After 30 plus years in the fitness industry, a few thousand kilometres running bush trails and at the ripe old age of 67, my knees have worn out, says Wendy Richmond.
Fitness is not a career that is kind to your body and I always expected my body would eventually ‘pack it in’. So, what does a couple of worn-out knees feel like? Well, it starts with stiffness and pain doing certain movements, like running or squatting or getting up after sitting for a while, and eventually progresses to feeling like you have broken glass in the knee joint and every step is painful. You look at stairs and take a deep breath before going up or down them and hang on tight to the handrails because you don’t trust your knees. The pain wakes you at night and then never leaves during the day. At the end stage, most people are in denial about needing new knees and battle on with the help of painkillers and anti-inflammatory drugs. In reality, a total knee replacement (TKR) is inevitable.
The diagnostic process
This was simple: the GP sent me for x-rays of both knees and the results demonstrated advanced osteoarthritis in both knees – bone on bone, with medial sublaxation (dislocation) on both knees. A referral to an orthopedic surgeon was generated and two weeks later I find myself booked in for a total knee replacement on the left knee. The surgeon recommends one knee replacement at a time, and I am sent off with an impressive amount of reading material which suggests I be in good physical shape for the operation but gives me no detail on what to do preoperatively to prepare. Doctor Google only gives me post-op programmes.
My exercise scientist brain sees a challenge: what can I learn from this surgery? How do I prehabilitate? Mentally, this challenge is a good diversion from the fear of the unknown and the upcoming pain and period of disability. This is major surgery and I am scared of the surgery, the pain and the outcome.
The prehab period
I am fit aerobically and already perform bodyweight resistance exercises on a regular basis but, to get to the stage where I can create overload, I need to use machines, so I join the local gym. My programme is based on the need for whole-body strength with a specific focus on leg stability and strength. Timewise it has to happen in one hour max. Aerobic conditioning is done at home with a spin bike and rower and gym time is 100% resistance training.
One of the hardest things about this period is actually starting the programme and then maintaining it for three to four times a week for the five weeks of prehab – my slogan is “don’t give up” and it is muttered quite a few times over the entire prehab and rehab periods. The other difficult thing is remembering what I used to be able to do, but can’t do anymore.
The prehab routine
The programme is based on the idea that the knees and associated muscles – quadriceps, hamstrings, hip adductors and abductors and calf muscles – are the most important. Upper-body and core strength is also included, as I will end up with crutches.
By the end of the five weeks’ prehab, I am stronger and fitter than I have been for a while. I like what I see in the mirror. It is funny how the pain in the knees is much better and I ask myself several times if I really need this operation. I am prepared but scared. I check and recheck personal paperwork and tidy my house just in case I don’t come home.
The prehab routine
|Smith machine squat (front or back)||3||10|
|Stiff leg deadlift||3||8-10|
|Leg extension||3||10-12 – eccentric focus|
|Smith machine incline bench||3||10, 8, 8|
|Lat pull-down||3||10, 8, 8|
|Pulley row||3||10, 8, 8|
|Triceps pull-over/dip combo||3||10/10|
|Seated calf raise||3||15|
|Hanging leg raise||3||10|
|Bridges – prone, supine and sides||1min hold each|
Day zero – the operation
I wake four hours after being ‘put to sleep’ – my brain struggles to sort things out. The repaired leg is under a constant ice pump pack, the other leg has a nifty white plastic stocking on it that inflates and deflates rhythmically. The pain is OK and I feel better than anticipated. I float around in a lovely haze of drugs and anaesthetic. Later that night, I am allowed to use a walker to go to the bathroom. It is about this stage I am glad that I am fit and have prepared for this adventure. I can partially weight bear on the operated leg but, to get onto the toilet seat, I have to do a one-legged squat on the good leg and hang on tight to the handrails as I sit down. Still, this is better than having a catheter. Strangely, my back hurts more than my leg.
Rehab! Bring it on
Rehab starts straight away. The nurses warn me that Day 1 is a big pain day, but things will get better. My walker has been replaced with crutches, which is apparently not normal on Day 1. Go me!
- Day 1 – Bed rest, walk 20 metres with crutches, perform heel slides, static quad contraction, ankle pumps
- Day 2 – Bed rest, walk 150m with crutches every two hours – perform heel slides, static quad contraction, ankle pumps
- Day 3 – Graduated into hospital rehab ward, two daily gym sessions – two hours in the morning and one hour in the afternoon
- Days 4, 5, 6, 7 and 8 – more of the same
By the end of the week, it is a mental challenge just being in hospital this long. I miss home, my own bed, my dog, a nice hot shower and a hot cup of good coffee. Physically I am doing well, the knee pain is constant but is controlled with opiates. The idea is to stay on top of the pain – that is, to react before it is out of control. I have constant nausea from the drugs, so eating is not a high priority, which is OK because I am not hungry and the food is pretty ordinary.
Exercise-wise it is the same each day: a mix of squats, lunges, steps, quad contraction and forced knee flexion. The physios have figured me out and try to challenge me each session. Today’s challenge is reformer leg press 3 x 10-15 x heel, toes, and flat foot. I think the physio is trying to hurt me. She succeeded and I have paid the price with deep quad pain in both legs through the night.
I have had an interesting discussion with my hero Pete, who has two knees done at once, about the mental aspect of this adventure. We conclude that it’s tough and you need to be prepared to hurt and push through the rehab. No pain, no gain. The other interesting gem from Pete is the mortality rate for double knee replacements apparently: approximately two in every 100 die! Lucky I only did one at a time.
The end of hospital rehab – going home
My last rehab session is cut short as, during forced knee flexion, blood appears from the wound, which has developed a small split. Blood thinners mean that a little split results in a lot of blood. I have become unglued – physically, not mentally. I am sent back my room to put my leg under ice. It’s a cold, grey, miserable day and I stay sitting for the rest of the day. I want to go home – tomorrow can’t come quick enough.
The next day I pack my bags, collect a big bag of drugs and take enough painkillers for the trip home. At home it is good to see my dog and daughter and my naughty sheep, who had their own escape adventure while I was gone. I can walk without crutches inside; outside, I take one for balance just in case. I actually trip in my shed, as I sort out the sheep food. The pain is pretty intense and I make a mental note to be careful. I am so slow and careful, taking twice as long as normal to move from point A to B. My crutches go into the cupboard after one day.
I am alone for the first time in nearly two weeks; I can cope with activities of daily living and feed myself and the animals, but I must have a nap every day – this is not optional. The rehab exercises are now done in the garage where my gym equipment lives. I have added a chair to the set-up to use for balance exercises and support. It is strange to be doing stuff that, in the past, I would allocate as seniors’ exercise. I used to ‘own’ the gym. Ego is a dirty word and mine is dented. I have to remind myself that I am in rehab and I need to let stuff heal, but patience is not one of my virtues.
The current exercise programme is the same as I was doing in hospital. I have to improvise with what I have in my home gym to get all the joint movements I need to do. I use the balance disc for lunging onto and standing on; the foam roller as a foot roller to do seated knee flexion. I find the concept two rowing machine on low resistance can also be used for ‘knee slides’ (instead of heel slides). I row for three minutes on minimal resistance and I am reminded that I have had major surgery and I am not superwoman. I raise the seat on my spin bike about three inches. I can just reach the pedals and, initially, I can get the bad knee to complete a full rotation backwards but forwards is impossible. By the next session, I can get full forward rotation.
As the weeks progress, I overload by increasing the reps on the rehab exercises. I add in core bridging exercises to help with my back pain. I increase the bike and rower time by one minute every two days until I reach 10 minutes on each. I return to the gym after four weeks and train the upper body. The post-op fatigue is still there; functionally, I can do most things and the hardest action is getting up from the floor as I cannot kneel on the bad leg. I am bored with the rehab process and would love to start some actual training to increase my stamina.
Six weeks post op and I have my final review with the surgeon. He is extremely pleased with my range of motion and recovery and he sets me free. The only restriction is no jogging. Apart from this, I can do whatever I want. My knee, however, tells me when I have done something dumb or too much. I feel that complete recovery will take at least four months.
Things I did not anticipate
I expected initially to have a very sore knee, but the pain extends from the hip to the ankle of the operated leg . The quads explode with pain; the ITB band feels like it is going to snap; my tibia is on fire and my calf and knee are completely numb (they still are to some extent). This operation is often described as brutal and I can confirm it is not for the faint hearted.
I did not anticipate that the rearrangement of my knee would totally unbalance my kinetic chain. My hip hurt; my lower back ached; my ITB was agony. This meant that, as well as doing knee rehab, I had to implement core training and specific stretches to get things back in balance. I will need new orthotics, but these will have to wait until my second knee is fixed.
Beforehand, I did have a list of drugs that would be prescribed but, when it came to actually consuming so many pills, it was frightening and foreign.
Rehab was fun. I landed in the party end of the ward where the company made the journey easy. The rehab process in hospital was invaluable in making good progress.
The thought of doing this again for the other knee is frightening and, while it is inevitable, I will not be rushing back.
Wendy Richmond has worked as an Exercise Scientist for three decades in the fitness industry. Wendy has a Master’s degree in Exercise Science and Bachelor’s degree in Biochemistry. She is a Cert IV Trainer and Assessor and has qualifications in clinical Pilates. As an exercise scientist, Wendy has worked with normal and special needs populations. She worked with sporting teams to design and deliver fitness and rehabilitation programs. Wendy has worked with RTO’s to design, deliver and assess health and fitness educational packages.