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Offline RLE

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Regression after manipulation
« on: October 14, 2011, 10:00:41 PM »
I have read all the posts I can find on here about manipulation but they seem to be all over the place. It would be great to have specific areas for specific procedures.
After 3 weeks immobilized then 3 weeks of PT my knee was just not moving. The swelling has never gone down (after an injury I posted about-dislocated kneecap/torn ligament)
I knew it was scar tissue since my body produces a lot of scar tissue. On Monday I had a manipulation. The surgeon bent my knee all the way to touch my backside. He did nothing else. I had intensive PT daily since then plus a CPM machine in which I can get up to 120 degrees though not for very long. On Wed. I had 120 degrees of flexion. The PT pushed me hard yesterday and I pushed myself after and woke up today with a lot of pain and swelling. I again worked for an hour and a half of intensive physical therapy today and when the PT measured me I was only 101. I've regressed. She said she doesn't know the reason it could be inflammation from yesterday or not.
Has anyone had this happen or know the reason for less flexion today than two days ago? I use the CPM all night and most of the day.
Thanks.
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T

Offline Rollerblader

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Re: Regression after manipulation
« Reply #1 on: October 16, 2011, 12:14:36 PM »
LER

Soooo sorry you had to have a manipulation.  I had one @ 9 weeks post op from a patella break.  My OS got my to 120 ROM while I was under.  I did not do the CPM, not sure why as it seems to be typical.  I was scheduled for PT 3x a week for 6 wks.  I just finished my 3rd week.  Regressing is pretty typical from what I've read.  My PT was only able to get me to about 78 ROM the next day after the procedure.  I was soooo swollen and sore for first week I could hardly sit on the PT table.  My OS did not prescribe any anti inflamitories.  My PT was concerned that I had too much swelling to be able to do anything.  I regressed to 60 ROM a week following my MUA.  Started on Aleve that day and swelling went down immediately.  I was back to 70 ROM and then this past friday, my 3 week point I got to 99 ROM.

The  MUA shocked my muscles and i had severe brusing on the underside of my thigh btwn wk 1 and 2 from being clamped down.  This prevented me from moving forward immediately.  I'm pretty sure this is typical.  I'm surprised that your PT doesn't know this.  I think it just takes time.  I have been pretty miserable since  the manipulation.  I've haven't slept at all.  My leg twitches constantly and has shooting pains.  By the way, I was at a ROM of about 45 when I had my MUA. 

Hang in there!!!!  It will come.
7/26/11-broke patella ORIF 2 scr, fig 8 wire, FWB, fract elbow: pl w/10 scr
8/3/11-Leg IM brace, arm cast
8/11/11-hinges fully on brace, cast rem arm
9/15/11-7wk ckup, ROM 35
9/26/11-MUA knee and elbow, 3 screws rem elbow
10/20/11-ROM 99 able to drive
12/1/11-ROM 145 rel from PT

Offline aaa

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Re: Regression after manipulation
« Reply #2 on: October 16, 2011, 02:04:44 PM »
i know this probably isn't helping things, but i think one should know that immobilizing for 3 weeks after a patella dislocation is the worst thing you can do.

actually, maybe it is helping things to tell you this, because i went through a very similar situation ... and you need to find a new doctor who knows how to help you

its making me furious to read it, because countless people have been made to endure unnecessary pain and difficulty.

see: http://www.kneeguru.co.uk/KNEEnotes/node/2160 - quote below regardingj on HOW NOT to manage a dislocated patella

Quote
This common problem has been mis-managed for years, with the knee put into a plaster cast for a period of four weeks, after which the patient was basically discharged. What we have learned over the last five to ten years is that the last thing you should do after this kind of injury is to immobilise the knee. Of course the patient should rest their knee for a few days – it will be painful and swollen and difficult to use. Ice, compression and anti-inflammatory tablets may further help reduce the swelling. The patient may benefit from the use of a brace (a cricket-pad splint or some form of immobilisation for a few days) but basically they need to start exercising the knee, and in particular the inner quadriceps muscle (the VMO or vastus medialis obliquus). This medial quadriceps muscle is a key player in keeping the kneecap sitting where it is supposed to sit. If you immobilise the knee in a plaster for a long time this muscle will waste away. It is really important that patients start exercising their VMO muscle.

While the part about the VMO is still argued somewhat, in that the hips are thought to play a critical role in patella stability as well, it is true that the quads waste away very quickly after being immobilized.

And as you've experienced, you're knee is stiffened up now after immobilzation.  i was fortunate that i didn't have the stiffness, but i did have the severe atrophy and years of frustration.

where are you located?  i would suggest finding someone who specializes in patellofemoral isntability

as for the lateral release, do not rush into this surgery, it is rarely indicated and quite often performed by OS's who do not know what they are doing, so they just take a chance and hope maybe it works.

again, i would suggest someone who specializes in patellofemoral instability, and i would encourage that you read the set of articles, particularly part III - http://www.kneeguru.co.uk/KNEEnotes/node/559

i don't know how to advise about the stiffness, but if your knee was normal before the injury - i.e. no anatomical abnormalities, no rotatoinal issues,  and the injury happened in an impact as you described , then sometimes physiotherapy is enough ... if physiotherapy fails and the patella remains unstable, then its quite likely the MPFL is damaged and a reconstruction will correct the problem.
« Last Edit: October 16, 2011, 02:16:06 PM by yb »

Offline RLE

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Re: Regression after manipulation
« Reply #3 on: October 17, 2011, 03:04:08 AM »
Thank you for the replies. I live in Los Angeles. I worked on my knee all weekend and today it's all stiff again just like before the MUA. Very demoralizing.
I also tore a ligament which is why I think it was immobilized.(?) I couldn't stand on it for a long time.
I'm wondering if the surgeon shouldn't have removed scar tissue before doing the MUA since I've read some surgeons do that or since it was only 6 weeks and I'm trying to use scar tissue to keep the kneecap in place that wouldn't have been a good idea.
It's extremely inflamed. I wonder if I should try Alleve instead of painkillers? It's just so painful to move without pain medication.
Another odd thing. I use a cold pack for my back-I swear by it. And the doctor and PT insist I use ice on my knee. The ice inflames and stiffens it more so I stopped a week ago and today I put hot wet towels on it instead and it was much better.

I should add that my kneecaps were ok prior to the injury but I had a condition (don't know the medical term for it) where my kneecaps go to the side because they are not cupped and are only held in place by my ligaments. I never had any problems before except this injured knee would ache a bit when I climbed a lot of stairs all day and I wore a brace on it when exercising. I guess at my age (middle age!) I was lucky never to have a problem and probably never would have had I not been run into by a huge heavy dog.
« Last Edit: October 17, 2011, 03:31:47 AM by LER »
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T

Offline aaa

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Re: Regression after manipulation
« Reply #4 on: October 17, 2011, 10:01:28 AM »
when the patella dislocates, typically there is some tearing of the medial restraints / ligaments ... still, i think its becoming more common to rest this for a shorter period and start exercising it, but whats done is done and i don't mean to discourage you , many have gone through a similar situation and end up doing ok long term

i think what you're referring to is shallow trochlear groove, the groove holding the kneecap possibly isn't that deep.  There are procedures to deepen the groove, but that might not be necessary, its really improtant to find a specialist

i'm not sure about patellofemoral specialists in los angeles .... but there is a patello-femoral forum here on kneeguru, i would recommend posting a new thread there about a specialist in your area.

Offline Rollerblader

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Re: Regression after manipulation
« Reply #5 on: October 17, 2011, 12:19:49 PM »
I really can't comment on your dislocated patella, but re: the swelling you should call your OS office and they should be able to tell you if you can take Aleve with the pain meds.  I was told I could after my bone was healed.  So you shouldn't have to give up the pain meds...

I mostly use heat now that my swelling has gone down.  I ice if I'm swollen or if I have certain pain.  It kind if freezes the pain, but sometimes it makes the pain worse.  I don't use heat if my knee is hot.  I've used heat mostly on my Quads as they have been very sore.  Alot of times if you over due it, a night of ice and elevation will get you back to where you were.

Re: removing the scar tissue.  I'm not sure what the answer is.  Some tend to think by going in and cutting it loose it just allows for more scar tissue to form if you are prone to scar tissue.  Others think it's the best way.  I really have no idea.

I think you are still early in the MUA recovery and it should get better.  I really didn't feel better and start improving until after my first or second week.

Good Luck!!!
7/26/11-broke patella ORIF 2 scr, fig 8 wire, FWB, fract elbow: pl w/10 scr
8/3/11-Leg IM brace, arm cast
8/11/11-hinges fully on brace, cast rem arm
9/15/11-7wk ckup, ROM 35
9/26/11-MUA knee and elbow, 3 screws rem elbow
10/20/11-ROM 99 able to drive
12/1/11-ROM 145 rel from PT

Offline RLE

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Re: Regression after manipulation
« Reply #6 on: October 18, 2011, 03:08:22 PM »
On Monday I hung my knee over the table and the PT measured the angle. I asked what it was and her face got tight and she slammed away. She told me to lie down and without giving me a chance to bend my knee she shoved it backwards as hard as she could. I screamed and she measured it. It was 95. I then moved it slowly back myself and asked her to remeasure. It was 100-same as last week. After the manipulation it was 120 and it went down to 100 and has stayed there.

I don't know why she did what she did? Is this standard procedure? She's never done it before. She then proceed to tell me that this is all my fault because I'm "afraid" of the pain (yeah, I am it's excruciating) and so I'm babying myself. My knee is very stiff even after I've just exercised it. Aside from the pain sometimes it just gets to a point where it doesn't move. And the pain while on the bike is out of this world or if someone forces it.

And it's extremely swollen after 8 weeks. First because of the accident now because I assume of the manipulation. She keeps me 2 hours and sometimes when she finishes my knee is hugely swollen, hot and painful. The next day she tells me it's my fault because I'm not pushing through the pain. I've lived with pain the last 12 years and this is absolutely the worst. I'm really struggling. Am I wrong or is it her? She's a good therapist, cares about her patients but is very high strung and gets angry easily. I have this week 4 days of PT and next week 3 days and then I'm done. What if I can't move my knee more than 100?
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T

Offline aaa

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Re: Regression after manipulation
« Reply #7 on: October 18, 2011, 03:41:17 PM »
Find another Physiotherapist.  She should not be getting angry with you.  Geez, its making angry just to read this ... I would've probably lost my cool if that happened to me


« Last Edit: October 18, 2011, 03:42:53 PM by yb »

Offline Lottiefox

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Re: Regression after manipulation
« Reply #8 on: October 18, 2011, 10:23:52 PM »
LER

**** me. I am seething! I agree - find another physiotherapist. This is not right. I think that you need to have a read of the approach to rehab after an MUA in the Information hub where scar tissue is involved and print off the pages and give them to your PT. It sounds like you are being pushed to the point of extreme inflammation (through the pain) and then the whole cycle of pain, inflammation, swelling, and loss of motion sets in. The key to regaining motion after an MUA (with or without a removal of the adhesions through surgery) appears to be a slow, steady program that does NOT set up the chain of inflammation in the joint. I would recommend having a read of some of the diaries on the Arthrofibrosis board to review some experiences. By forcing your knee into a hot swollen state there is no way you are going to retain the ROM that was gained when you were asleep. Yes, some pain is to be expected. You need to stretch, you need to work, but you MUST balance this with what your knee is telling you. Be careful with the whole heat-ice thing. Heat when you're swollen and inflamed isn't generally a good idea, it causes the blood vessels to dilate more and that isn't great for swelling. Ice is generally accepted as useful for swelling but be careful not to overdo it, if you find it creates more pain then stop and just try a cool (fridge temperature) compress to soothe the pain. We have a lot of nerves in the knee and they are responsive to extremes of temperature.

I am so angry for you at your PT's lack of professionalism. NO it isn't standard procedure. It isn't your "fault". I hope you can get someone to listen a little more to what you're telling them. You sure don't sound like you're afraid of the right type of pain - but pain regardless after an MUA isn't right/

Lottie
Bilateral patella OA since 2009, no surgeries.
Euflexxa working well x3 to current
Right forefoot CRPS post fusion surgery 2011
Refusing to let the ailing parts stop me....

Offline Stergios

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Re: Regression after manipulation
« Reply #9 on: October 19, 2011, 12:13:01 AM »
There are 3 kinds of ROM: Active ROM, Active-Assisted ROM and Passive ROM. What counts most? Of course Active one. The PT usually use PROM to inform each other about. Regression is logical, as your knee is so much swollen after your manipulation. Adhesions usually are getting grown up again, as your knee is so much inflammed and your manipulation torn some adhesions. Maybe they did it again. You should avoid as much as you can to irritate your knee more. Ice is a good solution, even some theory says that it can inflamme the injury. If you use it not more than 15 min., I think it can not harm your knee. My PT says the max. time should be 20 min.
About the measurement that PT tried: ROM is different in a supine or a  prone position. Obviously she tried to take a PROM measurement, but to turn you upside down and measure, it is a bit bizarre to me. I think she should push in  only one position. About professional behaviour: Well, I think it is not much professional, but the result counts most. If she is good and effective, if I was you, I could be patient to wait the result. Our knee counts most after all:-)

Offline RLE

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Re: Regression after manipulation
« Reply #10 on: October 19, 2011, 02:34:09 AM »
I ice my back religiously and have never used heat for anything but I think what's happening is my quads are freezing up from the pain and getting stiff and the warm water relaxes them. My PT sent me to the pool before the manipulation and the water was very nice.
I'd like to know other people's experiences with their PTs post-manipulation since mine said that we have to use the first week after MUA to get the range of motion and to keep the scar tissue from growing back.

I'm really struggling with pain and stiffness. Today is Tues and my MUA was done last Monday. During physical therapy with a lot of pain medication (about Percocet 8) I can bend my leg still to 100 (hasn't changed) and finally after 8 weeks with a fantastic new brace-Bauerfeind-I can walk on my right leg a small amount. I can step down and bend it somewhat normally but it tires quickly.
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T

Offline Rollerblader

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Re: Regression after manipulation
« Reply #11 on: October 19, 2011, 07:04:26 PM »
LER

I'm sooo sorry for you!  Did your OS prescribe this particular PT?  I had to find my own.  I would change Therapist and when you make your appt, ask for someone who has worked with knee manipulations... 

I have a post, kind of a diary, under Bone Breaks around the Knee section.  Just look for my ID under the authors. 

I was at about 45 ROM at 9 wks, the OS got me to120 ROM during MUA.   The PT got me to 78, the day after my MUA.  I regressed to 60, about a week later.  I was so swollen and sore in my thigh, the PT was pretty easy on me until I got my swelling down with Aleve.  The day I was at 60, PT encouraged me to get on an anti-inflamatory or go to the OS and have him look at my swelling and bruises, which showed up about 5 days post
MUA.  That was an awful couple of weeks.  My quad was like concrete and and felt like it was being pulled to the ground.  The quad stiffness, knots were the limiting factor for to bend.  I'm a little over 3 wks post MUA and I got to a ROM of 113 assisted today and 97 unassisted.  I've been gaining ROM everday.  Therapist is very happy with my progress.  I do wake up stiff every morning and my ROM is sbout 65-70 until I tide my stationary bike.

My PT sessions are 45 min for knee and 15 min for broken elbow rehab.  My therapy originally was massaging the knots out of quad and then PT would push my leg.  Now I riide nustep for 10 min, stationary bike for 10 min, then PT massages around the knee, and then pushes...  Today we started some balance board, and  steps.  Used to end PT with ice, but now we end with heat.  As long as I'm not swelling, i prefer heat at this point.  The heat is also for my quads.  I'm not sure people without a MUA understand the SHOCK the MUA does to the thigh.  My knee was not sore in PT until about a week ago.  My PT said that most people dont have all the knots in the quads.
Your PT is right in in that you have to keep the scar tissue at bay and keep the range of motion, but the problem is that there is regression the week after MUA due to swelling and your never expected to reach what the OS reached the week after the MUA.
The MUA was a total set back for me.  I was getting out, feeling good and painfree.  I had the MUA, and I was back on pain killers, haven't slept more than 3 hours at night and My leg just aches all day with some sharp shooting pains in my knee, thigh, shin.  I got off percoset, it depressed me and made me weepy.  I'm now taking vicodin only to sleep. 

I hope this helps.  The post mua pain was worse than my original pain from patella and elbow surgery.  I just wasn't expecting it to be so bad.  Hang in there and find a PT who knows what to do with a MUA. 

Take Care. I think you have another couple of days before you turn the corner, but you have to get your swelling reduced.
7/26/11-broke patella ORIF 2 scr, fig 8 wire, FWB, fract elbow: pl w/10 scr
8/3/11-Leg IM brace, arm cast
8/11/11-hinges fully on brace, cast rem arm
9/15/11-7wk ckup, ROM 35
9/26/11-MUA knee and elbow, 3 screws rem elbow
10/20/11-ROM 99 able to drive
12/1/11-ROM 145 rel from PT

Offline RLE

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Re: Regression after manipulation
« Reply #12 on: October 19, 2011, 07:21:25 PM »
Wow, my PT is so different. I've told her about the quad stiffness and nothing. I do leg swings, leg bends on the wall, the bike, forwards and backwards on the treadmill, practicing walking with the crutches and a walker.
She keeps me an hour and a half for my knee. When she forces my leg I think I'm going to go out of my head with the pain. Does your forced ROM hurt? The stationary bike also the pain is crazy. I took aspirin for a few days but I have an ulcer (from taking aspirin for my back) and can't tolerate it. It helped a bit with the swelling. My knee is still very swollen.
I think the CPM is what's saved my sanity. It bends my leg gently and the pain is not bad and has kept it from stiffening since when the PT finishes with me the pain is excruciating.
This is week 2 after the MUA. The PT is part of the surgeon's office. This whole thing has been so painful. I can't say the post-MUA was worse since the pain has just been bad period.
I hope you're right that it will settle down and start getting some ROM. Thanks for sharing your experience.
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T

Offline Rollerblader

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Re: Regression after manipulation
« Reply #13 on: October 19, 2011, 10:43:22 PM »
Yes, our PT is very different.  My PT definitely pushes past what I think is my breaking point and then she holds it.  After my swelling went down, she moved me to table in another room where very few people are and she put a seatbelt type strap over my thighs and put a cuff on my foot.  The cuff has a strap that hangs down.  She faces me and puts her foot in the loop of the strap and pushes my foot under the table until I'm about to hop off the table.  The first few time it hurt soo bad.  Since my ROM has improved so well over the past week, she hasn't used the cuff every time.  She did use it today, she couldn't seem to push my leg under the table very well without it.  It also hasn't been as painful the last few days.

The upright bike is miserable...  I just got around this past week.  I've gotten around on my recumbant bike at home.  It takes me about 4 min to get to where I can get around, and then I just go around slow.  I keep thinking it will get easier, but it seems to about the same.

It sounds like you are doing some quad strength.  My PT has mostly been ROM.  She wanted to get me over 90
 before we started on strength.

When is you next OS appt?  My OS prescribed aggressive ROM, but mine is not near as aggressive as yours.  You might want to share your PT experience with your OS.  You also need to figure out a way to get your swelling down, so you won't be in so much pain.

Good luck, keep us updated.  Hopefully someone else will tell of their experience.

Take Care,

RB
7/26/11-broke patella ORIF 2 scr, fig 8 wire, FWB, fract elbow: pl w/10 scr
8/3/11-Leg IM brace, arm cast
8/11/11-hinges fully on brace, cast rem arm
9/15/11-7wk ckup, ROM 35
9/26/11-MUA knee and elbow, 3 screws rem elbow
10/20/11-ROM 99 able to drive
12/1/11-ROM 145 rel from PT

Offline RLE

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Re: Regression after manipulation
« Reply #14 on: October 22, 2011, 02:20:09 PM »
I'm seeing the OS on Tues. I went to the pool yesterday. I had complained to my PT that the PT at the pool doesn't do anything (he just sits at his computer the whole time and doesn't talk to patients.) And his assistant is too busy supervising 3-4 people in the pool to do much so when I got there she was there though she left before I started.
 Somehow the workout was different (better than the times I had been there before) One thing I noticed was that when she finishes with me I'm so exhausted I can barely lift my legs but my leg is soft and loose after. Hurts like heck the next day but I'm progressing. The pool was not much of a workout. I wasn't tired or sore the next day and the worst thing was the stiffness and tightness I've been fighting came back two hours later after the pool. On the days I see my PT the stiffness/tightness doesn't come on. I used the CPM machine until hurts and that works on the tightness. I don't know what I would have done if they had taken the machine after the first week as they were going to.
I hate the stupid bike too. Hurts like anything. I still can't sit normally and pedal.  :)
How is your ROM now? Thanks for all the details it's very helpful! I hope your pain level is better.
Accident 2011: permanent dislocation, hole under the patella, bone fragments/debris embedded, scar tissue, 3 torn ligaments, fracture, cartilage sheared off, contracture,
2011 MUA
PT on-going
2012 MPFL reconstruction,TTT
        TTT
        Lateral lengthenin
        Arthroscopy/clean out
Thx Dr. T