Avoiding Knee Replacement
What follows is a written summary of our Interview with Michelle Stiles PT who discusses strategies to avoid knee replacement. To listen to the full interview from The Bee’s Knees Podcast click on the PLAY button above.
I was very fortunate to work with an outstanding orthopedic surgeon early on in my career. He was on the East Coast in Virginia Beach. His name was Dr. Louis C. Jordan. It’s called the Jordan Young Institute. He was really a pioneer at the time; still early-going in those years. People didn’t get their knees done right away. And their range of motion was much more abbreviated. And they had profound weakness in many cases. The rehab was a lot different back then.
Dr. Jordan and His Knee Patients
Dr. Jordan realized that if he didn’t make the rehab go smoothly for his patients it didn’t matter how good a surgeon he was. If the rehab screwed up his surgery there wasn’t going to be a good outcome for his patient. He also knew that an excellent outcome was a walking marketing tool for him. We understood that right away. And he actually came through the home health agency that I worked for and instructed us on what he wanted done with his patients. I’d never had that happen before.
And he would only see a patient who advocated doing the exercises four times a day. And as a young PT I thought ‘boy I think that’s a little bit too much. Geez can my 80 year old lady with sugar diabetes do that?’ And as I worked with him longer I was just blown away. Then I added some things of my own. And that’s the system that I ended up creating. And that became the book that I ended up publishing.
After I finished working with Dr. Jordan, I worked with another pretty top physical therapy group in New York. Then I went on the road and that’s when I found out that there are a lot of knowledge gaps out here.
The Standard Knee Recovery Protocol
Early on, before I had had those training experiences, rehab was pretty straightforward. There was a basic set of exercises that we gave everybody. And generally speaking if somebody didn’t do well it’s the patient’s fault, lack of compliance. They say they’re doing it, but they’re not. But what I really found out was that they were actually doing the exercises, but they weren’t effective for them.
So I’ve tried to fix that with motivation and measurement. I put different pieces of this puzzle together as I had a lot of time with knee patients in their homes. It allowed me to be one-on-one with people to figure out what didn’t work for them and why they didn’t succeed. And I did get a system down. And I created kind of a niche in physical therapy particularly for knee surgery recovery.
My Knee Recovery Protocol
When you show somebody two to three degrees on a goniometer, that little tool that you use to measure angles, they see that it’s not very much. But when you when you put two or three degrees together every day for a week, you get 21 degrees range of motion. It’s phenomenal for people. So I would track it very closely. I would go into a patient’s home on a Friday and I would predict their progress, and then when it happened just as I said, they would continue to grow in confidence that they truly were in control of their recovery.
“You’re at this amount here, let’s get two or three degrees today. You should be here by Monday.” And we’ll check that. And they were. So that’s what I put it out there.
Daily Rehab Frequency
One of the keys is the frequency. It’s four times a day. And the reason for that is everyone who has a knee replacement will say the morning stinks. You get up you feel like it’s Groundhog’s Day, that movie. “I got to start over again and my knee feels like garbage.”
When you do this twice a day thing or even one time a day it is worse. You then basically will only get back to the baseline. There is swelling in the knee and the fluids tend to creep back in. You’ll drive it out you’ll get back to that let’s say wherever you were and then you’ll wait eight hours. The fluid comes back you drive it out again. And so there’s this sort of plateauing treadmill ‘getting stuck type effect’ that happens when you do low frequency. So frequency is really key to this thing.
The sessions aren’t very long. They’re maybe 20 to 30 minutes by the time you do the icing and elevating.
Overnight Knee Stiffening
Overnight you’re not moving, and swelling comes back into the knee. And then you do the bending exercises in the morning and you get back to square. Then, in the second session, you can move off that mark and make some progress.
But another key is that there are three phases.
- You work on range of motion first.
- Then you work on your baseline strength.
- Then you focus on body weight functional mobility.
And if you don’t confuse those three phases mixing them all together, you have a much better outcome.
This is something for people to start three days post-surgery. That was one of the things we did at Jordan Young. We would start them right away in the hospital.
The Trend Toward Knee Replacement Surgery
More and more I was alarmed at the growing number of people getting early knee replacements.
We have the baby boomers tripping into 65 and over. There’s three quarter of a million of these things done right now. That is scheduled to double in a few years. So we are talking about more initial surgeries and more revisions. And as a society right now total knees are one of the highest Medicare expenditures. So where is the money going to come from when we double the number of surgeries? We are just putting ourselves on a real dependent track down the road.
I don’t want to be dependent on something that I can possibly avoid. The marketing claim is that the implants are going last 20 to 25 years. However, all those numbers are based on 70 and 80 year-olds. We don’t have numbers for a younger population. In fact the numbers we do have are kind of scary. We have a 95% implant survival rate in people over 65. About 2% of this population needs a revision surgery after five years. That’s pretty good.
However, that rate drops by 5% if you’re if you’re under 60 or 65 for the first five years. That’s now a 93% survival rate which if you extrapolate that out suggests a much lower long-term survival rate for younger patients This is primarily because younger people are much more active.
And more and more people are having this surgery at a younger age. That’s the largest growing category of people having knee replacements.
Knee Pain May Indicate Other Conditions
Chronic knee pain is like a check engine light on your body dashboard. We find that people who have osteoarthritis have a 38% increased risk of cardiovascular disease, 55% increase risk of ‘all cause mortality’, 98.5% increased risk of diabetes and a 128% increased risk of cancer.
To me this is very alarming. But is this because of the lack of mobility? Is that where this is headed where you’re going to have all these other potential comorbidities or conditions, because you can’t move because of the OA?
That’s really head-scratching.
What is CRP (C Reactive Protein) and Why Should We Care?
A C Reactive Protein is an inflammatory marker. It is a substance produced by the liver in response to inflammation. What they found is that in a certain kind of phenotype of osteoarthritis, C Reactive Proteins register from 6 to 11. This means they are slightly elevated. Elevated C Reactive Protein will predict progression of knee OA.
This is so important!
So maybe some of your pain is related to your high inflammation levels, driving early degeneration of your knee.
And then I have a great study from 2018. It looks at four inflammatory markers that have been implicated in knee degeneration as well as cardiovascular and cerebrovascular problems. It suggests these markers are affecting your knee are also affecting your heart and your brain.
They’re connecting the dots on these things. They’re looking at the same sort of factors that are influencing many chronic degenerative conditions that are really exploding.
The theoretical model says that osteoarthritis is wear and tear. So if the knee is like a brake pad and it’s worn out what do you do? You go to the service guy and replace it. But if it’s inflammatory and there are conditions circulating around my knee causing it to degenerate earlier, then it’s a completely different idea.
Getting Your C Reactive Protein Score
You can ask your doctor for a test.
They also do direct labs now except for in three states (New York, Rhode Island, Massachusetts).
It’s about $30 to get that test.
The Kellgren Lawrence Test
There’s a thing called a Kellgren Lawrence score. Traditionally you had to have a Kellgren Lawrence of three or four that demonstrated that you were actually in need of an appropriate surgical intervention. But now some of the research is suggesting that people are getting early knee replacements when their Kellgren Lawrence score is only a one or a two. Meaning they do not meet the traditional criteria for a knee replacement surgery. And these patients are more unhappy with the results, and continue to have lingering pain.
When facing the prospect of a knee replacement… if it were me, I would absolutely give my knee a chance. I mean at the very least you’re going to give it a 30-day test. A 30-day anti-inflammatory test to see if you can move the dial in any way. For many it is possible to avoid knee replacement with the right program.
But it takes a little time. Most chronic diseases are the result of one or two decades of problems internally homeostatic problems that are sort of subterranean according to the medical model.
Precision Nutrition (A Program I Love)
Precision nutrition really is an awesome program. It’s about nutritional transformation. Once you get the principles it can act as a life transformation. Everything they do is well done.
We concentrate our efforts towards maximizing that health and see where your knees go and maybe your knee problem will be eliminated. We do a basic simple blood chemistry analysis.
We take some inflammatory markers see where you’re at there and then make some recommendations. Supplements are part of it, but if you don’t make major changes in your diet and lifestyle, supplements will not help you. Then you get the customized precision nutrition program. And then we bring in the exercise piece. If you’re in a large amount of pain then you’re going to address the diet first. The building blocks to avoid knee replacement are right here.
And then we would work with knee range of motion if there’s any lack in that.
And then you get one-on-one coaching. You get people getting me actually looking over your program, giving you comments or feedback. I’m touching base with you throughout the program which usually lasts one year.
If you’re going to make changes that stick you need to persist with it and be committed to really making a lifestyle change. We can figure out what might be good for you and what would be the best path.
I’ve seen some research and I’ve seen a lot of rehab in practice. I learned a lot from my experiences and felt the need to share what I had learned. In 2012 I published my book on total knee replacement recovery. It’s available on Amazon now for those who want to read it. It’s called Fast Track Your Recovery from a Total Knee Replacement.
We are so thankful that Michelle was so generous with her time for our Bee’s Knees Podcast Interview. She is readily available for you to learn more about the many good programs she offers. For a free 15 minute consultation with Michelle click here: Meet Michelle
Source Material and Resources
CRP (C reactive protein)
- Spector, T.D. er al., Low-Level increases in serum c-reactive protein are present in early osteoarthritis of the knee and predict progression of disease; Arthritis & Rheumatism,40) 4, April. 1997, pp 723-727.
CRPM (slightly different marker)
- Saberi Hosnijeh et al. Arthritis Research & Therapy Association between biomarkers of tissue inflammation and progression of osteoarthritis: evidence from the Rotterdam study cohort (2016) 18:81 DOI 10.1186/s13075-016-0976-3
Related to the discussion of the same types of inflammatory markers that are hurting the knee are hurting the heart and brain.
- Al-Khazraji, B.K. et al., Osteoarthritis, cerebrovascular dysfunction and the common denominator of inflammation: a narrative review, Osteoarthritis and Cartilage, (26) January, 2018, PP462-470.
Tests and test panels that can determine if you are likely to be dealing with more inflammatory OA
- To learn more click here.
A simple hs- CRP can be obtained (cost $33)
- Click here to explore getting a test of your own.
We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Avoid Knee Replacement Surgery’.
In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing
To subscribe to the blog click here.