In this episode, we discuss knee pain, a problem that most men will experience at some point in their lives. Most of the time, the problem can be solved by simply taking a pain reliever. But what if the pain keeps coming back? How can you prevent it from getting worse? What noninvasive and minimally invasive treatment options are available? And when is it time to start considering surgery? We presented these questions to orthopedic surgeon, Dr Erik Zeegen.
Dr. Erik Zeegen
Dr Zeegen attended UCLA and UC Berkeley as an undergraduate. He then graduated from UCLA Medical School and completed his residency in orthopedic surgery at UCLA. After residency, Dr Zeegen completed an Orthopedic Surgical Oncology fellowship at Massachusetts General Hospital and an Adult Reconstructive Surgery fellowship at New England Baptist Hospital. After his training, Dr Zeegen returned to Los Angeles where he served as the Associate Medical Director of the Valley Hip and Knee Institute until recently when he was named the Chief of Joint Replacement Surgery at UCLA.
10/7/2021
Better Man Clinics
What are the potential common causes of knee pain?
Dr Zeegen
Well, first off, just to make it clear, my sub-specialty is joint replacement surgery and, because I’m at UCLA and have a pretty specific practice for joint replacement, most of the people coming to see me these days have pretty significant arthritis and they come to see me to discuss knee replacement surgery. That being said, I can put on my general orthopedics hat. Knee pain can be as simple as a sprain or strain, which really just means that some of the soft tissues around the knee have been injured to a minor degree. It can also represent more significant soft tissue injuries, like a ligament tear, which is probably the most common injury to the knee in sports related activities. A lot of athletes have ACL (anterior cruciate ligament) tears or meniscus tears. The meniscus is the cartilage that sits between the two bones of the knee (the femur and the tibia). Some people have knee pain due to problems with the kneecap (patellofemoral syndrome) while others have irritation of the thick band of tissue on the outer side of the thigh that runs down to the knee (the iliotibial band syndrome.) As I was mentioning before, many people have knee pain due to arthritic conditions, the most common of which is osteoarthritis but also includes subtypes such as rheumatoid arthritis or psoriatic arthritis or other inflammatory arthritis conditions. Other causes of knee pain include traumatic injuries (fractures, subluxations, or dislocations), infections and tumors.
Better Man Clinics
What are the red flags associated with knee pain that should trigger someone to see a doctor?
Dr Zeegen
That’s a good question. One thing to be aware of is significant swelling of the knee. If, all of a sudden, your knee is two or three times its normal size, that’s something that you probably ought to have looked at. If the knee is warm and red or hot, that can be a sign of an infection. If you can’t put weight on the knee or cannot fully straighten or bend it, you know that that’s also an indication that there is something pretty significant going on.
Better Man Clinics
Let’s take the acute knee injuries out of the picture and focus on chronic conditions like arthritis. Are there any specific activities that make knee pain worse for men with chronic knee pain?
Dr Zeegen
High impact activities certainly can put a lot of stress on the knee. Activities like running, jumping, and even deep squats can put a lot of force on the knee. When we look at kinematic studies (we can do this in the biomechanics lab), we can measure how much force is placed on the knee through various activities. Walking doesn’t put that much stress on the knee (probably about half your body weight). But, if you start doing things like jogging, about seven times your body weight is going through your knee. If you are doing a deep squat, up to about 20 times your body weight is going through your knee. Those types of activities can put a lot of stress on the knee. If you compound that with somebody who is carrying extra weight, the amount of force transmitted through the knee is exponentially increased during those particular activities.
Better Man Clinics
What can guys do to potentially mitigate or limit chronic knee pain? Does weight loss help?
Dr Zeegen
Absolutely. If you are carrying an extra 10 pounds (which doesn’t seem like a lot) and going out jogging, that is 70 extra pounds your knee is feeling in terms of force across the joint, which is pretty substantial. I think that keeping your weight optimal is one important factor. I think, as we all get older, it’s really important to listen to our bodies. For example, I used to be a runner. A few years ago, I started realizing I just couldn’t run four or five times a week because, if I was doing that, my knees and my back would really start hurting. So I started mixing things up and incorporating low to no impact activities into my exercise regimen. So now I may run one or two times a week, ride a bike, and hike a little bit more. I also think it helps to do resistance exercises. It doesn’t have to be massive amounts of weight, but some sort of resistance exercise (either with bands or light weights) to keep your muscles strong, can help take some stress off of the joints.
Better Man Clinics
You mentioned activities like bicycling and swimming as low impact exercises. How do you determine if an activity is low impact?
Dr Zeegen
Here is a simple way to think about it: a low impact activity is any activity where you always have at least one foot on the ground. If you think about it, the difference between walking and running is that, when you’re walking, one foot is always on the ground between each step. In contrast, when you’re running, there is a moment in time between each step that the body comes completely off the ground. And it’s that impact of landing that really creates that shearing force on the knee. So any activity in which both feet come off the ground is probably going to impart a lot more stress on the knees.
Better Man Clinics
How does strengthening the muscles of the legs help keep chronic knee pain from getting worse?
Dr Zeegen
Keeping the muscles strong takes some of the stress off the knee itself. The muscles can stabilize the knee. Instability can lead to shear forces and stress to the articular cartilage and meniscal cartilage. If your muscles are nice and strong (and stable), there’s less chance of that happening. That said, it is important to understand there are different types of resistance exercises. When we’re talking about the knee, there are what we call open chain and closed chain exercises. Think of your leg as a chain. If your foot is free (rather than on the ground or pushed up against something) that’s considered an open chain. The key exercise I tell most of my patients to stay away from are the knee extensions. We’ve all seen those: you sit at the chair and you put your foot on the on the lever and you extend your knee against weight. This type of exercise creates a huge torque on your knee. In contrast, with closed chain exercises, where your foot is against the ground (like with squats or leg presses), that torque is eliminated and it’s just a force being dampened through the tibia. You are still getting the workout on your quads and hamstrings without that huge torque. Doing those types of exercises is definitely a better idea. However, you want to be careful to not be doing deep squats. I tell my patients to not squat beyond the point where the angle of the knee is 45 to 60 degrees. It is important to stop at that point rather than squatting all the way down. Hamstring curls are also okay. They are opposite of the knee extension. Even though the foot is free with that exercise, it’s not putting a huge torque on the knee as is the knee extension.
Better Man Clinics
Are some types of shoes better than others in helping men with chronic knee pain?
Dr Zeegen
I don’t know of any data that shows that there’s a particular shoe that makes a difference for knee pain or knee arthritis. I get asked that question periodically and I just tell patients to just use common sense. You want to have a shoe that’s comfortable and provides good support. You probably want to stay away from a shoe that is causing pain in your foot or feeling like it’s throwing your gait off and making you walk differently than normal.
Better Man Clinics
What role do heat and ice play in managing knee pain?
Dr Zeegen
That falls into a pneumonic we call RICE: Rest, Ice, Compression, and Elevation. Ice is good for an acute injury. If you’re playing basketball and your knee starts to hurt, putting ice on it right away is definitely something that we recommend. Ice is good because it decreases the inflammatory response and can be very helpful for an acute injury. Heat is good later, maybe a couple of days later, when you’re in a little bit more of the recovery phase, the acute inflammation has settled down and you’re trying to get the knee moving a little more comfortably. Heat will do the opposite of ice by causing vasodilation (widening of blood vessels) which brings more blood flow to the area and helps loosen things up a little bit.
Better Man Clinics
For men with chronic knee pain, is activity a good or bad thing for the knee?
Dr Zeegen
Well, you know, every patient is different. If you do have some pre-existing arthritis in your knee, you want to be smart about how you’re being active. You want to pick activities that are low to no impact. You certainly don’t want to be a couch potato, because not being active will decrease the muscle tone. You know, we need to be weight bearing for the strength of our bones. We know that if you’re not stressing the bones then the bones can become more osteoporotic, which is not healthy. So, we generally recommend that even patients who have advanced osteoarthritis of the knee try and stay as active as possible. They just need to be smart about it and stick with low or no impact activities.
Better Man Clinics
Men with knee pain often rely on NSAIDS like Motrin or Advil to help manage their pain. Is there a certain point when a guy needs to realize that he is relying too much on this medication to manage his pain and to function? Is it a matter of how much of the medication they are taking each day or the length of time for which they have been taking it? When should men taking this medication for chronic knee pain start giving some significant consideration to seeking help from a doctor?
Dr Zeegen
Every patient brings a unique set of circumstances to the situation. I don’t think that there’s a real hard number to go by. Generally, when patients come to see me and tell me that they’ve been taking 600 milligrams of Ibuprofen, three to four times a day for months on end, that’s somebody I’m worried about. Nonsteroidal anti-inflammatories (NSAIDS) like Ibuprofen and Naproxen can have a significant effect on kidney function. They can also raise blood pressure and cause problems with the gastrointestinal tract. People taking the medication can develop bleeding ulcers. There have been many cases of patients who have severe osteoarthritis that take tons of Ibuprofen and develop a bleeding ulcer and come to the hospital with significant blood loss. Those are extreme cases, but it is something you want to avoid. When somebody comes in taking that amount of anti-inflammatories, it’s time to have a discussion about alternative treatment modalities to deal with their arthritis.
Better Man Clinics
What is the role of Glucosamine and Chondroitin in treating chronic knee pain?
Dr Zeegen
It is a huge industry. Tons of money is spent in the United States on these products. There is a lot of hype about them. They have been studied pretty extensively but the data is very soft. There are a lot of systematic reviews and meta-analyses looking at all the different studies of these supplements. There is some suggestion that if you take this stuff for about three months or more, you may see a very mild improvement. But again, it’s a soft call. We’re talking about statistics. Something can be statistically significant in terms of there being a difference between these remedies and a placebo, but is there a meaningful clinical difference? When you look at some of the scoring systems that we use to objectively see if somebody’s knee pain is better or worse than placebo, there’s really no clinically meaningful difference. When you look at the guidelines put forth by the American Academy of Orthopedic Surgeons, glucosamine and chondroitin are not recommended for use for severe osteoarthritis.
Better Man Clinics
What are your thoughts on the use of kinesio tape for managing chronic knee pain?
Dr Zeegen
A lot of physical therapists are big believers in it. My feeling is that there’s no harm in it. I don’t know that there’s a lot of hard data to say that it makes a difference. So I tell patients, “if you feel it’s helping, by all means continue, but I don’t know of any data to show that makes a big difference.”
Better Man Clinics
Some guys have tried many of these conservative treatments without success. Is there a right time to see a doctor about knee pain aside from the red flags that we mentioned?
Dr Zeegen
I think when it becomes really intrusive into somebody’s life, it’s time to seek medical attention. For every patient that’s kind of a unique set of circumstances. For some people, it’s when they have difficulty going up and down stairs and they live in a two-story house or if they’re a golfer, and they can no longer play their 18 holes of golf three times a week or a cyclist who can no longer do that ride that they want to do, or they can’t pick up their grandchild. Basically, when the things that you are used to doing are no longer tolerable because of the knee pain, that is a sign that you should go see a doctor.
Better Man Clinics
What should someone going to see a doctor for evaluation of knee pain expect at the first consultation?
Dr Zeegen
An important part of any doctor’s visit is taking a good history – listening to the patient, hearing what’s going on. You can get a lot of information just from the history. “Does it hurt when you’re just walking? Does it hurt only when you flex the knee in a certain way? Does it feel unstable?” Right away, I’m trying to differentiate all the different things that can be going on. After taking a good history, we proceed to a physical exam which involves watching the patient walk up and down the halls. I watch their gait pattern, see if they are limping or if there is a deformity to the knee, and assess the range of motion and the stability of the knee. I then examine the knee, checking the cruciate ligaments, the ACL, PCL, as well as the collateral ligaments, and then doing provocative maneuvers to see if there’s any potential meniscal injury, assessing the kneecap or the patellofemoral compartment. There are a lot of things we can do pretty quickly to get a good sense of what’s going on with the knee. After the exam, we then use some sort of imaging modality to assess the knee. Imaging usually starts with a plain X ray and then proceeds to more sophisticated modalities like CT scan or MRIs.
Better Man Clinics
If you think that a patient’s knee pain is due to arthritis, is imaging still important? What are you looking for in that situation?
Dr Zeegen
Imaging is very important. I rely on it quite a bit. The key is that we want to get weightbearing X rays. A lot of times I see patients that come in and see me and they’ve had x rays elsewhere, but they weren’t weightbearing x rays. You can see dramatic differences in the joint space between a supine (lying down) non weight bearing X ray versus a weight bearing X ray. We want to see how much joint space there is, as well as radiographic signs of arthritis. If we start to see those things, then we know that somebody has more significant osteoarthritis of the knee. We can also use plain X rays to get a gestalt view of the knee: looking at the overall alignment, the quality of the bone, whether or not osteoporosis present or not, and ruling out any other acute things like fractures and dislocations. We can get a lot of information from just a plain X ray.
Better Man Clinics
What is the role of physical therapy in the management of men with knee pain due to arthritis?
Dr Zeegen
I’m a big believer in physical therapy. I think it definitely helps. It goes back to what we were talking about earlier with generalized strengthening of the muscles around the knee. A good physical therapist can do a really good assessment of a patient, analyze their gait mechanics and see if there are some things that they can work on with the patient on in terms of improving their gait. They can work on some range of motion exercises. They have some treatment modalities that use ultrasound stimulation and something called iontophoresis, where they use a combination of ultrasound and maybe some topical corticosteroids. There are a lot of different modalities they can use to help over about four to six weeks. I think that can certainly help patients with, maybe not getting rid of the pain completely, but dialing it down several notches so that they can get back to doing the things that they want to do.
Better Man Clinics
What is the end point of physical therapy? What happens when someone completes a 6 week treatment course and feels better? Do they have to maintain that physical therapy indefinitely or do the therapists teach them how to perform some of these treatments independently at home?
Dr Zeegen
It becomes something like brushing your teeth. It is something that you have to do on a daily basis to maintain those gains that are made with physical therapy. The home regimen includes doing the exercises that you’ve learned in therapy for quad strengthening or hamstring strengthening, stretches, and practicing the proper gait – how to get up from a seated position in the chair properly, how to go up and down stairs. All those things are really important and can make a big difference.
Better Man Clinics
What role do cortisone shots play in the treatment of chronic knee pain?
Dr Zeegen
Cortisone shots have been around for a long, long time and are one of the workhorses of injection therapy for knee and hip arthritis. We use them quite a bit in orthopedic surgery. Basically, cortisone is a very potent anti-inflammatory. Instead of having to take huge doses of Ibuprofen, we can deliver a very concentrated amount of a potent anti-inflammatory into the knee joint, and it stays there for a while. People can see a significant reduction in the inflammatory response in the knee after an injection. I use it a lot in my practice for people who are coming in that have chronic osteoarthritis and say, ”my knee is just acting up, it’s starting to hurt more.” I’ll give them a shot and the effects can last about three months. I’ve had some patients that I don’t see back for a year after a cortisone shot. On average, though, most cortisone shots last somewhere between two to three months and then start to wear off. They are a good option for a short term fix. But if we’re talking about somebody with more advanced arthritis and the idea of a knee replacement is starting to come up, I’m not a big fan of trying to have that patient use the cortisone as a way to treat their arthritis for months or years on end. I think that’s expecting too much of cortisone.
Better Man Clinics
So, just to summarize, getting cortisone shots every 3 months indefinitely is not a good option to manage chronic knee pain?
Dr Zeegen
Correct. As you know, as with anything in medicine, there’s always a risk-benefit ratio. The risk of a cortisone injection is quite low. However, anytime we put a needle into a joint, there’s always a very small risk of introducing an infection. If the healthcare professional performing the injection is somebody who has done a lot of them and is skilled at doing them and uses proper sterile technique, the chance of infection is extremely low, but it is not zero. There is always a small chance. There is also a small incidence of patients who get a flare up of inflammation from the cortisone shot itself. Some patients describe getting a cortisone injection and then, 24 hours later, develop pain. It happens infrequently, but we do see it from time to time. It can resolve on its own but it can take several days for that to occur. It’s a little disconcerting for us as physicians, but even more disconcerting for the patient. But that’s rare. Also, a cortisone injection itself, if done repetitively for months on end, can weaken some structures and soft tissue around the knee, so you don’t want to be doing it indefinitely. That’s just not a wise idea.
Better Man Clinics
Are platelet rich plasma (PRP) injections beneficial for treating chronic knee pain?
Dr Zeegen
PRP or platelet rich plasma is basically what we call a biologic injection. It involves taking a patient’s own blood and spinning it down to concentrate the platelets in their own plasma. This solution of concentrated platelets in plasma is then reinjected into the knee. The thought is that it helps stimulate some growth factors in the knee that might help stabilize some cartilage cells and reduce inflammation. It’s been around for a while and has gotten a lot of press. However, similar to a lot of other things that we’ve talked about, the data is mixed. There are some studies that may show a statistically significant difference when you look at some of the scoring systems that we use when we compare PRP injections to say, a placebo, or maybe even some other injections we haven’t talked about, like hyaluronic acid injections. But there is often no clinically meaningful difference between them. I see a lot of patients that come in and tell me they’ve tried it but they didn’t really feel it makes a difference. Now, that’s somewhat of a biased view, because I’m a joint replacement surgeon and they’re coming to me for surgery because other options did not work. But if you look at the data, like I said, it’s mixed in the large scale studies. It is kind of hit or miss. I rely a lot of the guidelines put forth by the American Academy of Orthopedic Surgeon. PRP is not something that is endorsed by the American Academy of Orthopedic Surgeons. In my practice, I don’t use it. There are a lot of my colleagues who offer it to patients. I would say it’s kind of plus minus.
Better Man Clinics
You had mentioned hyaluronic acid. How does hyaluronic acid injection help with chronic knee pain?
Dr Zeegen
Nobody knows exactly how the injections work. There is some thought that they just merely help lubricate the joints by increasing some of the synovial fluid production. There is a theory that it helps stabilize some of the contact sites for the cartilage cells, keeping them from degenerating even further. But nobody really knows exactly the mechanism by which it works. That being said, I use these injections a fair amount in my practice for patients who are on the fence and not quite ready to talk about surgery, but they want something to help them. I would say that probably about 60-70% of the patients to whom I give the injections have some degree of a favorable response. They may notice that the knee doesn’t hurt quite as much as before and they can see those effects lasting for six to eight months. Then it wears off and then they come back and do it again. Usually after about three rounds of those injections, I start having a more serious discussion with the patient about the need for surgery.
Better Man Clinics
It sounds like the take home message for injectables is that they might provide a short term fix, but none of them seem to be a true long term solution?
Dr Zeegen
Yes, as I tell my patients, it’s a temporary treatment for the symptoms but it doesn’t treat the underlying cause of the problem, which is that the arthritis has become so severe that the bones are rubbing against one another. The cartilage has really deteriorated to the point where it’s just gone or almost completely gone.
Better Man Clinics
What are the most common surgeries performed to treat chronic knee pain?
Dr Zeegen
The most common knee surgeries are arthroscopy (some sort of minimally invasive surgery where you’re just making tiny little incisions and putting a camera in the knee) and joint replacement surgery. A generation ago, it was popular to talk about osteotomies around the knee. If a younger person had developed arthritis in just one compartment of the knee, we could perform an osteotomy, which means cutting the bone and then realigning the bone so that you’re now redistributing the forces across the knee. For example, people who have bad arthritis in the medial or inside compartment of their knee tend to have what we call a varus deformity or bowlegged deformity. And if you drew a mechanical axis from the center of the hip down in the ankle, that mechanical axis would fall onto the medial side of the knee so that all the stress is along that medial side of the knee. If you do an osteotomy, and correct the tibia, you can now reorient the mechanical alignment so that it is falling down the middle of the knee and taking some of that stress off the middle of the knee. That is an older type of procedure. It is really not that popular anymore. It has fallen out of favor. It has been really replaced by more of a partial replacement, which is replacing just one compartment of the knee. Arthroscopic surgery is really more for patients who have a meniscal tear- we can clean up the meniscus, shave away that torn portion of the meniscus or, in some situations, we can actually repair it. That depends on the location of where the tear is and whether there’s a good blood supply to the meniscus that can allow it to heal. For patients who come in with pretty significant arthritis (with already bone on bone), we try and stay away from arthroscopic surgery because we now know from large scale studies that, when you do an arthroscopy on someone with bad arthritis, that actually accelerates the arthritic process. We try and steer patients away from that arthroscopic cleanout. Patients come in and ask for that all the time and we have to have a discussion to educate them on why that’s not such a good idea.
Better Man Clinics
What exactly is a knee replacement? Are you implanting some sort of bionic knee?
Dr Zeegen 43:35
That is a great question I get asked every day. Just the term knee replacement conjures up all kinds of thoughts of cutting way up the femur and the tibia and taking the whole knee out and putting in a bionic knee. The better term would be a knee resurfacing because that’s really what we’re doing. We are basically resurfacing the ends of the bone. We are just basically sculpting the end of the femur to take away whatever small amount of remaining cartilage there is and maybe about a centimeter of bone. On the top of the tibia (the lower leg bone) we are taking about a centimeter of bone and cartilage off. We are then putting metal caps, so to speak, on the ends of those surface. And then, in the middle, we’re putting a plastic liner. We are basically recreating a very smooth surface for the knee to articulate so that there’s not that rough surface like there is with the arthritis. And at the same time, while we’re doing that, we’re also trying to realign the knee. A lot of patients who develop severe arthritis also develop either bowlegged deformity or knock-kneed deformity when it goes the other way (what we call valgus). In those situations, we have to reorient the alignment because we don’t want to leave their knee deformed because then the implant will have a higher chance of loosening earlier and failing earlier. We really want to get the alignment right and, at the same time, with all that we’re trying to balance the soft tissue so that the tension on the medial side is equal to the tension on the lateral side. That also helps with the stability of the knee and the ability to get the full range of motion and helping to make sure that the implant wears appropriately.
Better Man Clinics
How long does a knee replacement surgery take to perform on average?
Dr Zeegen
The surgery takes approximately one hour and 15 minutes.
Better Man Clinics
Does it require hospitalization or can people usually go home the same day?
Dr Zeegen
We are at the point now where people who are relatively young and healthy and don’t have major medical comorbidities can be discharged the same day. They arrive in the morning and can go home that same afternoon. It’s not for everybody, but for a small subset of the patients. Right now, I would say that probably about 30 to 40% of our patients are going home the same day. Otherwise, patients are spending one night in the hospital and going home the next day. On rare occasions, for some of the older patients who are over 80 and maybe have other medical conditions, we might keep them up to three nights depending on how they do.
Better Man Clinics
Does the procedure require general anesthesia?
Dr Zeegen
Typically, these procedures are all done under regional anesthetic (meaning spinal or epidural anesthetic combined with a nerve block). We utilize what is called an adductor canal block, where the anesthesiologist places a small catheter into the adductor canal in the leg where the saphenous nerve runs. That catheter is attached to a pain pump that slowly infuses local anesthetic. We usually leave that in for 72 hours. So that really makes a big difference in terms of the pain control after a knee replacement. This adductor canal block is combined with a spinal anesthetic and some sedation. Most patients are in a kind of twilight sleep. They do not have a general anesthesia with an endotracheal tube, but rather, are just sedated. Most patients don’t even remember being in the operating room. It is a very pleasant experience for them.
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What are the risks of this type of surgery?
Dr Zeegen
The two things that we worry most about with joint replacement surgery are infections and blood clots. The risk of infection after a knee replacement are probably on the order of about 2% to 3%. That’s kind of the national average. If infection does happen, it can be a big problem. However, we are very meticulous with how we keep the environment as sterile as possible. You can’t make the case completely sterile, but we try and keep things as clean as possible. We wear special “spacesuits” that help decrease any shedding of microscopic particles that can get into the surgical field. We also administer antibiotics before and for about 24 hours after the procedure. A lot of the risk is technique dependent. You need to make sure that you’re not taking too long with the surgery because surgeries that take significantly longer than the national average are at higher risk for infection. Also, some patients with various medical conditions are also at greater risk for infection. This high risk category includes obese patients, smokers, diabetics with poor glucose control, and patients who are immunocompromised. So there are things that we can control and some things we cannot control, but we will try and optimize the patients ahead of time to really make that risk of infection is as low as possible.
The other big risk we worry about is blood clots. Blood clots are always a small risk after knee and hip replacements. As we’ve gotten into the more rapid recovery phase over the last several years, and patients are getting up and walking much more quickly (like a few hours after surgery), the risk of developing a blood clot or DVT (deep vein thrombosis) becomes much, much less. A lot of the data on DVT occurrence is based on older literature when patients were staying in the hospital for seven days and not getting up for physical therapy right away. In this more modern era, the risk is lower, but it’s not zero. Keeping this in mind, we put patients on some form of a blood thinner after the surgery. In this day and age, if a patient has had no previous history of a blood clot, we usually start them on a low dose aspirin twice a day for about four to six weeks after the surgery. That has been shown to be as effective as preventing blood clots and pulmonary embolism as compared to some of the more traditional anticoagulants like Coumadin or Lovenox. We try and stay away from those types of agents because those have a much greater risk of bleeding at the operative site, which we want to avoid. Now, if a patient comes in with a previous history of a blood clot, or they’re already on a blood thinner before the surgery (say for atrial fibrillation), or they’ve had a history of many blood clots and they’re on chronic blood thinners, then we have to pay close attention to that and then put them back on a blood thinner after the surgery. So those are two big risks. There are other lesser common risks like stiffness of the knee, limited range of motion, fractures around the knee, ligament injuries, problems with the skin healing, and nerve injury. Those are all very rare but are things that we mention to patients beforehand.
Better Man Clinics
How much pain is expected both immediately after knee replacement surgery?
Dr Zeegen
Immediately upon waking up in the recovery room, most people are actually quite comfortable because they’ve got that block in place. We also administer what’s called a peri-articular injection at the end of the surgery. After we’ve put all the implants in, but before we start suturing up the knee, we inject a “cocktail” in the soft tissues around the knee. The cocktail is a combination of short acting and long acting local anesthetic and an anti-inflammatory and even a small dose of a corticosteroid to help with decreasing inflammation. The combination of those medications really helps make patients feel really comfortable when they wake up from procedure.
Better Man Clinics
What kind of pain should be expected in the first few weeks after the procedure?
Dr Zeegen
Knee replacements definitely are known to be associated with a considerable amount of pain after the surgery and once the block is worn off (once they take that pain medicine catheter out at the 72 hour mark). It can be sometimes shocking to patients that they’re having pain, but with the right combination of pain medications and anti-inflammatories, we can really keep the pain under control and get them through the process. On average, I think the more significant pain occurs during the first couple of weeks and then it really starts to ratchet down. But I always tell my patients that it generally takes about three months to completely rehabilitate the knee and get through the whole recovery phase. Even at three months, you’re probably only about 90-95% of the way recovered. To feel like you’re 100% recovered, I think takes a full year. And that’s where patients can get a little frustrated. I see patients back at the three month and six month mark and at that six months they are off pain medications and back to playing golf, or hiking and doing all the things they want to do. However, they are still reminded that they had surgery. They might have a day where they feel a little more pain or sometimes they complain that the knee feels a little mechanical (they might feel a click or hear something in there moving around). That is because it is an artificial knee- it is metal and plastic. So it can give you that sense. I think it takes about a year just to kind of acclimate to that whole notion that this is a mechanical knee.
Better Man Clinics
Do patients require bed rest immediately after surgery or can they start walking around pretty quickly?
Dr Zeegen
They start walking the day of surgery. For the patients that we send home the same day, the physical therapist comes and sees them in the recovery room an hour and a half after they’re fully awake and gets them up and they are walking up and down the hall. We even have them go up and down stairs before they leave that same day.
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Does every patient undergoing a knee replacement require physical therapy for some time after surgery?
Dr Zeegen
For knee replacements, I think physical therapy is a very critical part of the recovery process. I personally recommend physical therapy for all my patients after knee replacement surgery. There are some surgeons out there who are starting to move away from it. But I still think it’s a very critical part of the recovery process. Most of us have gone away from therapy after a hip replacement, because it’s really not necessary. For the knee, I still think the patient really benefits from working with a therapist to help them really bend the knee and work on getting full extension. A lot of patients use a walker for the first week and then transition to a cane and their therapist can help guide them in that process like when to transition and when it’s okay to get off the cane. I really rely on the therapist to handle that part of the recovery process.
Better Man Clinics
When can people with desk jobs usually return to work after a knee replacement surgery?
Dr Zeegen
For people with desk jobs, which are the majority of my patients, it’s really when they feel comfortable getting back to doing that. I’ve had some patients who return back to a desk job within a couple days after the surgery because they can work from a home computer. You do have to be careful because the knee and leg will tend to swell. So if you are trying to sit at your desk for six hours at a time, it’s not going to be good – it’s going to swell and become painful. You need to be smart about it and break it up into very small increments, but it is doable.
Better Man Clinics
How soon can you drive after knee replacement surgery?
Dr Zeegen
If it is the right knee, which we use to shift from the gas to the brake, we usually tell patients to probably wait about two weeks before you’re behind the wheel. We used to recommend a longer period of time, but we’ve had some more recent studies to show that the reaction time of going from the gas the brake was actually pretty normalized by about two weeks. If it is the left knee, it’s really once patients are comfortable getting in and out of a car and they haven’t taken a pain pill within four hours of driving.
Better Man Clinics
How soon after knee replacement surgery can you return to the gym and exercise?
Dr Zeegen
I actually tell people they can start doing exercise like riding a stationary bike, walking, and doing the elliptical, as early as they feel comfortable doing those things because those things will help with regaining the full range of motion of the knee. It has to be done in a in a graduated fashion. You don’t want to just get on a bike and ride the first day after surgery.
At 3 months, I basically say that they can do whatever they feel comfortable doing. But they can start doing things much earlier in that recovery phase.
Better Man Clinics
How durable is a knee replacement? Is it good for life or does it need to be replaced in 10 or 20 years?
Dr Zeegen
The average time that we tell patients that a knee replacement is going to last is about 20 years based on large scale studies looking at all the implant data out there. Twenty years is a good estimate. For some people its longer, for some people shorter. A lot of it has to do with how well the implant is put in as well as patient factors like their activity level. It is kind of like tires on a car- if you only drive your car from your house to the supermarket once a week (very low mileage) the tires are going to last a long time. But if you’re taking your car and going off roading every weekend, you are going to wear the tires out a lot sooner.
Better Man Clinics
What should someone planning for a knee replacement surgery be asking of or looking for in a perspective surgeon? Is it just experience? How many years they’ve been doing this? Is it specialization? Is it number of cases? What should I be looking for in a surgeon to do my knee replacement?
Dr Zeegen
I think it’s a lot of those things. Certainly, experience is probably the number one thing. Just like anything in life – if you do something over and over again, you become quite good at it. The 10,000 hour rule does not come from out of thin air. There is a real science behind that. Finding a surgeon that does a lot of procedures is important. If you as a patient ask a potential surgeon how many cases they do a year and they say, ”I do one or two a year”, that is probably not good. I think that 100 or more cases per year is reasonable. It is important to find someone who has a lot of experience. Now, you know, there are people that come out of training, and they’re very experienced right away because they have done a lot in training. However, years in practice also plays a role. Somebody who is just fresh out of training may not have the experience of dealing with certain unexpected things that happened during surgery, whereas somebody who’s been in practice for 15-20 years is going to have a lot more experience on how to get out of that situation and handle something that might come up unexpectedly.
Better Man Clinics
Is robotic knee replacement currently mainstream? Is it superior to traditional knee replacement?
Dr Zeegen
Robotic knee surgery is becoming more popular, but I certainly wouldn’t say that it is mainstream at this point. We don’t have any data yet to show that it makes the overall outcome of the knee replacement better. We do have some studies that show that the overall limb alignment can be more consistently reproduced with some form of either robotic assistance or navigational assistance. We do have data to show that but not whether that truly means the knee is perceived to be better by the patient. We don’t have enough data at this point to say that so I don’t think that robotic surgery is a must. I feel that, personally, I can still do a very good knee replacement without the robot, but it is becoming part of our reality.