Friend needs help coping with knee replacement

In My Humble Opinion
1

The usual disclaimer applies here. You’re not a doctor? No problem, I understand. You’re a doctor, but not my doctor or my friend’s doctor? That’s fine too. If you have any experience, training, or knowledge that might be of use here, I’m all ears. If you know something, please say something.

A close friend (in her early 60s) is having a miserable time recovering from single knee replacement surgery that happened back in early June. She knew to expect pain during rehab, but she’s having severe pain and has been unable to make progress. The major issues:

#1:
She does not tolerate narcotic pain meds well. Nausea is one issue, but she’s able to manage that with Zofran. The bigger problem has been that after a few days of oxycodone or morphine, she felt like her brain was out of control. She was having panic attacks and was not able to properly direct her thinking toward being well. She also tried tramadol and said that it gave her the worst hangover of her life, even when pre-treating with Zofran. I haven’t had any joints replaced yet, but from what I understand, narcotic pain relief is virtually indispensable if one expects to make progress toward restoring anything near full range of motion. So without pain management, it shouldn’t be any surprise that she really hasn’t been able to make much progress at all.

#2:
She is experiencing involuntary muscle guarding (presumably because of the pain) that is making it virtually impossible to flex her knee.

#3:
A couple of weeks ago she underwent mobilization under anesthesia (MUA) to break up the scar tissue adhesions in her knee, which (as I understand it) resets the rehab clock to zero. But with problems #1 and #2, she still hasn’t been able to make progress.

#4:
Her mental/emotional state is deteriorating. She’s usually rock-solid and busy with life, but after many weeks of severe pain, immobility, and lack of sleep, she is bordering on suicidal. I mean no active suicidal ideation just yet, but she told me yesterday that she is “tired of existing” and said that if you told her she was going to die soon, she wouldn’t care and might even feel a sense of relief. The replaced knee is on her right, and so she can’t even drive herself anywhere. She’s got a great support network – her husband is wonderful, and her kids live nearby and are doing their part; together with her network of friends, they are all chipping in to help with daily logistics, e.g. meals, laundry, driving her to appointments, and so on. That’s all great, but the core issue is her severe chronic pain, inability to make progress with her rehab, and now severe anxiety and pessimism about whether she’ll ever really be able to walk again. For a long time (unrelated to her knee replacement), she’s been taking mirtazapine to help with insomnia. Last week her primary care doctor added Prozac on top of this. She said it helped a bit, but not as much as she needs; when I talked to her yesterday, she was a wreck, a lot of really heavy-duty crying. This is really not her style at all, and I’m worried.

It seems to me she hasn’t had good care following the initial surgery. She was never told that there was a limited amount of time (8-12 weeks, depending on who you talk to) in which she would have the opportunity to achieve maximum range of motion. She was never told that when using her hands and arms to bear most of her weight when getting up from a seated position, she should try to keep her wrists straight instead of putting her palms flat on the armwrests/seat; after doing this the wrong way for many weeks, she is now suffering chronic wrist pain.

I’m guessing she’s not the first person to struggle with an intolerance for narcotics, or the first person to deal with muscular guarding, or even the psychological complications that come with struggling through a lengthy and painful rehab. Does anyone here have any advice on what she can do to help tackle these problems? Any advice on what she can tell her doctor, PT, or surgeon, or what she can ask them?

Thanks for any help you can provide.

2

This sounds horrible. I had both knees done separately and in the first few weeks the pain was terrible and I needed oxycodone to get through the first 6 weeks each time. It may not be considered a lot of drugs, but the early PT was extremely painful even though the therapist were fantastic. And I had no problems getting around on arm strength alone. So your friend sounds like she’s in dire straits right now and the problems are compounding.

I think she should find new doctors. If they did not know she wouldn’t be able to tolerate pain killers through no fault of their own then maybe they didn’t do a bad job, but they’re not dealing with these circumstances well and it doesn’t sound like anything to wait and see about.

I hope she can get in contact with a major medical center that has the personnel and resources who can get her back on the right track right away.

3

The mention of muscle guarding and not standing up properly makes me think PT may be, at least partially, an issue.
When I did PT for my shoulder (not a replacement, just a tear), while it was probably the worst part of the ordeal, a big part of it was them teaching you how to stop guarding and how to move everything properly. That makes sure the muscles that are supposed to be doing the heavy lifting, are. Otherwise it’s really, really easy to get into bad habits. My surgery was several years ago and I still regularly catch myself with my shoulder tensed up.

I’m curious, however, if the other part of the problem is her sensitivity to narcotics. If she doesn’t want to take them, is she at least taking some NSAIDs? I remember my doc once mentioning (unrelated to my shoulder) that he wanted to reduce my pain since it’s going to take longer to heal if I’m walking around with that area all tensed up.

Zofran is the go to for nausea, but there are other options. Also, WRT narcotics, she might ask about Oxycontin so the dosage is spread out over time instead of getting hit with it all at once.
Also, WRT to the hangover, she could inquire about some migraine meds (ie imitrex or maxalt). I know they’re for migraines, but if by ‘hangover’ she’s getting a nasty rebound headache, a migraine med might just do the trick.
Also, maybe muscle relaxants?

Another option could be a slow released nerve block. It only lasts a day or two, but maybe that could buy her some time to move around a bit and start loosening things up.

But, this might all be gibberish as I have no experience or real knowledge of joint replacement recovery.

One last thing, if she’s going through all this with her primary, it might not be a bad idea to set up an appointment with the ortho that did the surgery. Or maybe a different ortho/primary/PT. It might just take a fresh set of eyes/ears/hands on the problem for someone to see something the other’s missed.

4

Okay, this is not active suicidal ideation but it is passive suicidal ideation. Nobody in this thread can help your friend with that. Whatever mental health support your friend currently has isn’t enough.

If her PCP gave her Prozac, I take that to mean she doesn’t have a therapist of any kind. She needs to get one. Yesterday.

5

If it’s for mental health, I agree, however, Prozac is often part of a pain management strategy, so it could just be that. Granted the other things mentioned in the thread (ie being tired of existing) suggest otherwise, it doesn’t necessarily mean that’s why she’s on it.

Having said that, since the S word is on the table, I knew a guy that went that route after a knee replacement. Not sure if it makes a difference for the OPs friend, but he was a nervous wreck for months leading up to it. In the few minutes, once a week, I interacted with him he seemed like a perfectly normal, well adjusted person. However, this surgery was weighing on him to the point that, most people, upon hearing that he died (and this was a few months post-op), correctly guessed that it was suicide.
But, again, I only saw him a for a few minutes here and there. I think the only thing I knew about his personal life was that he’d been to something like 50 Blue Oyster Cult concerts.
IOW, I have no idea if what he did was just about the surgery or if the surgery was a tipping point after a lifetime of mental health issues.

6

Yes.

My answer is admission to an acute inpatient rehabilitation hospital. Unfortunately, if in the U.S., the first answer of the insurer is likely to be that they only even consider it if the knee replacement was bilateral. However, there seems to me special circumstances here.

Now, the push in terms of insurance would probably have to come from a doctor.

In case anyone is wondering, you don’t make an up front issue of the number of days in the acute rehabilitation hospital. Once in the hospital, they will make the case to insurance that it is too soon to go home as long as needed.

I had both knees successfully replaced four years ago — two operations one week apart. Ten days in the surgical hospital, and about ten days in rehab. My understanding is that my surgeon, or his office, has to make an individualized case to insurance, for each patient, why they have a special need for acute rehab. (Word “acute” is important — those are the better inpatient rehab facilities).

P.S. If any kind of good rehab hospital, they have mental health docs as well as physical medicine.

7

Thanks to all who responded; I see several potentially helpful suggestions here that I will be relaying to my friend later today.

The ortho that did the surgery is a bit of an ass. During a follow-up visit several weeks after the surgery, the surgeon was basically criticizing her for having not achieved a better range of motion, as though her circumstances were perfectly normal and she was simply not trying hard to enough. A second opinion might be in order.

I forgot to mention the prednisone, which was prescribed after she told her doc that she couldn’t handle the narcotic pain relievers. She didn’t say what that did for joint pain, but she did mention that she developed thrush and two separate UTIs. What she’s been through would be a lot for anyone to take.

8

Maybe it’s time for her to find a new ortho. If she likes her primary, she could ask their office for a recommendation. It doesn’t even have to be awkward. I switched to a new PT office at one point and simply told my doc that I had a personal issue with someone that worked there and I was uncomfortable*. But just a simple ‘We’re just not on the same page’ would work as well.
I also try to remember that if I feel this way, there’s probably others who do as well. IOW, there’s a good chance this isn’t the first time her primary has heard this complaint and likely (hopefully) won’t push back.

*The receptionist was my ex-wife’s new MIL. I have exactly no interest in being in the same room as her, but that’s a whole other story.