Managing pain after knee surgery

Physiotherapist Jason Lee answers Val’s question on whether she should manage pain after a knee replacement with more rehabilitation or better medication.

Q. Val

I have read several articles on this matter and wonder you it could help me. I have very weak bones that break easily. I have a Prolia injection every six months to help strengthen the bones.

About six years ago I fell into a wine cellar and had four bad breaks just below the knee. After six weeks in hospital I left in a brace of plaster below and above the knee, with a hinge in the middle so I could move it at whatever angle the surgeon wanted at that time. This was changed at several intervals over the next few years.

Whilst in hospital they decided to operate on the knee. After prep time they asked my husband to look at the extras and told him what they intended to do. It was a matter of cutting the knee front and back with a 90 per cent chance of cutting the nerves and losing my leg.

We decided on the subtle approach and let the leg heal itself.

After five-and-a-half years of pure hell they decided to do a knee replacement, but they stuffed up the rehab and I was no better off. That was in May last year. In August they decided the knee was still not right and did a manipulation, but the aftercare was still non-existent. In December they decide a full new knee replacement was necessary with a longer shaft.

I did get good rehab after that but the operation was twice as long and twice as difficult. I have been to a great physio and am now doing hydrotherapy.

I went back to see the surgeon last week and was informed that, due to the length of the injury and the operations, I could be in considerable pain for up to two years. I am taking synthetic morphine for the pain, as well as Panadol Osteo.

Do you think that Glucosamine would help, or could you suggest any other medications or supplements? My husband takes curcumin and finds that it helps his arthritis. 

The doctor wants to reduce my heavy painkillers and although I have reduced them quite a lot I am still in quite a lot of pain. Do you have any other suggestions?

A.  Provided by Jason Lee

Rehabilitation following knee replacement surgery varies significantly from person to person. Unfortunately, whilst there are ideal time frames on recovery and many surgical procedures may appear similar, rehabilitation varies depending on many factors. These factors include the nature of the surgery, current medical history, previous joint mobility, previous strength, pain tolerance and overall fitness. 

Following knee surgery, the early aims of rehabilitation are to manage pain levels, manage swelling around the joint and get sufficient movement of the knee to allow functional movements such as getting in and out of bed or on and off a chair. Physiotherapy will aim to get you weight bearing with the assistance of gait aids such as crutches, walking frames or walkers within the first day (if not that afternoon). Patients will generally be discharged from an acute hospital setting within five to seven days following surgery. Following discharge from hospital, patients may be transferred to a rehabilitation setting or continue rehabilitation from home. This can continue for several months up or up to a year depending on previous history.  

However, these time frames can vary significantly depending on how well the knee was moving prior to surgery. The longer surrounding muscles haven’t worked efficiently or have weakened over time, the longer it takes to restore strength following surgery. Likewise, the amount of movement prior to surgery is an indicator of how quickly (if at all) that movement will return. Surrounding soft tissue such as the joint capsule and ligaments stiffen up and lose elastic properties if not used regularly. Hence, if the knee has not been fully straightened or fully bent prior to surgery, it takes considerably longer to regain that range despite having a new knee.  

Pain management during rehabilitation is vital. As the wound, surrounding soft tissue and muscles are being woken up, physiotherapy treatment in the early stages can be uncomfortable. Your doctor or specialist is well placed to advise on pain management. Natural remedies such as glucosamine and fish oils may be used in some circumstances. Whilst there is currently not strong evidence for these supplements, it is important to discuss the use of these with your doctor as there may be interactions with other medication. Bed-based exercises or hydrotherapy by be included as part of early rehabilitation to restore movement and strength without exacerbating pain. 

Val, from your description of events prior to surgery, it sounds like you’re doing incredibly well. It is important to remember that whilst many knee replacements are performed each year, it’s a very significant surgical procedure with numerous muscles, ligaments and soft tissue stretched, cut, or manipulated throughout the surgery. My advice would be to be patient and listen to the advice of your medical and rehabilitation team. From the sounds of things you’re doing all the right things by commencing hydrotherapy and I’m sure your physiotherapist will progress you to land-based exercises as you improve.

Jason Lee APAM
B. Physiotherapy
Malvern East Physiotherapy  

Jason is happy to answer any questions you may have, simply send an email to [email protected].

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