After your knee replacement surgery, stiffness of the knee joint is a feared complication.
It’s sometimes unsettling, and patients who have undergone total knee replacement have identified improved range of motion.
The duration of post-surgery stiffness will vary from person to person. However, a good range of movement without any stiffness is not guaranteed after a total knee replacement.
I write this article to reassure you about it, I rely on medical scientific studies and my own experience as a diagnostic radiographer.
Happy reading!😀
Any questions? remarks? Let’s meet in the comments section at the end of this article.🙏
Last updated: August 2024. Written by Juliet Semakula, a diagnostic radiographer.
Disclaimer: no affiliate links.
Summary: After surgery you will experience Knee stiffness for several weeks to a few months. For some people it could take 2 and half years. But with simple exercises and sometimes medical interventional you can have a full range of movement.
Knee stiffness after total knee replacement.
Most patients say the range of motion of the knee continues to rapidly improve in the first 4 weeks of the surgery.
The range of motion further improves in the first 3 months and continues till the first 6 months.
Rarely some patients may show improvement in range of motion even after 6 months to 2 years.
▶️What are the causes of this stiffness and limited range of movement after knee surgery?
In the ideal world, after a knee replacement, you are expected to achieve full extension and full flexion.
However, I have seen many patients who have achieved less than a full range of motion in the knee when trying to bend the affected knee.
The main causes of pain and discomfort due to stiffness are said to be surgery-related issues or the prosthesis itself.
Lack of normal motion after knee replacement can be due to one of several causes:
🟠 Insufficient pain control and swelling in the knee
After your knee replacement pain control is usually a manageable problem in some people but to others it can be very difficult.
There may be excess fluid or swelling and increased pressure in the knee region causing pain and stiffness causing limited range of movement.
🟠 Poor motion before surgery
If the knee does not fully extend at surgery, it probably will not fully extend after surgery.
Correction for a remaining flexion contracture should therefore be performed during the surgery and may include:
Rebalancing of the soft tissues, resection of additional bone from the distal femur to increase the extension space size, or posterior capsular stripping.
🟠 Knee osteophytes before and after surgery
Tibial / knee bone osteophytes or spurs are smooth, bony growths, usually near joints. They develop over time in patients with arthritis or joint damage.
Image: showing the AP/Lateral views of posterior femoral and tibial osteophytes making it impossible to both flexion and extension the knee.
Usually before surgery larger osteophytes in the knee joint must be removed. If these osteophytes are not removed, the knee joint is blocked from its full flexion, and you may find it difficult to bend your knee.
Such osteophytes can tense the back capsule in extension as well as in flexion and cause a terrible block to full extension.
🟠Excessive scar formation
Some people make more scar tissues than others, a condition known as arthrofibrosis. The new formation of excessive scar tissue can result in limited range of knee movement, your knee will feel stiff when you try to move it.
🟠Improper positioning of the implants
Surgeons try to balance the knee at the time of surgery. This means finding the proper size and alignment of the knee replacement so that the knee joint is not too tight and not too loose.
Errors in the positioning of an implant may not be apparent on the operating table and may only become noticeable when the patient is slow to recover from surgery
Malposition of the tibial component likewise can cause a limitation of flexion after surgery. And you may feel a tight stiff bend.
Image A: An upslope of the tibial resection can lead to a diminished flexion space posteriorly and limitation of flexion after surgery.
Image B&C: The use of a femoral component that is too small in the front view and the inadequate capping of the bone at the back can result in a limitation of flexion.
🟠Physical therapy program issues.
When you use a continuous passive motion (CPM) machine, the knee axis often is not aligned with the flexion axis of the machine.
A continuous passive motion (CPM) machine is a motorised device that passively moves a joint through a pre-set range of motion.
These devices may be used after surgery to reduce joint stiffness and improve range of motion.
If the machine is allowed to cycle throughout the night and day, you often will never come to full extension and may begin to develop a flexion contracture. This is especially true in the patient with a heavy thigh or calf.
To minimise stiffness in the knee, you are advised to do passive flexion exercises on stairs or steps to supplement the benefit achieved from a CPM machine (Laskin,2004)
🟠Obesity is related to poor range of knee movement and stiffness after surgery.
Sometimes if you are over weight you will find it difficult to move or bend your knee.
In summary, limitation of motion after surgery is a combination of factors related to surgical technique, prosthesis design, and inherent patient anatomy, physiology and rehabilitation protocol.
It is up to the surgeon to minimise those factors related to surgical technique to maximise the potential for functional motion postoperatively.
🟠Also, the rehabilitation protocol is one of the most important post-operative risk factors to knee stiffness.
If you have a delayed start of rehabilitation after knee replacement and there is no consistency in frequency, or your compliance, this is more likely to result in scar tissue arthrofibrosis formation.
Also too aggressive of a rehabilitation program can also result in inflammation, leading to excessive scarring, Inadequate pain control and hematoma formation and knee stiffness.
▶️How do you treat postoperative knee stiffness?
The treatment of stiffness of the knee remains difficult and controversial.
Their various approaches to the treatment including both nonoperative and operative treatment modalities.
After knee replacement surgery, it is important to work with a physical therapist to help you restore as much range of motion as possible.
Nonoperative methods.
🟨Moderate stretch intensity and high frequency will be most effective for regaining knee range of motion.
Overly aggressive or painful stretching is not advised.
Mild discomfort or soreness is to be expected, but not with a dramatic increase in pain lasting greater than an hour after exercise.
🟨Early mobilisation and physical therapy.
The first three months after surgery are very beneficial for simple exercises that target different muscles such as quadriceps sets, heel slides, leg raises and various knee straightening exercises.
These exercises should be done patiently and persistently to help with your knee stiffness and movement.
🟨Pain management
You can try to manage any pain and stiffness by using painkillers such as (nonsteroidal anti-inflammatories, opioids) consult your doctor before you take anything
🟨Applying Heat and cold therapy helps to relax muscles and improves lubrication, leading to a reduction in stiffness. Use a hot water bottle or a warm pad.
🟨Massage as you stretch your knee. It can reduce inflammation, swelling, and pain, improve circulation and range of motion, and strengthen the muscles and soft tissues around the knee
🟨An initial non-invasive treatment option is the manipulation of the knee under anaesthesia
After 12 weeks after the operation, you still feel knee stiffness. Usually, an IV injection may be applied to your knee and the surgery forcibly moves the knee to break up the scar tissue.
The primary concern with a manipulation is the risk of bone breakage because most patients who have a manipulation treatment are older and at greater risk of osteoporosis.
Breakage is also more likely if the manipulation is performed more than a year after the replacement.
🟨Revision surgery of a knee replacement
The stiff bend feeling is not a sufficient reason for changing or revising the knee prosthesis
Sometimes you may have an operation again on your knee. The surgeon will reoperate on the knee to make some modifications to the prosthesis to allow better knee motion.
But this is not the most common reason for surgical revision. You are more likely to get a revision if you have:
⚫Infection around the operated knee.
⚫If the knee prosthesis has loosened from its original position
⚫Poor alignment or positioning
⚫Fracture around the prosthesis
⚫Pain and complication of the patella
▶️How to ease the stiff or tight band feeling in the knee?
Here are some suggestions you can try at home. In many cases:
⚫Rest and elevate your foot higher than your heart, using cushion for support.
⚫Apply Ice packs for 15 to 20 minutes at a time, several times a day even at night.
⚫Wear compression stockings which will help relieve and limit swelling.
⚫Over the counter medications can help alleviate knee stiffness and associated symptoms.
⚫Lying on your back, place a folded towel over your operated knee and drop the towel to your foot.
Bend your knee and apply gentle pressure through the towel to increase the bend. Hold for 5 to 10 seconds. Repeat several times until fatigued. This exercise should take 2 minutes.
▶️Should I force my knee to bend after knee replacement?
You may feel a little stiff and uncomfortable immediately after your surgery but do not force the knee to bend.
Working with your physiotherapist will help to regain your mobility and strengthen the affected area.
You should also practise banding and stretching your knee gently between 70-90 degrees until you can do it naturally.
Doing knee stretches can provide relief. These stretches loosen the muscles around your knee, which reduces pressure on the joint
Some rehabilitation exercises for knee stiffness
1. You struggle to bend completely.
2. Your knee may have difficulty fully straightening.
3. Your knee may also be stiff and limited in both flexion and extension.
Precautions to take before exercise?
⚫You have not been advised by your doctor not to flex your knee following a patellar fracture because knee flexion is only limited to a maximum of 90 degrees.
⚫Your pain should be tolerable and not severe, if it does you need to take it slow, reduce movement and speed of motion.
⚫Pain, you feel during these exercises should remain consistent with each repetition.
⚫Each time you return to the starting position during the exercises, the pain should immediately disappear of return to its initial level.
Not all these guidelines above are all applicable if you are taking pain killers. And this is not a diagnosis or treatment plan, always ask your doctor or physiotherapist.
1️⃣Exercise to help you regain knee extension.
⏭️With this exercise you will need two chairs, sit on one chair, place the foot of the stiff leg on the other chair with the knee hanging freely.
⏭️Gently try to straighten your knee by pressing it down. if it’s too painful, bring the chair closer to reduce the other knee hanging
⏭️ You can also press a cushion under your leg to relieve discomfort.
Sitting places your hip in flexion position, increasing tension on the muscles behind the leg. This helps stretch these muscles which may partly be responsible for the lack of flexibility in the knee.
2️⃣Exercises to regain knee flexion to bend your knee completely.
⚫Standing with a chair positioned in front of you, foot of the stiff leg on a chair. The higher the chair the more difficult the exercises and more knee flexion required.
⚫Then shift your body weight forward to bend the knee further.
⚫Choose a lower chair to reduce the amount of knee flexion, aim for 1 to 2 times per day minimum. Hold the position for 30 seconds to start then increase to 1 to 2 minutes.
These standing exercises help put your hip in flexion, which helps in knee flexion by stretching the quadriceps muscle less, which can limit knee flexion.
3️⃣Laying on your stomach, you can lie on a flat surface, you need an elastic band or strap. Lay on your stomach. if you are unable to reach your foot with your hand, use a strap or belt to pull your leg towards you.
Aim for 1 to 2 times per day minimum, hold the position for at least 1 to 2 minutes to start then gradually increase to 10 or 20.
Those exercises can place your hip in extension, when you bend your knee, it stretches your quadriceps muscles. Which is beneficial as it can partly contribute to your knee stiffness.
▶️Can exercises really improve knee stiffness
Most studies look at the effectiveness of knee exercises when you have pain, few studies examine the range of movement due to stiffness.
Results from most studies varied depending on the cause of stiffness such as:
⚫Total knee replacement.
⚫Osteoarthritis.
⚫Patella fracture.
⚫Muscle or ligament pain.
A systematic review of randomised trials of therapeutic exercise in patients with knee problems such as surgery, osteoarthritis, pain and stiffness indicated that exercise can significantly reduce pain, improve physical function and quality of life
Also, exercise is known to be an effective complementary therapy known to improve cardiorespiratory function, increase muscle strength, stabilise posture, and general health.
When you have stiff and painful joints, exercise will help you to reduce joint pain, tissue healing and help fight tiredness.
After you have had any knee operation you are always encouraged to start moving your muscles and joints as soon as possible. You may be slow to start but you need to do something.
The thought of walking around the block or swimming a few laps might seem like too much.
There’s no need to run a marathon or swim for miles. Even moderate exercise can ease pain and stiffness.
⚠️Caution!⚠️ You can stop these exercises if they make your symptoms worse, or if they cause new pain but it is worth trying to see if they work for you.
We have come to the end of this article, wishing you a good recovery!🙋
📚Source:
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Randsborg PH, Tajet J, Negård H, Røtterud JH. Manipulation under Anesthesia for Stiffness of the Knee Joint after Total Knee Replacement. Arthroplast Today. 2020 Jun 28;6(3):470-474. doi: 10.1016/j.artd.2020.05.019. PMID: 32637518; PMCID: PMC7329891.
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