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Severe pain with sitting after 8 weeks TKA postop

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Severe pain with sitting after 8 weeks TKA postop - February 11, 2018 5:52:39 PM   


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I could use some help. A patient of mine had a total knee 8 weeks ago at the age of 60. She was a college tennis althlete and became an avid golfer and gym exerciser when she had to eventually stop tennis due to multiple joint surgeries. She had more pain than expected from day one of the knee replacement , with severe stabbing pain upon standing/walking the first few steps, constant aching in her knee and a deep joint “boring” pain that travels up to her hip and low back on that side if she sits for more than 10-15 minutes. She is still taking opiod pain meds at this point, but they have been gradually stepped down over time. She feels significant pain in the 1-2 hours between when her meds wear off and when she can take the next dose, but she is only taking them as prescribed. She has constant pain even on meds, but it is just more bearable. Her exercise was very limited due to pain at first (she was literally crying if we tried to do anything that wasn’t extremely gentle), but after about 4 weeks she was able to start gradually progressing exercises. Now, she is walking with a cane outside the home and no assistance in the home. She is doing a normal postop routine for ROM and quad strengthening. Her ROM is acceptable but a little tight into extension. No redness, unusual swelling or heat coming off the knee. But she still can’t sit for more than 15-20 minutes without the pain escalating and becoming unbearable, even with imopiod pain meds. She still has pain with walking more than a few hundred feet and canmt stand long enough to cook a normal meal due to pain. The surgeon is known to be the best in town for TKA and does several hundred each year. I personally see the results of these in my clinic. He is an excellent surgeon, but this lady is having a totally different experience from the rest of his patients. I’d also like to add that I have seen her for 3-4 other tennis-related orthopedic surgeries, and I have never seen her react this poorly. She has recovered well from those, even when she has minor complications. I am concerned that something is wrong, but the surgeon thinks she just needs to wait and that she will get better in time. Has anyone ever experienced a patient that has so much pain with sitting after TKA? Any suggestions on what could be going on here or what I might be able to do to help? We’ve done some patellar mobs, MFR and IASTYM with no change. She basically has to sit in a recliner most of the day, with her knee relatively straight and elevated.
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RE: Severe pain with sitting after 8 weeks TKA postop - February 23, 2018 10:27:04 AM   
Tom Reeves DPT ATC


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read Explain Pain by Moseley and Butler. Pain can have lots of contributors but it is ALWAYS ultimately because the brain decides that there is credible evidence of danger. pain is a warning system but sometimes the brain is wrong.

Watch this video.

(in reply to heidiPT)
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RE: Severe pain with sitting after 8 weeks TKA postop - February 25, 2018 10:29:12 PM   


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treat her low back Heidi, mobilisation works best. Find and eliminate spinal protective behaviour and what is likely to be severe referred pain to the limb will be undone. Common, treatable, fairly straight forward provided your hands are good and your method is optimal.


Geoff Fisher

(in reply to Tom Reeves DPT ATC)
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RE: Severe pain with sitting after 8 weeks TKA postop - April 9, 2018 12:12:06 AM   
CardioFlex Therapy


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Yes I've seen some TKR surgeries that did not go well. The main problems are the prosthesis not fitting properly and rapid scar tissue development. I would say that this case is either one of these two scenarios or both. Most likely it's scar tissue development that's pressing on a nerve. I would try to figure out exactly where it's hurting and use some deep modalities in that area to try to break up the scar tissue. Cold Laser, Deep Trigger Point Massage, and deep point electrical stimulation may help to ease the pain. Also try icing the painful area while in sitting to get additional relief. Eventually, the pain should resolve itself.


Terry Abrams, MPT
Director of Physical Therapy
CardioFlex Therapy

(in reply to heidiPT)
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