A PT’s Total Knee Pain Expectations: (Day 1 through Day 30)

A question I often hear from my patients before undergoing a total knee replacement:

Is total knee replacement painful?

Total knee replacement is a painful procedure, however, following normal post-surgical protocols, a patient should not experience constant pain at 7/10 or greater. They may experience sharp fleeting pains above 7/10, but that pain should dissipate within a couple of seconds.

While a total knee replacement patient is in the hospital, the pain is well regulated. Some of the surgical pain is still being suppressed by the medications given at the time of the surgery. And some of the pain suppression is the result of the pain medications given after the total knee surgery.

Patients will continue to take these post-surgical prescription drugs independently once they are discharged to home.

What home physical therapy will I receive to decrease pain after knee replacement?

  • Monitoring the effectiveness of prescribed pain medications.
  • Instruction in the use of cold therapy.
  • Exercises to increase pain-free range of motion.
  • Instructions using ambulation devices.
  • Instructions about ambulation endurance limitations.

All of my patients are using either Ice Packs or Cold Therapy Machines (Amazon affiliate links) multiple times daily to help control pain levels.
See my article: Ice After Total Knee Replacement: A PT’s Complete Guide.

Once a total knee replacement patient is discharged to home a home health care agency will contact the patient to initiate home physical therapy, if the surgeon orders home therapy.

Usually the frequency will be 3 times a week for up to 4 weeks. When ready, the patient is discharged to outpatient physical therapy once home therapy goals are met.

The home health team may be just one person, the physical therapist, but could also include a nurse and an occupational therapist.

As a physical therapist, I will see the post-surgical total knee replacement patient 3 times a week for up to 12 visits. My average total knee replacement patient has usually met our home health physical therapy goals between the 7th and 9th treatment sessions.
See my article Total Knee Replacement Outcomes After Home Physical Therapy…..

Once I discharge my knee replacement patient from home health physical therapy, I recommend continuing physical therapy on an outpatient basis for up to about one month.

How much pain is expected the first weeks after knee replacement?

  • A day or two after surgery, with pain meds and physical therapy, pain should be 6/10 or lower.
  • The pain levels should be 4/10 or less within 10 days.
  • Pain should be 3/10 or less by the end of 3rd week.
  • There should be little to no pain on weight-bearing after surgery.

The patient should be walking without a device and no pain increase by the third week of home physical therapy.

Once home, after knee replacement surgery, the pain frequently increases to more than pain levels the patient was experiencing in the hospital.

The patients I see are never in the hospital for more than two nights unless they have other problems as well. The vast majority of my knee replacement patients are being discharged to home after one night in the hospital.

Patients will generally be feeling pretty good at hospital discharge time, even impressed at their lack of pain and great mobility.

Normally that will change, sometimes dramatically, within a couple of days after returning home.

Surgical technique plays a part in how much pain the patient will have in the first three weeks after surgery:
See my article Knee Pain After Total Knee Surgery: A Physical Therapist’s View…..

By the time I see the knee replacement patient in the home setting on my first visit a day or two after the surgery, the patient’s knee has usually increased in swelling (compared to in the hospital) and the pain levels are vacillating between 3/10 to 6/10 depending on how long ago the patient took their last pain medication, and how active they have been.

One day, between the 5th to the 10th day after home physical therapy was initiated, I expect to hear “It feels like I have turned the corner”. That change usually happens quickly, over about a 24 hour period of time. It is not a long drawn-out event.

By the time my knee replacement patient is ready to be discharged to outpatient physical therapy, the pain is usually down to 3/10, using only non-prescription medications like Tylenol with an occasional need to take the prescription medication, usually night pain. That includes while walking without a cane or walker.

The human body makes its own anti-inflammatories and painkillers in the form of enkephalins and endorphins. These are released on a circadian rhythm, released at sunrise, and often exhausted at about 2 or 3 am, 2 or 3 hours before sunrise.

I frequently hear patients complain of increased pain at 2 or 3 am. I instruct them to postpone their last pain medication of the day to be taken as late as possible, preferably midnight or later. This allows the pain med to dampen the pain during the period between 2am and sunrise when their endorphins and enkephalins are depleted.
For more information, see my article Sleep Through The Night After Total Knee Surgery…..

What pain medications will be prescribed after knee replacement?

Pain medications prescribed after knee replacement falls into two categories:

  1. Powerful “Breakthrough” opioid/acetaminophen pain medications such as:
    Norco
    Oxycontin
  2. Less powerful “maintenance” pain medications such as:
    Tramadol

All these medications are effective but also additive.
Ask your pharmacist about precautions with all pain medications.

While opioid medications are very effective at pain reduction, they do have some side effects including patient balance interference and patient bowel movements.

Any opioid medication will cause constipation because it decreases or stops “gut motility”. Gut motility is the action that is taking place when you hear your stomach “growl”. It is your gut squeezing the food, liquid, and air through your intestinal tract. This action is going on continually under normal circumstances, even if you can’t hear it. Opioids stop or greatly reduce this activity thereby causing constipation.

Most knee replacement patients taking opioid medications are also instructed to take stool softeners, either prescription or over the counter stool softeners.

For my non-diabetic knee replacement patients, I recommend eating 1 or 2 prunes every time they take pain medication until such time that their stool is normal.

Will home physical therapy reduce my knee replacement pain?

Home physical therapy will help control knee replacement pain by monitoring the effectiveness of pain medications and adding additional pain-reducing interventions such as the use of cold therapy, walking, and home exercises.

Cold Intervention

Cold interventions are an excellent way to decrease knee pain levels after knee replacement surgery.

  • The very best way to cool a knee after replacement surgery is to use a Circulating Cold Therapy Machine Cooler which keeps the knee cooling pad temperature at about 40 degrees.
  • The next best way to cool a knee after replacement surgery is to use a commercially made Cold Gel Packs with a gel fill that will mold to the knee’s contours. Be careful with these cold packs as when they come out of the freezer, they will be at about minus 20 degrees Fahrenheit, so you will need a little bit of protection between your skin and the cold pack. You usually won’t need more than a couple of layers of pillowcase material for protection. Just be sure the material is not wet as the wetness will freeze and may give you a freezer burn, especially on the skin over the kneecap.
  • See my article Ice After Total Knee Replacement: A PT’s Complete Guide….

Walking

Walking the right amount of distance can reduce a total knee replacement patient’s pain significantly, but walking too much can cause a significant increase in the patient’s knee pain.
See my article Walking After A Total Knee Replacement: (When & How Much)…..

Home Exercises

Home strengthening exercises promote better blood supply to the new knee replacement, carrying away some of the toxin build-up of the healing process.

Range of motion exercises increase the patients pain-free range of motion allowing for better positional changes to decrease the knee pain.

After a physical therapy session of walking the correct amount and doing a home exercise program, I expect my patients to experience a 1 point decrease in their pain on a 0/10 to 10/10 pain scale.

Should I take pain medication before my physical therapist arrives?

Upon starting home physical therapy after knee replacement surgery a patient should not take pain medications for 2-3 hours before the therapist’s arrival.
To do so will mask pain during treatment, one of the primary guiding metrics for advancing ambulation and exercises.

Activities to pain, not through pain, is the guiding principle.

On my first visit to see a total knee replacement patient, I will ask them about their pain level, and I will also ask them “when did you take the last pain medication”?
Invariably they will answer “Just before you arrived. I was told by the hospital staff to be sure to take pain medication before the physical therapist arrives because physical therapy is going to hurt”.

WRONG ON BOTH COUNTS!
Here’s what I tell my patients:

  • Home physical therapy should not be painful, in fact, I expect a patient’s pain level to decrease about 1 point after we have completed that day’s treatment session.
  • No pain no gain does not work here. A new total knee replacement patient can push up to pain but not through pain.
  • If the patient does something that they did not know was hurting, but it hurts once the activity is stopped, and it hurts for longer than 5 minutes, then that activity is too much and that activity needs to be decreased. Hurting for longer than 5 minutes after stopping the activity is the indicator telling the patient they have done too much and had pushed through the pain.
  • If a patient takes pain medication just before the therapist’s arrival, the pain medication will cover up the patient’s pain and the therapist will not be able to use pain as a guide to determine or advance the patient’s home exercise program and walking. The home program will have to advance at a pace slower than optimal. I would prefer that my patients not take any pain medication for 3 hours before my arrival so that it’s mostly worn off by the time I arrive for the treatment session.

What is the long term outlook for pain after knee replacement surgery?.

  • 1st 10 days you will wonder: “Did I make the right decision?”
  • 5 to 10 days after surgery I hear: “I have turned the corner.”
  • 30 days after surgery, 3/10 should be the worst pain a patient is experiencing.
  • 3 months out the pain should be so low that the patient has to think about the question “do you have pain?”
  • 6 months out will have to stop and think “which knee did they do?”

Pain is affected by the patient’s willingness to follow instructions.

There are three kinds of knee replacement patients that I see:

  • 1st kind is the patient that STAYS IN THE LANE. They follow the surgeon’s and physical therapist’s rehabilitation plan of care precisely. They don’t do more or less than the plan of care instructions. They follow the protocol even when they think they can do more. They are content to baby-step through the plan of care.
  • 2nd kind is the patient that is very apprehensive or poorly motivated to follow-up on their own with the instructions given them in the form of homework to do independently between physical therapy visits.
  • 3rd kind is the patient, frequently a type-A person, that does more than they have been instructed to do.

The person “staying in the lane” walks through this process without incident.

The apprehensive or low motivation patient is usually easily moved into the “lane” with encouragement from the physical therapist and the experience of no pain increase when the therapist does the activity with the patient.

The type A personality is usually a problem unless they are continually questioned about the activity level between physical therapy visits and continued reinforcement of the need to not overdo activities. My experience with these patients has been one of about 25% of these patients will set their rehabilitation back by 1 to 2 weeks because of increased pain from doing too much, even with continual feedback to the patient to slow down.

STAY IN THE LANE!

How can I tell if I’m doing too much the first weeks after knee replacement?

  • Too much activity after a total knee replacement will cause an increase in resting pain levels lasting for longer than 5 minutes after the activity is discontinued.
  • Too much activity will cause staining of the bandages.

If the bandages have ANY staining, the patient should decrease the activity level and consideration needs to be given to changing the bandage, depending on the severity of the staining.

When do I know I need “breakthrough” pain medication after knee replacement therapy?

After knee replacement surgery, 7/10 pain level and above is difficult to reverse, regardless if the patient’s pain tolerance is high or low.
This level of pain generally requires the use of the “breakthrough” pain medication to get pain back under control.

Final thoughts:

  • Please remember, you just had major surgery. Your surgeon cut the ends of your bones off and replaced them with man-made material.
  • Given the severity of the surgery, it is astounding to me the ability to control pain and restore mobility.
  • The first three weeks of recovery allow your physical therapist to baby-step you to full recovery.
  • If you have been using prescription medications for a long time before surgery, it is likely the pain medication prescribed will be less effective as compared to someone not taking pain medications before surgery.

Wishing You Pain Resolution Quickly

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One option would be to do as I am doing.
Read my article How To Generate Retirement Income: Cash In On Your Knowledge.

See My Other Total Knee Replacement Articles:

Best Exercises To PREPARE For Total Knee Surgery
Precautions After Total Knee Surgery: (Immediate and life-long)
TENS After Total Knee Surgery: (A PT’s Settings & Pad Placement)
Showering After a Total Knee Replacement: An OT’s Recommendations
Total Knee Replacement Manipulation: (When & Why To Consider)
Total Knee Replacement Outcomes After Home Physical Therapy
Pain Control After Total Knee Surgery: (A Complete Guide)
Sleep Through Night After Total Knee Surgery: (Dos And Don’ts)
Walking: The Perfect Exercise After Knee Replacement
Walking After A Total Knee Replacement: (When and How Much?)
Knee Pain After Total Knee Surgery: A Physical Therapist’s View
Ice After Total Knee Replacement: A PT’s Complete Guide

Paying It Forward.

Dr. Robert Donaldson

Dr. Donaldson is dually licensed; physical therapy in 1975 and doctor of chiropractic in 1995. He held credentials of Orthopedic Clinical Specialist in physical therapy for 20 years, QME in California, and taught at USC. He owns and operates an orthopedic physical therapy practice. See "About Me" page.

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