Post-TKA stiffness with a new calf asymmetry
Ms R is 64 and is 5 weeks after a right total knee arthroplasty. At discharge two weeks ago her knee flexion was 85°; today it is 70°, with an 8° extension lag, a moderate effusion and warmth over the joint. She rates pain 6/10 at end range. She stopped her home exercises 10 days ago because her leg felt "heavy" and now spends most of each day in a recliner. Her right calf measures 3 cm more than the left; she says it is not especially tender. She walks short distances with a rolling walker, weight-bearing as tolerated. Her goal is to kneel in the garden by summer, and she has booked a holiday in 8 weeks.
1. You had planned aggressive end-range flexion stretching today. Which findings change your plan, and what do you do in the next 60 minutes?
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Findings that change the plan
- New unilateral calf swelling (3 cm asymmetry) in a limb that has had recent major surgery and 10 days of near-immobility.
- Regressing range of motion (85° → 70°) plus warmth and effusion.
- Reduced activity and dependency on a recliner.
These make a deep vein thrombosis a diagnosis that cannot be excluded in an outpatient setting. Regressing ROM with warmth could also represent infection or an reactive effusion, which likewise warrants medical review rather than more force.
Actions now
- Do not perform aggressive stretching, sustained end-range mobilisation, or any calf massage/compression.
- Measure both calves at a fixed point below the tibial tuberosity, and document colour, temperature, pitting oedema, and calf tenderness.
- Screen for systemic features: pleuritic chest pain, sudden breathlessness, haemoptysis, syncope. An affirmative answer escalates to emergency assessment.
- Apply a validated pre-test probability tool (e.g., Wells) to structure your communication; do not use it to rule out.
- Contact the operating surgeon or on-call orthopaedic team the same day and request urgent assessment (duplex ultrasound as directed). Document who you spoke to, when, and what was advised.
- Provide safety-netting instructions in writing and confirm she understands.
- Substitute safe, non-provocative work: gentle active-assisted knee ROM within comfort, quadriceps setting, ankle pumps, seated functional tasks, and gait practice.
The clinical error would be to interpret "stiff knee" as purely a mechanical problem and push harder into an undiagnosed medical one.
2. She asks: "Can't you just push harder and break the scar tissue?" How do you answer, and what does an evidence-informed plan look like over the next four weeks?
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Answering the question Correct the model without dismissing her: adhesions are not "broken" by force. High-force end-range work increases effusion, pain and protective muscle guarding, which is often what drives a further loss of range. Range is better restored with low load, long duration input plus strength and oedema control. Frame it as working smarter rather than harder, and link it to her goal (kneeling, holiday).
Plan components
- Range: sustained low-intensity end-range stretch, 3–5 times daily, 5–10 minutes per bout; prolonged low-load knee extension (e.g., prone hang or bag over the knee) for the extension lag.
- Accessory mobility: patellar and soft-tissue mobilisation as tolerated.
- Strength: quadriceps activation, inner-range closed-chain work, sit-to-stand, step practice; maintain hip abductor strength for gait.
- Effusion and pain control: elevation, relative rest after loading, activity pacing; use a pain-monitoring model (pain should settle to baseline within ~24 hours; if not, reduce dose, not intensity of the whole programme).
- Function: gait retraining to reduce extension lag and reliance on the walker.
- Monitoring: repeat flexion/extension and effusion weekly.
Decision point Agree an explicit review trigger: if flexion is not progressing meaningfully by roughly 8–12 weeks post-operatively despite good adherence, discuss referral for manipulation under anaesthesia or arthroscopic lysis with the surgeon. Referring early with objective data is better than presenting at 6 months.
3. She has abandoned her home programme once already. Write measurable goals and an adherence strategy you would document.
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SMART goals (examples)
- Knee flexion 0–100° active-assisted, and extension lag ≤5°, by 4 weeks, measured with a long-arm goniometer in supine.
- Walk 300 m indoors with a single-point stick and no rest by 6 weeks.
- Ascend/descend one flight of stairs with a rail, supervision only, by 6 weeks.
- Kneel on a padded surface for 30 seconds with support by 12 weeks, in line with her garden goal.
Adherence strategy
- Diagnose the barrier rather than scolding: she stopped because of "heaviness" and an unrecognised problem. Ask what made it hard, and what would make it possible.
- Reduce to a core set: 4–5 exercises, one sheet with photos or a short video, clearly marked dose and frequency.
- Habit stacking: link exercises to fixed daily events (after breakfast, before the afternoon news).
- Self-monitoring: simple tick chart plus a 0–10 pain and swelling diary to give her agency.
- Contact: a scheduled phone call at day 3 and day 10 to problem-solve, not just to remind.
- Social support: invite her partner to the next session so cues are consistent.
- Review: fortnightly supervised sessions to progress load and check technique.
Document goals, baseline measures, the barrier identified and the agreed review dates - this makes both progress and non-progress auditable.