THE SPORTS DOCTOR

STAYING FIT AFTER A TOTAL KNEE REPLACEMENT

By Dr. miCHaeL L. Gross

More and more patients are having knee replacement surgery at younger and younger ages. While once frowned upon, joint replacement surgery for patients in their 50s has become commonplace.

These patients may have arthritic knees not simply from aging, but possibly because of a previous sports injury combined with an active lifestyle that continues to put stress on their joints. Either way, these patients are not having surgery to slow down. These patients are having knee replacements because conservative management is no longer controlling their symptoms, particularly pain, to an extent that allows them to continue doing the things they enjoy. Their goal is not only relief of pain, but also restoration of a healthy active lifestyle.

Knee joint replacement surgery involves inserting a strong, durable implant to replace a diseased or injured knee joint. While a knee replacement procedure can relieve pain, past knee replacement implants did not allow for the same range of motion or weight-bearing abilities as the knee joint itself, making it necessary to use caution when engaging in activities that may loosen or increase wear on the replacement. However, advances in joint replacements have increased patient’s ability to participate in sports. While high impact activities, such as running, are not recommended, there is a myriad of activities that are available for patients after knee replacements. Always check with your physician before beginning an exercise program to ensure your joint replacement and knee has healed enough to begin activity.

After knee replacement surgery, the artificial knee will wear out at a slow rate. This is unavoidable. The heavier, younger and more active you are, the faster the wear process will be. Therefore, your goal should be to remain active to maintain fitness and weight control, but to avoid those activities that will accelerate joint wear. Excessive wear of your joint replacement is initially a silent problem (will cause no pain), but in the long term, it will result in loss of bone around your joint known as osteolysis. Osteolysis can eventually lead to loosening and the failure of your prosthesis that may then require a revision (repeat) surgery. Therefore, choosing the right exercises and avoiding the wrong ones is extremely important.

Following total knee replacement, patients are encouraged to resume an active lifestyle. However, they are strongly advised against doing activities that produce high impact loads, such as running and jumping. Some sports, such as golf, cycling, swimming and walking, are permissible. You should discuss with your physician the exact level of sport participation recommended for you.

Again, total knee replacement is a predictable and durable procedure. But how you treat your new knee will influence its longevity. Therefore, it is critical to know which activities are permissible and which are not following total knee replacement.

The pain relief achieved by total knee replacement is benefit enough, but when combined with the cor-

rect regimen of exercise and sports, this will do even more to improve your overall health and quality of life.

The benefits of an active lifestyle have been well documented. Following total knee replacement, you should be instructed about limitations and have good self-control and self-awareness when returning to recreational sports.

Cycling is an excellent aerobic workout. Calisthenics, swimming, low-resistance rowing, stationary skiing machines, walking, hiking and low-resistance weightlifting all are excellent ways to maintain fitness without overstressing the implant.

Other suitable activities include bowling, croquet, golf, doubles tennis, table tennis, and dancing. Other activities that are suitable but slightly riskier include downhill skiing, scuba diving, in-line skating, ice skating, softball, volleyball, speed walking, horseback riding, hunting and low-impact aerobics.

In general, patients who have undergone total knee replacement should avoid high-impact activities that cause high stress loads on the implant and therefore may increase the risk of early failure.

Activities to avoid include baseball, basketball, football, hockey, soccer, high-impact aerobics, gymnastics, jogging, power lifting, rock climbing, hang gliding and parachuting.

One recent study on golf found that it places higher forces than jogging on the knee replacement implant. Specifically, the forward knee of the golfer is stressed significantly during the golf swing. Therefore, patients should be cautious about playing golf after a knee replacement.

The activities described below are meant to give you an idea of what to expect if you undergo knee replacement surgery. Before you begin a new exercise program, it is important that you discuss this with your doctor. If there is an activity you do not see listed, and you are curious about your participation, ask your doctor.

WALKING Walking is one of the best exercises you can do to

build up strength in your knee. It’s also a good way to burn calories while benefiting your heart. Start with smaller steps and shorter walks as you work your way up to longer distances. Timing your walks and tracking your performance is one way to make it more challenging and gauge your progress.

SWIMMING Because swimming is not a weight-bearing activity, it’s a great way to exercise without putting stress on your artificial knee. Many knee replacement patients can resume swimming within 3-6 weeks of surgery. Check with your physician or physical therapist before diving into the pool.

GOLF The golf course provides a good way to walk and exercise various muscles in both your lower and upper body. Avoid wearing spikes that could get caught in the ground and make sure you maintain good balance when you hit the ball. Spend adequate time warming up at the driving range and use a golf cart once you hit the course. If you experience any problems, call the round off and consult your doctor.

YOGA Gentle stretching is a great way to avoid stiffness, improve your flexibility, and boost the overall health of your knee. However, it’s important to pay particular attention to twisting movements and it’s critical to protect your knees by keeping them aligned with the hips and ankles. Before you start, talk with your yoga instructor so she’s aware of your limitations. This will help prevent extra strain on your knee. If you feel any knee pain, modify the exercise or consider taking a break. WEIGHTLIFTING Incorporating a strength program into your workout regimen can pay dividends. Lifting moderate weights helps build strength and diminish knee pain. What’s more, bones grow and become stronger with resistance training. Use weights that are appropriate to your size and strength. Check with your doctor before engaging in a weightlifting program. If necessary, consult with your physical therapist or a trainer to map out a regimen.

CYCLING There are few better ways to regain strength in your knee than cycling. Whether you use an actual bicycle or an exercise machine, stay on a flat surface and increase your distance slowly. As with walking, you can time yourself and track the activity to make it more challenging.

CALISTHENICS These basic exercises, which rely on simple, rhythmical movements, help build up strength while increasing flexibility. These include crunches, push-ups, and lunges. Also consider gentle aerobics. These classes are available at most gyms. Just make sure you skip any high-impact exercises.

ELLIPTICAL MACHINES These machines can provide a good workout without placing undue stress on the knees. Like cycling, you knees move in a circular motion, which means you can go for longer distances. An elliptical is a great alternative to running because you can move faster than walking without the impact.

BOWLING

DOUBLES TENNIS Because doubles tennis requires less movement than singles, it’s a good way to exercise without placing undue stress on your knee. In most cases, you can begin playing tennis six months following surgery. Be sure to keep it low impact and avoid running. It’s generally safe to bowl after knee replacement surgery, though it’s wise to check with your doctor and, if you experience pain while bowling, avoid the activity. You may want to consider using a lighter ball to reduce stress to your knee.

DANCING

ROWING Because rowing provides a good upper body and heart workout and places minimal stress on the knees, consider including it in your workout regimen. Make sure you adjust the seat on the machine so that your knees are bent 90 degrees or more. Ballroom dancing and gentle modern dancing are great ways to exercise. In fact, they’re a good way to use leg muscles and engage in light aerobic activity. Avoid twisting and abrupt movements that could get your knee out of alignment.

After surgery, the choice of activities requires some reflection and often some modification. Your level of expertise in any activity needs to be considered. In addition, one must consider how important any activity is to you. If it is a banned activity, is there another acceptable activity that can be substituted that will give you the same level of satisfaction? Sports and fitness regimens must be individualized. Although there are good and bad activities, there are also borderline activities. There is no one size fits all solution to exercise with artificial knees. Participation in sports and recreational activities should be discussed with your surgeon, but the more you know going into that conversation, the more you’ll get out of it.

Michael L. Gross, MD is the founder and director of Active Orthopedic and Sports Medicine in Hackensack, now a part of Summit Health. He is the section chief of sports medicine at Hackensack/Meridian University Medical Center and an assistant professor at Hackensack Meridian School of Medicine. He is also the director of Orthopedic Surgery for Summit Health.

He can be reached by at mgross@summithealth.com or at 201-3432277.