If you spend enough time out of doors observing nature’s ways, you learn to recognize that the occasional movement of a tree branch or bubbles breaking the surface on a body of water means something is moving about (sometimes far) below your site line. Even though I cannot see them initially, I know that squirrels are near our balcony when I see the smaller branches of our tree shaking. Worse, in this teeming urban city of Bangkok, I know that rats are in the garbage area when I see trash moving without apparent assistance. Micro-movements of this particular sort serve to warn us, perhaps even to protect us.
In orthopedic terms, micro-movements operate along the same principal except that the hint of movement below your site line indicates joint instability, or proximal stress shielding**. Its signals are lower leg pain, ankle, shin and calf muscle fatigue and joint buckling (giving out) or all at the same time. Any sign of pain or buckling indicates that the metal joint is moving more than it should at or above or below the knee joint itself: surrounding musculature is over compensating for the instability and contributing to the pain.
The effects of micro-movements are not to be underestimated. They cause discomfort at best, searing pain and immobility at worst. Orthopedic research has long clarified that micro-movements of a joint replacement, over time, causes not only joint damage but causes particulate buildup between the metal and the bone. Eventually, this build up serves as a wedge to loosen the metal, forcing its owner to have a revised joint replacement.
But, what happens if the revised joint replacement begins to shake its branches just months after the surgery? I can tell you in some detail since it is happening to me now, seven months after my knee revision surgery. To be clear, the revision knee surgery was a mechanical success. All alignments were precise, and the physical therapy routines were followed. I just happen to thrive on physical discipline and on endorphin highs that come from good workouts – and slowly but surely subjected my knee to more movement that it should have endured. I have been experiencing severe shin splint pain, and an occasional sensation of the bone bending – this is an odd, painful and haunting sensation, like watching a contortionist bend backwards just too far to comfortably watch. Last week, as I stood cutting a lemon, my knee once again just buckled and the surrounding musculature went into cramping overdrive to compensate. These shin splint sensations and lower leg muscles giving out finally forced me to pull my crutches out of the closet (where they had been happily stored for over two months) and made my way back to my orthopedist for new x-rays. Sure enough, the metal tip of the lower leg prosthetic had begun to lean into one side of the marrow of the tibia. A clearly articulated balloon of space now surrounds the tip, caused by micro-movements said the doctor. Like a hippo underwater, this bubble warns me that changes have to be made in my daily life in order to give this new, revised (and in my book, final) replacement a chance to recuperate. Otherwise that hippo (second revised surgery) will attack.
(While this photo is of a first time total knee replacement, it effectively showcases bone loss/bubble aggravated by micro-movements.)
What needs to change? The amount of rest and the amount of movement in my daily life.
- Practicing disciplined leg rest. I resurrected my bed-tray to carry books, liquids and snacks to wherever in the home I need to plant myself for hours at a time.
- Prioritizing my weekly calendar so that I rest for enormous periods of time before going to this or that event.
- Walking slowly and walking less. To and from the bedroom and kitchen is a hike.
- Needing to lose weight is critical too – and easier said than done when movement is limited. But I have managed to minimize starches (grains) and sugars and to control my need for sticky rice. The truth is, this is the hardest part of healing for me. I am not enormously overweight but losing 15-20 pounds can only help.
Adjusting my PT routine is also essential:
- Reducing gym workouts to 3 times a week
- Eliminating double leg bridges using a large physio-ball (65) since this exercise contributes to shin stress
- Focusing on abductor and adductor exercises with the ball
- Rolling the ball from one extreme side to the other, relying only on stomach muscles to give core muscles a decent workout
- Starting and ending the gym workout with a plank hold for 70 seconds
- Paddling non-stop in the pool for 25 minutes at a time. There are many products to buy to help ones pool exercises. But I like to recycle what I have, including all my lead-based weights bought for my first knee restructuring surgery over 35 years ago. I wear a five pound weight like a shoulder bag. It forces the torso muscles to remain activated in order to keep the head above water. The aerobic effects are tremendous and every aspect of the body gets attention without undue stress. Five minutes spent with straight-legged lifts (70) while sitting on the pool ladder rounds out the heavy breathing portion of my pool time. I strap one-pound weights to my thighs – avoiding ankle weights for the micro-movements they impose on the knee – and off I go.
- If I can stomach the hot and dubious water quality of Bangkok’s 50 meter pool, I stretch myself out there once a week. It is a pleasure to crawl stroke uninterrupted by walls.
- Using swim noodles to hold the body up while laying in the water and mediating. Meditation is front and center to my overall revised program since peace of mind is in higher demand now that my limitations are clear. With ears underwater, I can only hear my breath and an occasional bird. What could be more relaxing?
- Adjusting my self-perception again. I am an active person, still young(ish) at heart and certainly not willing to stop being out in the world, though too many times, I stay inside repairing. What seemed extreme before now seems practical: a wheelchair. The possibility of another surgery is unbearable. So yes. Now a wheelchair looks like a friendly, smart tool to rely on just as my crutches, canes and arms of friends and family members have been.
So reader, two steps forward, one large big step back. In my case, a revised knee replacement has truly required a revised life. Each post-operative phase reveals how to continue adjusting. One thing, for me, that remains true through all of my surgeries: The faster I strive to heal the more I need to slow down, this time for some time. Thankfully, my reading list is long.
** Among the many research articles on the subject is this handy-dandy one: journals.plos.org/plosone/article?id=10.1371/journal.pone.0177285
NOTE: All photos are stock internet photos aside from the photo showing weights.