Little progress in knee amplitude after 9 months of massage and physio treatments

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Hello I am a massage therapist with 22 years experience from Canada but now living in Roatan, Honduras, an island in the Caribbean.  I have a client who had a full knee replacement (Titanium) of his right knee at a reputable clinic in the Cayman Islands.  The orthopedic surgeon said after the surgery that after over 600 knee replacement surgeries, his was the second worst he had seen up to that time.  Its important to note that he played football and had had a somewhat botched surgery on his knee over 40 years prior.  The surgeon noted small amounts of calcium build up in and around the knee joint and did his best to scrape most of it out.  Since the operation this client has been getting three sessions a week of massage with me and 3 sessions a week of physio therapy treatments with a certified physiotherapist from Austria that now lives on the island.  After initially finding that there was progressive improvement he seems to have hit a plateau and on some days it seems like he is loosing those gains.  He still can't bend his knee to 90 degrees and has a lot of nerve type pain.  The Surgeon is coming to the island next week to review the case however I and the physio will most likely not be able to meet with the surgeon.  He is bringing some medicine that can't be found on the island to deal with the nerve pain that he is experiencing on the inside of his right knee.  To add a little more detail this client is clinically obese and efforts to get him to lose weight have not been successful.  All that being said he is much more mobile in comparison to before the surgery however his good knee has been taxed and is also hurting him.  I dedicate some time to his "good" knee to balance things out.  I've also continued using ice up to this point.  I'm looking for suggestions, insights, links for sites with information, videos, anything that can help me get my client to progress past this plateau.  Thank you all in advance.  

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  • Posted

    Sorry I have no answers or solutions. If your patient won't help themselves by losing significant weight and making huge exercise efforts then his current result may be all he can expect.

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  • Posted

    Not a doc...but...  After being on the Forum for two years for my own TKR and reading/responding to over 3,000 posts, I have a few thoughts...

    - Patients who cannot get past 90-degrees after tons of PT work typically undergo Manipulation Under Anesthesia (MUA)...very successfully.  That may be what the ortho will decide on doing.  The scar tissue has to be broken down to achieve the desired ROM and some people's DNA generates more of it than others.  The rate of people needing MUAs is small but not uncommon.

    - Here are some ROM exercises your client can try that, with PT @ 2X/week, got me from -14 / +84 to -1 / +123 in 10 weeks...focus on the heel slides to get past 90-degrees...

    https://patient.info/forums/discuss/tkr-rom-work-at-home-620053

    - Nerve pain along with a TKR is pretty typical but should be lessening by this point.  Voltaren Gel (RX in the US) is a GREAT topical anti-inflammatory and OTC Aspercream with 4% Lidocaine plus Lidocaine patches help with nerve pain.  I absolutely HATE the nerve meds like Gabapentin (Neurontin) and Lyrica.  Lots of people report huge weight gains on the Gabapentin plus there are a lot of side effects and negative interactions with other drugs.  I'd stay away but be very careful.

    - Long term nerve "discomfort" when trying to kneel on the new knee is caused by the unavoidable nerve damage, not the new knee.  Have the patient always use a 3-4" foam pad indoors and padded tactical (SWAT) kneepads outside for kneeling.  This nerve "tingling" on kneeling will lessen in time but will probably never go away completely.  A full recovery with all the ROM and strength work takes 12-18 months.

    -The obesity definitely doesn't help.  After the ROM work, everyone has to hit the gym to rebuild their atrophied quads, glutes and core.  Without that strength, stairs will be a problem forever.  Maybe that will be an incentive.  My daughter started me on a  P l e x u s  regimen where I lost 57 pounds in 11 months.  Gotta do something for the weight.  It only puts more stress on the knee and without the strength rebuild for the supporting musculature, the knee takes all the pressure.  Not good.

    Hope some of this helps... 

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  • Posted

    Its is hard but losing weight is important. No way round that one. Sorry cannot suggest anything else. Responses from Chico all excellent. I have heard results are limited by condition pre operatively. Sounds like It was dire. Maybe best possible is 90 degrees. Seems odd they have lost some of their range of motion.
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  • Posted

    Hi

    Besides what has already written , maybe too much physio and not enough time for healing.

    As nerve pain normally should decline, but there are no real rules , as we are all different.

    Good healing

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