work, and now one hour later it is hot & puffy again.  I am starting to think dead end for the first time in 8 yrs.  Let's keep the faith long term.