13. Micro-Movements



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.

Tibial stem bubble

(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.

Tray with ipadAdjusting 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.

swim gear

  • 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?

48-letting-go-of-past-mistakes, meditating in water

  • 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.

chair in library 2


**  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.

Author: amartinelbehri

Retired from working for large non-profits. I now write, take care of extended family, tutor English, and manage all aspects of living abroad while my husband works. I am recouperating from my 14th knee surgery and have some thoughts to share on many aspects of managing trauma, healing and starting over.

7 thoughts on “13. Micro-Movements”

  1. I have also had a TKR revision of my left knee after 6 years – due to instability ostensibly caused by lax ligaments in the front of my knee. My revision was done in April 2019. The tibial component was not replaced – just the femoral component and the spacer. Almost a year out and I still experience pain, stiffness, buckling, …. Most frustrating is – it still feels unstable! But differently. Yes – as you said – it is larger and I can feel it. I feel really alone with all this. I really appreciate finding your blog. Nice hear from someone else who is going through a similar thing.


    1. I appreciate your comments and bow to your experience, which provokes many thoughts: a) I am sorry for the continued stress you have to live with, and the uncertainty of it all. On a practical note, I have found a knee brace to help during those phases when I (still) buckle. The name of the brace is: Orthoservice, Ro+Ten, made in Moldova. It’s sturdy,yet lightweight: bends when I need to. I am hoping that continued leg/core strengthening exercises might minimize the buckling (A strange sensation: how do we define the experience of ‘buckling’? Sudden sliding? Painful torquing? Would appreciate your thoughts) b) Your story highlights how the already stressful situations facing many ‘revised patients’ is aggravated by realizing that solutions to our complex mobility issues may very well lie somewhere outside the orthopaedic community – a community who, at our stage of intervention, benefit more than we do by learning from our direct, ongoing, experience – no matter how many computer simulated circumstances they conjure, a bad knee repair causes our lives to irrevocably change. Together, patient and surgeon are ‘Going where we have never gone before’ so to speak. c) Embarking on replacing a revised knee joint can be a singularly lonely experience . No matter how much effort others genuinely give to empathize or support with information, ice packs or dinner trays, the existential threat to our peace of mind haunts as the pain, the immobility phases, the rush of less than exciting images about the future weigh in. Thick issues. Here is hoping that you have found a physical therapist who respects your experience and who seeks complementary strategies to help, that you have a strong personal support system, and to a peace of mind in knowing that you are not alone. One step, brace, cane, crutch, or wheelchair at a time. All my best.

      Liked by 1 person

      1. Thanks so much for responding to me.

        – questions… any idea where I can get this brace you’re talking about in the US? – How is your walking these days? Can you get around w/o a cane or brace at all? – I really don’t have access to a pool – but I do want to exercise. People on bane smart have been telling me that the stuff I do in the gym is too much. Maybe they are right. Leg lifts, leg presses…etc.

        thanks again!

        I hope we can keep in touch.




      2. Richard, I think your friends are right. Literally, and please, ‘Stop the Presses!” Even I am in pain for your joint. Could it be that US therapists are too aggressive in their rehab.? My Italian physical therapists taught me that slow and steady wins the race. Thai therapists added that SOME MODIFIED, standard TKR exercises are acceptable to healing a revised knee, but not all and again, slowly but surely. Thigh weights yes, ankle weights no; thera-bands at or above the knees, none below. I wish for you access to a pool where you can straight leg kick more than you can walk, where you can lightly jog and vigorously do ‘sitting on the ladder’ straight leg pull ups, using your core and, NO weights on your legs but strapped to your body for overall aerobic fitness. Physio-balls yes, weight machines no. Isometrics every other day/pool every other day. If you send me your email, I can send you a picture of the brace I mentioned. Physio-tape works exceptionally well on joint inflammation and pain, even a year and some months out of surgery. I swear by it. Finally, accept that less is more. At this stage, you need to pamper that stressed joint. Buckling is a sign of not only overall joint inflammation caused by scar tissue, but of possible micro-movements and loosening. Pamper that stressed joint and yourself. Find a way to enjoy planks (with or without a ball under your thighs) and yoga inversions. I suspect that if you work on other parts of your body the knee will follow. Let’s hope for that.


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