The most read post on this blog deals with “Swelling, Effusion, Edema and Bruising – What’s the difference?”. I will take the concept one step further and discuss how knee swelling or joint effusions impact your ability to control your knee extension when you walk.
So, you injure your knee and develop swelling inside the joint. You may notice your knee giving way. That means when you transfer weight onto your injured leg the knee buckles. This is due to the quadriceps (front of your thigh) not contracting efficiently and hence not controlling the knee in extension. Knee extension is vital in walking because it stabilizes the leg to accept the transferred weight from the opposite leg when you are in stance phase of gait. If the knee is unable to go fully straight while stepping onto it you have difficulty swinging the other leg through to take another step.
This happens because of the swelling (and possibly pain too) within the joint. A neural reflex is set up by distension of the joint structures. It passes through the spinal cord and back to inhibit the quadriceps. It is then difficult to contract them at the right time and with sufficient speed during the gait cycle. Hence, unsafe walking and difficulty going up and down stairs, for example. You may notice immediate deterioration of your ability to contract the quadriceps following injury with a joint effusion.
To regain quadriceps function and hence to restore normal and safe walking you must control the swelling (see earlier post on this topic), avoid increasing it by careful activity modification and do specific exercises to regain normal quadriceps function. Physical therapists will instruct you in specific neuromuscular reeducation exercises to restore the quadriceps recruitment pattern. Such exercises may include seated quad sets, straight leg raises or short arc quad recruitment. These may be done with neuromuscular electrical stimulation (not TENS – that’s for pain and totally different type of current form) to facilitate recruitment of the muscle. In addition, you will be given terminal knee extension exercises in standing such as straightening the knee against a wall with a towel roll behind your knee against the wall or fully extending your knee against tension created by an elastic sports cord.
So, controlling swelling in a joint is necessary to regain function of the muscles moving that joint. This process is used in all knee injuries that result in joint effusions as well as in all postoperative rehabilitation, for example, following ACL reconstruction, meniscus repairs and debridement as well as total knee replacements.
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To my fellow Boomers out there ….. How are your knees doing? We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof. Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.
WHY KNEE OSTEOARTHRITIS?
Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older. It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking. Ouch! The prevalence of osteoarthritis is rapidly increasing due to two main factors. Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years. Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration. One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it. Wow! Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.
WHAT IS IT?
Osteoarthritis is the joints response to structural damage caused by mechanical problems. It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint. If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.
MECHANICAL STRESS YOU SAY?
Pathological mechanical stress of the knee joint may be due to:
Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis. Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively. Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well. Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.
HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?
Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees. Walking results in a force through the knee equal to 3 – 4 times your body weight each step. If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take! Talk about happier knees! An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.
For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.
In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors. Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few. Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition. As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed. A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life. Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function. Who would not like that!?
All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis. The therapists work as part of a team comprised of you the patient, your physician and the physical therapist. Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.
YOUR CALL TO ACTION!
You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain. You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.
I really enjoyed Laura’s blogging of her total knee replacement. I think this is a great idea and one which can help other people who are potential knee replacement candidates get a sense of what the process looks like from a patient’s perspective.
Great job, Laura. We all hope you are doing well.
Total joint replacements surgeries tend to increase towards the end of the year because insurance deductibles have been met and out-of-pocket expenses tend to be less. An additional cost to the patient is the rehabilitation after the surgery, which also tends to impact insurance deductibles.
The most frequent type of joint replacement that needs the most rehabilitation is the total knee replacement, also known as total knee arthroplasty (TKA). So what does the rehabilitation process involve?
The first thing to understand is that 50% of a successful outcome is the caliber of the surgery. If you have done your due diligence by being an educated healthcare consumer (see my very first post on this blog) and asked the best surgeon to do your total knee arthroplasty, you should be pretty confident that the actual prosthesis is the right size and was put in correctly. That is the easy part of the process; after all you slept through it!
Then you wake up and realize your knee hurts. It is swollen, stiff, and the muscles in your thigh (both quadriceps in the front and hamstrings in the back) do not contract well despite you attempting to make them to work. You have difficulty transferring from supine (lying on your back) to sitting and then to standing. Now you have to walk with a walker, another foreign experience. After 3-5 days, the doctor may send you home from the hospital. Now you need to get into the car to be driven home. This requires you to bend your new knee, another daunting thought. Once home you need to do the right thing to keep your progress going and prevent complications such as deep vein thrombosis (DVT: a blood clot) in either one of your legs, arthrofibrosis (excessive scarring from the surgery) and infection.
Physical therapists now become your best friends and should be for a number of weeks to months following the surgery. You will be guided through a steady progression to return you to full function.
FIRST INPATIENT PHYSICAL THERAPY:
You will have inpatient physical therapy to get you ready for returning home i.e. avoid DVTs, know how to take care of your surgical wound and, you need to learn how to walk safely with a walker. You will also need to ascend and descend stairs, You should return home with enough active range of motion (AROM) to get into and out of the car and be instructed in transfers from supine to sitting to standing as well as how to get in and out of a chair. Detailed instruction should be given regarding how to control the postoperative swelling.
Avoiding DVTs: perform the embolic isometric contraction sequence of the calf, quadriceps and gluteus musculature (in that order). Also, do ankle pumps.
Surgical wound care: keep it dry, no showering – I have had one patient, 13 years ago, who decided to shower before the surgical wound was healed sufficiently. The knee became infected and was never the same again. Luckily it was not a TKA and the infection, therefore, did not enter the bone. It is worthwhile doing it right and accepting you will be a little dirtier than usual!
Walking: The majority of TKA patients start walking with a front wheel walker, day one or two after surgery. The large base of support gives the individual more stability. You must use an assistive device as your quadriceps (muscles comprising the front of the thigh) are not contracting efficiently. This is because of the incision and the pain impacting the function of the extensor mechanism (quadriceps + patella + patella tendon). As a result, you have difficulty straightening your knee and controlling it in full extension. When you transfer weight to the leg, the knee will have a tendency to give way (knee buckles under the weight) and you may fall.
Negotiating stairs with your walker: The inpatient physical therapist will teach you the correct technique for going up and down stairs with and without the walker. All homes have at least one to three steps to ascend from the garage to the house or at the front door. Just remember: the nonsurgical leg does all the work so you lead with it up stairs and lower your surgical side down with it when going down stairs.
AROM: Immediately you need to start working on getting your new knee straight (OUCH!) and getting it bending (OUCH!). The inpatient physical therapist should show you simple but effective exercises such as passive knee extension, hamstring and calf stretching to get it straight. They will also instruct you in heel slides to regain knee flexion. If you leave the hospital with full knee extension (straight knee) and 90° of flexion, you will be ahead of the game. With 90° of flexion you can get into and out of as well as sit in the car that will take you home.
Transfers: Inpatient physical therapists are the gurus at instructing in transfers under a variety of circumstances, all in an effort to get you more functional and independent. You should leave the hospital knowing exactly how to do a variety of transfers e.g. change positions in bed, sit to stand, in and out of a car, the commode, avoiding low chairs like a couch. You walker is your friend here to and you must focus on safety in all your mobility.
Control the swelling: This is a vital component of regaining full range and quadriceps function and should be a major focus immediately following surgery. (read the second post on this blog which discussed this topic in detail). Make sure you get iced in the hospital for 45 minutes at a time, all around your knee at least 4-6 times a day. You, the patient, must be vocal about this to get it done. You will be glad you followed this procedure. Recognize you will have bandages around your knee so it will take a while for the cold to penetrate them. Do not get the bandages wet (see paragraph above on infection!). Once the bandages are removed (7 to 10 days after surgery) you will ice for 30 minutes.
Now you are home. Feel better already, albeit a little beaten up I am sure. Out patient physical therapy now takes over. (if you are frail, you may get home health physical therapy but make sure they follow the following guidelines).
OUT PATIENT PHYSICAL THERAPY:
The other 50% of a good outcome is dependent on a good relationship between you and your physical therapists. Here is where the hard work really starts and you must be dedicated. Focus on the right things and you will get a great result.
Note: There is no need for the physical therapist to aggressively bend or straighten your knee. This may inflame the joint and increase the likelihood of arthrofibrosis. I typically set my patients specific goals to attain each week and it is their responsibility to achieve the range required. I measure at the beginning of each physical therapy session to track progress. If they struggle to improve at the agreed upon rate (typically 10° to 15° of active flexion per week), then I will step in and stretch their knee gently.
Rehabilitation is typically broken down into phases. Transition from one phase to the next is dependent on specific criteria such as degree of pain and swelling. Progression is not based purely on a timeline.
Phase 1: Post op days 1-10
Phase 2: Weeks 2 – 12 post-op
So, there is a lot of work to do in recovering from a total knee replacement. It is not rocket science but it does require focused dedication. Focus on the right things based on your discussion with the physical therapist and be dedicated with your home exercises as well as those in the physical therapy clinic.
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Thanks for reading this.
If you sprain your ankle severely you may hear your doctor and physical therapist mention the words swelling, edema, effusion or bruising. If you have surgery on your knee for a meniscus tear or a ligament reconstruction you will hear similar terms (and see them too!). What is that bruising and swollen area in the muscles in front of your shin (tibia) when you ding your lower leg on the corner of a coffee table?
The Definitions (Dorland’s Medical Dictionary):
Swelling is defined as “a transient abnormal enlargement or increase in volume of a body part or area not caused by proliferation of cells.” The good thing is that it is transient so, as we have all experienced, swelling subsides over time (see below for hints on treatment). It is due to some form of trauma to the body such as an ankle sprain (the ankle looks bigger) or a muscle tear (larger girth of your thigh with a hamstring tear) or a surgery (which is really a trauma to the tissue). Fluid accumulates – the enlargement is not a consequence of cell division (proliferation) such as may occur with an enlargement due to cancer in a tissue or the enlargement seen in a bone from a healed fracture.
Edema is “the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body.” Here fluid accumulates between the cells (intercellular). This may be a consequence of tissue trauma, poor circulation resulting in lower leg edema, heart failure, blood clots, lymph node resection as happens with breast cancer, renal failure, pregnancy and cirrhosis to mention a few causes. In outpatient musculoskeletal physical therapy we mostly see patients who have edema due to surgeries (e.g. knee replacements) or an injury causing tissue trauma. We may treat someone who has a comorbidity (co-existing condition) which has resulted in edema but if caused by a particular medical condition your doctor will be treating it, not us.
An effusion is “the escape of fluid into a part or tissue, as an exudation or a transudation.” An exudation is “the escape of fluid, cells, or cellular debris, from the blood vessels and their deposition in or on the tissues, usually due to inflammation.” Inflammation may occur due to trauma or surgery. Blood vessel walls become more permeable or may be compromised. Fluid and cells can thus escape from the artery or vein into the surrounding area. Transudation refers to the passage of fluid across a membrane or tissue surface (e.g. the synovial lining of the knee joint), which may or may not be due to inflammation. In physical therapy, we commonly see a joint effusion where fluid has accumulated in the joint. This may follow a knee or shoulder surgery or an ankle sprain, for example.
Ecchymosis refers to “a small hemorrhagic spot in skin or mucous membrane, forming a nonelevated, rounded or irregular, blue or purplish patch.” This is a medical term for bruising which is defined as “a superficial injury produced by impact without laceration.” Both describe blood leaking into the surrounding tissue. You know this one! Remember biting your cheek when you were chewing gum? Your mucous membrane inside your mouth went blue. Next time you do it tell who you are with that you have just created some ecchymosis in the mucous membrane of your cheek!
In summary, based on the above definitions, you can safely say that swelling refers to the enlargement of the body part involved and the swelling is due to fluid accumulation (edema, effusion) or blood accumulation (ecchymosis, bruising).
How do we treat swelling, edema, effusion, ecchymosis and/or bruising?
In summary, swelling may encompass the terms of edema, effusion, ecchymosis and bruising as long as there is an increase in volume (size) of a body part or tissue due to fluid accumulation. RICE is the treatment of choice immediately after an injury/surgery but heat and controlled movement should not be avoided. If you have lymphedema you should consult with a physical therapist with specialty training in lymphedema management.
YOU CALL TO ACTION!
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Northwest location: 775-746-9222