Q&A Time! Total Knee, Pain Free? | Modern Manual Therapy Blog

Q&A Time! Total Knee, Pain Free?

Two readers recently asked about Total Knee Arthroplasty/Replacements and how you would go about treating them without causing pain.

Let's review a great blog post by my colleague Dr. Joe Brence, regarding the best predictor of success in a long term follow up for TKA. In case you did not click the link, it's fear avoidance, not strength, ROM, prior function, etc.

An example I use in many of my courses is the one that most of us have gone through on Acute Care internships. My first affiliation was in an Acute Care setting and one of my first patients was a sweet little old lady who just had a TKA. I was lightly stretching her and she told me how much it hurt. My CI simply stated, "Sorry Mrs. X, we have to get you to 90!" She then pulled me aside and told me how hard Mrs. X's recovery and quality of life would be if we did not get her to 90 pain or no, WHATEVER THE COST!" Ok, well she didn't really say that last part, but I think early on in our pre-careers we learn that it's ok and even necessary to cause pain as a means to an end.

One on of my last internships, I had the opportunity to watch 2 TKAs, I remember the surgeon, upon finding out I was a PT student ask me, "Look, after I'm done, they have full ROM." Then he ranged the knee easily and fully into extension and flexion. He then asked, "How come after I send them to you guys, they have such limited range?"

I really wanted to say, "How would you feel if someone just sawed off the ends of your femur and tibia, then used a big mallet to pound in the new prostheses, then sewed you back up?" Seriously, it was quite obvious to me back then. However, the take home for us all is that when unconscious, there is FULL ROM. It is only upon waking when both the chemical inflammatory mediators combined with the threat perception from the CNS take over.

This is why CPM does not work, it probably hurts like heck and does nothing to alleviate anxiety. Knowing that a majority of your patients actually have the requisite ROM needed for function, there is really no point on cranking on them "to prevent scar tissue" or "break up scar tissue." This is what I do for these cases, that normally results in most of their range, strength, and function restored (even on B TKAs) in around 12 visits on average.
  • very light IASTM to the anterior thigh, posterior thigh, anterior and posterior lower legs, but staying clear of the incision
  • light EDGE Mobility Band wrapping to help decrease threat during movement
  • very light passive ranging and encouraging active assistance
  • HEP is mini lunges, mini squats, step ups and downs and frequent movement in the pain free range
  • that pain free range is very important, you want to reduce threat, not increase with painful passive stretching
  • encourange them tell the patient their brain is doing a good job protecting the new joint, and pain/discomfort is normal
  • the range and function will come with some frequent movement, and gradual exposure to WB
  • regression to NWB exercises only if the patient is in so much pain they cannot perform WB (unlikely unless they come directly to your clinic and skip sub-acute)
It really sounds like I reiterate the same point every week, but it cannot be overstated. You do not have to cause pain (or increase existing pain) on ANY patient to get results. Of course a TKA procedure is going to cause pain. That is a given. There are of course hardy patients who can take a beating, but you cannot "force" increased range until the nervous system is ready for it.

Keeping it Eclectic..


  1. After reading the article that you posted on my comment the other day I noticed a few things. I love the painfree tx up there and over the course of reading your blog my painfree practices have dramatically increased. One critque I have of this study though is that they measured functional measures with a subjective outcome scale (womac) and it does not look like they utilized any validated functional objective measures such as a 6MWT, TUG, 30sec STS, or measured strength objectively either on a kincom/biodex. While I do see from this study and from experience that psychological factors play a huge role in sucess I'm not sure if the conclusion can be drawn from this study specifically that fear avoidance is more or a better predictor than other measurements.
    I'm also curious how you feel about surgeons going back and performing manipulations under anesthesia for someone who's knee is locked up, and if you have seen sucess or if they may be useless. Thanks!

  2. I have only seen maybe 10 MUA, and I once researched which conditions benefited from this. One of them I believe was TKA. In my experience, it never dramatically changes ROM, it more changed end feel and gave maybe 5 more degrees. Perhaps it's because you cannot break up scar tissue or easily and permanently deform soft tissues.

  3. Excellent article, Erson! I've felt he same way for years but always fell back upon the old "physical terrorist" aggressive mobilization. The past couple of years, I've begun incorporating IASTM and mobility band work and backed way off on the cranking with way faster, better results...and my patients like me!

  4. I think the liking part has a lot to do with faster outcomes! Oh yeah, and a lot less or no soreness post treatment!

  5. Donald Blake BerryApril 15, 2015 at 10:28 AM

    It floors me, that a surgeon would have such a lock of understanding of how the body actually works when not sedated! But it seems universal, sad

  6. I thought it was pretty obvious and he was pretty arrogant. Too bad I was only a student back then.

  7. Going with your theme of treatments should be pain free, what is your opinion on dry needling? Can IASTM be just as effective? I have found dry needling beneficial, but I do not enjoy inflicting pain my patient's.

  8. I have to agree with Matt. The article did not include any performance-based measures of function. Our lab and other have shown that self-reported measures (such as the WOMAC) and performance-based measures tell a very different story about post-operative recovery. Self-report is highly influenced by pain, whereas performance-based measures are influenced by strength and range of motion (Some articles on the topic: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008304/ and http://www.ncbi.nlm.nih.gov/pubmed/21665167). Given this relationship, it is no surprise that psychological measures were predictive of self-reported outcome.

    Now, saying that, there is a huge psychological and behavioral component to rehab after joint replacement. In fact, patients after total hip replacement most commonly cite fear of reinjury as the factor that prevented them from returning to sports and activities after surgery. In patients after knee replacement, we see that there is minimal change in physical activity and patients continue to be largely sedentary. I think there will be a lot of upcoming research interest in behavioral and physical interventions that change these aspects of recovery.

    Based on the article you mention though, I think that it is premature to suggest that we should avoid rehabilitation interventions that may be uncomfortable or painful after knee replacement. Range of motion, progressive and aggressive strengthening, and electrical stimulation to improve muscle function may be considered painful or irritating by patients. These interventions may improve performance-based measures, but have only minimal effect on self-reported outcomes. We, as rehabilitation researchers and clinicians, need to identify which interventions affect all domains of recovery, including measures of participation, physical activity, and measure of disability or overall quality of life.

  9. I use IASTM way more (in NY more than TX), so naturally I have better outcomes with it. I have a hard time integrating TDN into my practice because it's so uncomfortable. It is definitely effective, but I tend to use it as a tertiary treatment.

  10. I understand basing it off of that one article, but I am basing it off of the entirety of pain science and modern manual therapy. We should not cause pain on any technique, if we cannot deform fascia, joint capsule or lengthen tissues in the short term, why should we "crank" on patients? It makes no sense, especially if the patient's nervous system is already vigilant and they have high fear avoidance.

  11. Nice article, I loved it! It is the responsibility of a doctor to provide his patient a comfortable and pain free treatment. A surgeon should consider both the mental and physical strength of the patient. I was an athlete who mainly participated in marathon events until 2 years ago. I got an injury and that temporarily stopped my career. I had to take surgery from a nearby ACL injury clinic ( http://aesm.ca/physiotherapy-toronto/ ) and I was so anxious about the surgery and its pain. My doctor gave me some physiological tips to get rid of my anxiety which really worked. Even though the surgery was painful, I got a confidence to face it and it took almost 6 months to completely recover. Your theme of pain free practices is beneficial, It will help to forget the fear of pain.