RANGE OF MOTION

Range of Motion (ROM) is the measurement of the amount of movement of a joint.  I am referring specifically to ROM for knee joints here.  A goniometer (see picture below) is used to measure ROM.  It is a metal or plastic handheld device with two arms which works like a protractor.  So we can easily use a protractor which can be found in most homes to measure ROM.

Pain, swelling and stiffness are common symptoms of arthritis.  If we suffer from these symptoms for many years, our ROM would be greatly affected.  In serious cases, the limitation of the ROM may impair our functions and our ability to perform normal daily activities.

My ROM before TKR had already been affected.  I was only able to squat maybe halfway down.  Today, after almost 16 months post my bilateral TKR, I finally measured my ROM with a protractor and it's around 120 degrees.  If my knees weren't so fat, maybe I could bend a little more.  I know that my ROM now is the same as before TKR because the degree that I could bend and cross my legs while sitted is the same as before.  When I saw my OS for a follow-up check at two weeks after TKR, he examined my knees and said that my ROM was 90 degrees.  At three months, he said my ROM was 110 degrees.  Then he told me that I had to achieve maximum ROM within six months after TKR otherwise, it would be difficult to improve further.   When I complained to him about the stiffness and tightness, he told me that its due to muscle scarring.  He said that when muscles are scarred, they will always contract.  And he also told me that the more ROM I achieve, the better the stiffness would be.  Well, after months of trying at my own pace, I found that my ROM could not improve any further.  And my stiffness is still there (see post on swelling and stiffness).

I raised a question to my TKR forum members whether ROM can still improve in advanced recovery.  And to my surprise, they said Yes!  Some of them discovered that they still see improvements even after more than a year of recovery without doing anything much.  So that was a relief to me  and I stopped worrying about trying to increase ROM.  One day recently, while I was doing something, I suddenly noticed that my knees could bend a little more than before.  I thought that was a pleasant surprise.  It's strange that sometimes when we stopped trying and worrying, then something unexpected but positive happens.

From my TKR forums, I noticed that a lot of members are very concerned about their ROM in early recovery.  In fact, some are so impatient about it and would work their butts out. Then they will complain why their knees are so painful, swollen and stiff.   Yes, it can be very painful and the PT's mantra is "No pain, No gain".  But this concept is causing a lot of pain, swelling and stiffness which will eventually lead to a delay in recovery.  It can be an emotional trauma too for most people and that's why PTs have earned the name "Physical Terrorists". 

It's also quite typical that most people can achieve more ROM when they work very hard with a PT.  But the minute they go home, they find that their ROM has reduced and so, they feel disappointed.  This is because their knees have become swollen and stiff as a result of working too hard. So if you have a chance to choose your own PT, I would suggest that you choose one that is more caring and compassionate.  After all, we are not training for the Olympics.  Recently, I learnt that some people hardly do any PT and they ended up fine with reasonably good ROM.  So that's another interesting discovery. Well, I am glad that I did not have to go through this because I only had the PT at the hospital for a few days.  After that, I just did it on my own at home.  I did not pushed myself too hard.  I just did the exercises up to the point of discomfort.  So I did not suffer from prolonged pain and swelling and as a result, I had a reasonably fast recovery.

Contrary to the usual "No pain, No gain" mantra, our Bone Smart Forum's mantra is "No pain, More gain". The rationale is that this will lead to faster recovery.  All we need to do is rest, ice, elevate and take pain meds accordingly.  One important thing I learnt from this forum is that our knees are in charge in terms of the healing process, not us.  So if we become impatient and overwork them, they will be very angry and we will face a set back in recovery.  But if we do our physical therapy exercises gently at a slower pace and give our knees a lot of TLC, naturally they will heal faster.  I believe that once our knees are stronger and the wounds have healed quite a bit, then we can start to do more intensive exercises to gain more ROM.  It will not be too late as a lot of us are living proof of that.

WILL ROM IMPROVE AFTER TKR?

A lot of studies have been done on factors affecting ROM after TKR.  And these studies suggests that among the variables evaluated, the pre-operative ROM was the only significant predictor of post-operative ROM.  This does not mean that a patient with poor ROM before surgery will not achieve good ROM.  ROM is multi factorial and is very patient dependent.  The studies means that other observed factors such as diabetes, types of implant etc. do not have as much of a predictive value for post-operative ROM.  It seems that BMI is another factor that correlates with ROM as well.  This is certainly true because if I have leaner legs, I think I could bend more. 

So TKR may provide pain relief but ROM may not always be fully restored.  It's the same experience with stiffness.  Therefore, it would be a benefit if we do TKR when the knee joints are still in a better function as it will lead to better outcome.

HOW MUCH ROM DO WE REALLY NEED?

Seriously, how much ROM do you think we really need to function?  And will our limited ROM really limit our ability to carry out daily activities?  I did some research and found that normal ROM is around 130 to 140 degrees.  We need about 90 degrees of motion to climb up and down stairs, about 93 degrees to get up from a chair and 117 degrees to lift an object.  Now, if we don't live in a culture where we need to squat, kneel or sit cross-legged (which requires between 111 and 165 degrees), we would not be affected by the limited ROM.  So I feel there is really no issue with less ROM.  As you can see, normal routines like walking, sitting, climbing stairs and picking things up do not require high degrees of ROM.  Even with my 120 degrees ROM, it does not impair my overall function and I can still do high intensive exercises such as cardio, squats and lunges.  So I am at peace with my ROM and stiffness for that matter because the most important factor is that the pain from my knees had been removed and I am ever so grateful just for this alone.

HOW TO MEASURE ROM?

Here's a picture showing my ROM now below on the left.  The picture on the right uses a goniometer to measure ROM. I used the computer to draw an angular line from the hips to the knee and from the knee down to the ankle as shown.  Then I measure with a protractor.  It's as easy as that!  And to think that I had to procrastinate until now to do it.

Protractor

EXERCISES TO IMPROVE ROM

Here are some simple exercises which I obtained from the Internet to help improve ROM.  My favourite exercise is this first one below on the left as it's more friendly for my back.