A Knee Recovery Nightmare! Right Total Knee Replacement My Physical and Emotional Fight Against Pain Hypersensitivity and Protective Muscle Guarding – written by Cathy Banovac – interview by Lisa Pelley and Mary Elliott – Cathy was coached by Erin Rempher, PTA My name is Cathy and I reside in Arizona. I am 57 years old, a homemaker, and have had a genetic history of chronic osteoarthritis. From a very young age, I have always had a very low pain threshold. Prior to the commencement of pain in my knee, I considered myself a fairly fit and active person…loved gardening, entertaining family and friends, cooking, crafting, playing golf, traveling with my husband, walking our dogs, and playing with our grandchildren. Life was good! Early Summer In addition to the normal aches and pains that come with aging, I began to experience more than usual pain in my right knee. I was experiencing daily occurrences of popping/clicking, giving out when walking at times, difficulty negotiating steps or stairs, and nightly interrupted sleep due to pain. Over the counter medications, icing, heat, etc. was no longer managing my symptoms. Upon visiting an orthopedic surgeon for examination and subsequent imaging, I learned I was over 70% bone on bone in my right knee joint. I was told I was looking at a total knee replacement. I was preparing to head to Michigan for a family vacation on the lake with my kiddos in August, so was not happy to hear this news. I convinced my doctor to give me a steroid injection just to buy me the time I needed to take my vacation. He was reluctant and told me that he predicted it would do nothing to help my condition at the very least or, at the very most, last for a brief time. I made it through the trip, yet 3 weeks post-injection the symptoms had returned. No More Injections My surgeon declined my request for another injection, instead reiterating my need for the TKR. Over previous years, I had witnessed my mother, father, husband and a few friends have knee replacement surgeries. All came through their surgeries with what appeared to me to be a fairly pain controlled, timely recovery and successful return to their regular daily activities. I was told I was on the younger side for this type of procedure, nevertheless, would greatly benefit from extended quality of life and return to desired activity, given my current quality of life and daily activity was becoming more diminished by the day. My Knee Replacement I underwent RTKR on September 25. All went well and as expected with the surgery. I was up and walking, began some light physical therapy exercises, and maintained post-op range and motion through use of a CPM while in hospital. I was discharged to home on the third day post-op, with a couple of narcotic pain medications (initially Percocet/Oxycodone and Morphine) and directions to commence in-home physical therapy the following day. My follow-up visit with the surgeon was scheduled for 6 weeks post-op. Day one at home began my challenging journey of recovery, both physically and emotionally. I experienced difficulty managing my pain even with narcotics and over the counter medications. My swelling was as expected and able to be kept in check with anti-inflammatory meds and icing. I experienced annoying side effects from the narcotics, i.e., headaches, nausea, constipation, and thus was bounced from one medication and dosage to another, none of which seemed to be the right combination or solution to my pain. Out of complete desperation and in uncontrollable pain, I went to the emergency room after being home for four days post-op, hoping to get some relief. A Problem with the Surgery? I thought surely there must be something wrong. A few hours later, together with a lecture from the hospital PT and some morphine, I was discharged back to home. Back on more medication, I failed to again find relief from pain. I was averaging about 2-3 hours of sleep per night and little sleep during the day. My home physical therapist had her work cut out for her. Over the next 4 weeks (twelve 45 min. sessions of in-home PT), I had yet to reach better than 85 degrees flexion and 10 degrees extension. My in-home therapist said she spent most of those 4 weeks strengthening my calves, hamstrings, and quad muscles, all which were extremely weak. Therefore, already I was approximately 4 weeks behind in range and motion advancement. My pain was still very much out of control, all while I feared becoming more and more dependent on the narcotics prescribed. At the first follow-up appointment (six weeks post-op), my flexion was below 90 degrees and extension still not at the zero degree mark. I was informed by my surgeon that I needed a Manipulation Under Anesthesia (MUA). My knee felt very stiff, pain was still unmanageable, and I was stuck without advancement in physical therapy. Manipulation Under Anesthesia He took x-rays and made sure the appliance was not loose or slipping out of placement. All was found to be in proper order and an examination found no infection that could be causing pain or other symptoms. My surgeon had done his job. I was told however, that he believed I was stuck due to scar tissue build-up and thus was in need of the MUA to break up the scar tissue. This would also permit the ability to continue physical therapy, working towards achievement of the desirable degree of range and motion outcomes. I underwent the MUA six weeks and one day post-op and immediately resumed PT the following day. I was told not to worry about a reduction in my flexion and extension after having the MUA. An MUA tends to put patients back about 3-4 weeks, so it is almost like starting all over again. However, the idea is that advancement in range and motion should become easier now that the scar tissue has been broken up by the procedure. I went to PT for 5 days in a row the first week following the MUA, did my home exercises faithfully on my own twice a day, then returned to PT three times a week for the next several weeks. After the MUA At the two week follow-up appointment post the MUA, I was still in unmanageable pain, still getting only 2-3 hours of uninterrupted sleep per night, and running every gamut of emotion and temperament. My poor husband was beside himself and wondering whatever became of the woman he married 27 years ago. My flexion was still only reaching in the low 90’s and my extension was no better either. I was still experiencing great sensitivity to the touch anywhere on or around my surgical knee. I couldn’t stand wearing pants or having any sheet or blanket covering my knee. My pain was the worst at night, just when I was settling in for some restful moments on the couch watching TV with my husband. I would suddenly be lifted off my seat with either pain that mimicked touching a lit match to my knee, or the stabbing of a knife, or the shock of a taser. Dealing with the Pain This pain varied and sometimes was relentless for several minutes. I was in tears most evenings and headed to bed to ice or apply heat, which calmed the nerve pain somewhat. I would take meds (Hydrocodone/Norco, Extra-Strength Tylenol, Ibuprofen, Zofran (for nausea) Vitamins, a stool softener (due to Hydrocodone) and Gabapentin aka Neurontin. I was soooo sick of taking medications. I think my surgeon was beside himself as to how to control my pain and sensitivity, therefore, he recommended I seek help at a Pain Management Clinic for possible sympathetic blocks, as well as my medicinal pain management. Both he and my physical therapist told me I was forecasting pain neurologically before any exerted physical effort on their part was made to cause any pain. My intolerance for any amount of pain was prohibiting any measurable progress in my range and motion, thus scar tissue was building at a rapid pace. Physical therapy continued to be a challenge as I protective muscle guarded any force applied by my therapist to get better R&M. I cried through most of my sessions. Pain Management At my first appointment with the Pain Management Clinic, I met with the doctor. Most people have sympathetic blocks in their back to relieve nerve pain, but the doctor I was referred to chose to recommend a Genicular Neurotomy, accomplished through a procedure called Coolief Cooled Radiofrequency Ablation. I first underwent a test which involved Lidocaine injections in four areas surrounding my new knee. The patient then logs their pain and activities over the following 72 hours. A follow-up appointment with a Nurse Practitioner then reviews the log and determines eligibility for the ablation procedure. At this appointment she chose to cut my medication cold-turkey for a couple of days as she deemed I was dependent on them, even though I was getting little pain control. I experienced severe withdrawal symptoms for two days. A Change in Medication I thought I was going to go out of my mind. A change in my medication increased the Gabapentin I was taking, and I was found to be eligible for the ablation. I underwent that procedure approximately 6 weeks post my first MUA, just before the Thanksgiving holiday. I was told that I would still be experiencing pain for approximately 4-6 weeks, due to the fact that the ablation was going to make my nerves “angry” as they fought their temporary death. I was also informed that this procedure is temporary as nerve endings most often regenerate themselves over a 6 month to 2 year period. Some patients must undergo two or three of these procedures to get lasting relief. Unhappy News This was not happy news to my ear
