Why is there pain after Total Knee Replacement

So, you are seeing me for a second opinion regarding your painful total knee. You are NOT unusual. In some studies, 1/3 of patients are not satisfied with their pain relief. So, let’s go through my thoughts on what to expect.

In NO WAY am I implying that your surgeon “missed” something. You had an arthritic knee. How is one supposed to know how much of the pain is the knee versus the back or hip?! I do my darndest to try to figure this out ahead of time (thus the shots in the knee to determine if it’s the knee causing the pain because even very temporary pain relief tells me some of the pain is from the knee) but I am FAR from perfect. It’s too easy (and it pays well as revision surgery reimburses better than a simple primary knee) to just say “Oh, it needs to be redone!” Not on my watch! But if you are experiencing pain in a total knee you will NOT get a revision from me unless I know for sure it is coming from the knee!

FIRST, there is a very good chance it has NOTHING to do with the knee. Your knee may be in varus (bowlegged) or in valgus (knock-kneed). IN MY OPINION this does not cause knee pain! Think about it. The knee is no longer “bone on bone” so even if “crooked” it’s still relatively pain free because its “metal on plastic”. This won’t hurt!

It may be “stiff”. Again, this should not hurt especially in standing. True, it may hurt at the extremes of its limited motion, but if you are standing on it and it hurts there is a good chance it’s not the knee.

It may be “loose” or unstable from a twist or minor fall. First , we need to give time for the ligaments, which now are strained, to potentially heal before venturing forth with revision surgery.

Without this first step you are accomplishing only one thing- a car payment for the doctor! Again, it’s still “metal on plastic”, the arthritis is GONE, by definition, so one has to make absolutely sure it’s the pain is in the knee before undergoing a revision.

SO, get ready for a work-up! A VERY common thing that causes a painful knee is HIP DISEASE! That pain in the knee that goes up the thigh may be coming from a bad hip. I had one patient (a lawyer, ha!) that had three, yes THREE knee operations and came to me for a fourth. I looked at his history. He had good surgeons. Didn’t make sense. He’s considering doing a fourth operation and somehow I would do better? Nope. X-rays of his hip revealed a collapsed femoral head. A total hip operation took care of the “Knee pain”. In patients with both hip (groin and thigh pain) and knee pain I tend to do the hip first! The inability of the hip to rotate puts tremendous stress on the knee, especially if you are walking with your foot out (like a duck! Quack). Your knee of course is going to hurt! I have seen hundreds of patients who after getting the hip rotating properly their knee pain decreases dramatically.

Probably the MOST common cause of persistent knee pain after a knee replacement is THE BACK! Yeah, I know I know you have no back pain, per se, but YOU can have irritation to the nerves to the legs without any history of back pain. That “knee pain” you had pr- replacement causing ANY burning or pain in the LEG was nerve! I have to say that vast majority of patients over the age of 50 have spine issues without any back pain! Refer to Figure 1 on the diagram. Look where the 4th lumbar nerve root goes! Your knee! Many of the patients I see walk with what I call a stenosis gait. Your feet don’t go full stride. You shuffle. You probably have stenosis or degenerative disc disease. Now, I am not a spine surgeon. I leave that up to those that do that. But I often will refer out to a spine specialist not necessarily for back surgery but for completeness of the “pain” work-up. If the spine surgeon says “all you have is arthritis” that does NOT mean you have a normal back. You have what is considered a “normal” back for your age. At times I am insistent on getting a shot put around a nerve root in the spine to help figure out the cause of the pain.

These are my opinions after 35 years in practice, thousands of knee replacement surgeries along with thousands of second opinions. I hope this answers some of your questions about your knee pain.

BE PATIENT! LET’S FIGURE THIS OUT TOGETHER!
PETER HOLMES

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