Total Knee Replacement Case Study

This total knee replacement case study follows physical therapist, Royce Bowman, through his entire knee surgery process.

His insight, as patient and therapist, gives us a look at both sides of the surgery and knee replacement recovery.

The case study starts at the beginnings of Royce’s knee pain through the surgery, rehab, and recovery.

Progression of knee osteoarthritis

Do you recall any knee injuries from your younger years playing sports?

I had no specific knee injuries while younger and playing sports. Well into my 30’s, I participated in league sports such as basketball, volleyball, softball and tennis. This contributed to wear and tear on my knees.

These high impact activities cause repeated microtrauma to the soft and hard cartilage. The integrity of the knee joints begin developing small tears in the meniscus (soft cartilage) and “potholes” in the hard cartilage. Bone spurs form around the joint periphery which limits range of motion and causes pain.

What was done to address the injury or injuries?

In 2002, at the age of 41, I had arthroscopic surgery on both knees to “clean up” the meniscus and the cartilage.

In retrospect, with your extensive physical therapy knowledge, what treatment would you recommend for the old you? How would this help young people now who’ve had similar injuries?

Get in shape to play, not just play to get in shape!

Meaning, young people need to focus on all 4 pillars of conditioning:

1) Muscle strength

2) Muscle endurance

3) Cardio endurance

4) Flexibility and range of motion.

If an athlete doesn’t have sufficient strength, endurance and flexibility to participate in their sport, injuries often occur.

Over the years, when have you noticed knee issues?

Pain behind knee cap

In my early 30’s, I noticed left knee pain after playing sports or being very active.

Since then, the left knee has always been slightly worse than the right. My supposition is that’s because I mainly jumped off of the left leg.

In my 50’s, the bouts of pain became more frequent and intense.

In January of 2020, while getting out of a deer stand, I placed all of my weight on the left leg while stepping down with my right.

The step was further than I thought and my left knee twisted causing excruciating pain.

Since then, I have been dealing with a diminishing quality of life.

I have had difficulty sleeping, going down stairs, exercising and limping significantly on my left leg which has led to pain in my right hip.

On a recent trip, normally we would have done a lot of hiking, biking and horse back riding. I was only able to do minimal hiking. Also, I required a walking stick especially going down hill.

Effects of degenerative joint disease

Describe the difficulties you’ve encountered in regard to your knee.

I feel:

• constant pain
• limping
• uncomfortable sleeping
• loss of motion
• diminished strength
• unbalanced (especially on one leg – left) when getting dressed/undressed

The following are very difficult:

• squatting
• knee pain when bent
• getting off the floor
• walking up and down stairs
• sit to stand
• in and out of car
• jogging (even a short distance)
• hiking or walking more than twenty minutes
• jumping
• sports
• sitting in one position more than 30 minutes

How does your knee feel in the morning?

When first getting out of bed, my knees feel stiff and painful. After my knee cracks and pops a couple of times, it loosens up somewhat.

How does your knee feel at days end?

Actually, better.

How does knee pain affect your life, behavior and choices (i.e. are there activities you avoid due to your knee pain, etc)?

Walking the dog with my wife, certain exercises, avoiding stairs when I would normally take them, can’t play outdoors with grandkids when any quick movements are related.

Over the past few years, what have you done to relieve knee pain?

I take 200 mg of Celebrex daily for the arthritis.

Over the past 2 ½ years, three or four cortisone injections have been administered to my left knee which provided temporary relief.

I have used heat packs, cold packs and incorporated more stretching into my exercise routine. In the last six weeks, I’ve lost 10 pounds in an attempt to reduce compressional forces on my knees. Also, I’m using a Bauerfeind sports knee brace when exercising which helps a great deal.

The diagnosis for total knee replacement

What tests were performed to form your diagnosis?

X-rays mainly.

The doctor checked my range of motion and the amount of motion I lacked.  He checked the joint “end feel” to find out what is restricting the joint. If it’s a hard stop with bony end feel, it’s arthritis and bone spurs.  If the end feel has give to it, it’s likely more soft tissue problems.

What did your surgeon see in the diagnosis?

The doctor’s post exam narrative read: “There is extensive involvement of degenerative arthritis.  The left knee is much more advanced than the right.  The left is a late stage IV (out of IV) compared to a late stage III on the right. Additionally, the x-rays show posterior and anterior osteophyte (bone spurs) formation as well. Finally, the patello-femoral joint has more involvement on the left than the right with bridging osteophytes.”

Describe why you decided to seek out a surgical solution.

The pain and restrictions associated with a “bone on bone” knee begin to encroach on one’s quality of life.

I still enjoy being active with exercise, taking long walks with my wife and dog, playing with our grandkids, hunting and fishing, hiking, biking and horseback riding in Colorado, etc.

Most of these personal pleasures and hobbies have become severely limited or I’m unable to do them at all.

I will be 60 in 2021 and am not ready to be deprived of activities that make me happy. Especially, when it can be resolved through a surgical procedure. Once the knee is is in late stage IV degeneration, physical therapy, cortisone shots and lubricant injectables won’t help.

What fears or concerns do you have regarding this procedure?

Infection and length of time off work.

In the next installment, we’ll look at Royce’s preparations for total knee replacement surgery.