Friday Q A Pain After a Knee Replacement Part 2

This week’s question is a follow-up question that came in after the post we did on yoga and knee replacements (see Knee Replacements and Yoga) and Shari's answer to another reader about pain after a total knee replacement (see Friday Q&A: Pain After a Total Knee Replacement). It seems that pain isn't uncommon after a knee replacement, but in this case, the pain is coming several years after the replacement:

Q: My partial knee replacement was April 2007. I started back to Yoga this past summer-one day a week, but I found child pose with the knees wide uncomfortable, but I did do it for a few weeks this fall. I now have some pain in my knee and I'm hoping that I haven’t loosed the cement in the joint. Any help would be appreciated.

A: Thanks for writing in about this new pain in your knee. As always, I am not able to diagnose or prescribe a yoga program for you without first doing a more detailed history and physical exam in person, but I can share some thoughts that come to mind from the situation you find yourself in.

One of the challenging things to discern for new yoga students, or those returning after a long break from doing yoga is: How to gauge if “uncomfortable” is a potentially harmful warning sign from your body? This is tricky, because it may simply be that you are getting some intense sensation feedback from the body as you stretch and strengthen parts of your body that have been neglected for a long time. With the knees in particular, learning to recognize the difference between the healthy stretch sensation of the muscles and connective tissue lengthening versus the compression of the tissues and bones that often happens deep folds of the knee joints is an important skill to cultivate. The compression sensations can sometimes indicate pinching of tissues that could lead to inflammation, injury or bruising that may not resolve quickly or could lead to more chronic pain. It is sometimes hard to skip these poses—like Child’s pose—in a public class since they are so common unless you have an alternative offered by your teacher.  I often suggest that folks with knee pain flip onto their backs and draw the knees to the chest, essentially an upside down Child’s pose. Then almost all the pressure is off the knee joint and usually no pain is felt. The other thing to try is to vary the distance of the knee spread in regular Child’s pose until you find a distance that does feel uncomfortable.

It is also important to recognize that undergoing a knee replacement does not equal having the same healthy knee anatomy and movement you had before the surgery and the underlying knee problem that lead to your surgery. One of my students who had knee surgery to clean out a lot of arthritis damage to his cartilage found that his range of motion was less after the surgery than before, but he was now pain free. His challenge became how to gradually see if he could improve the range of motion without leading to recurrent pain.And another student of mine who had one knee replaced, but also had a second bad knee, found that although the new knee operated normally, the second knee become more painful secondary to the new way he was walking with essentially two very different knees. And sadly, having a successful repair does not guarantee that future dysfunction and pain will not arise.

In this case, it is also important to recognize the effect of the passage of time on both the surgerized knee and your other knee. A substantial amount of time has passed from 2007 until this summer of 2013. And with that the knees can undergo gradual changes in the architecture and function of the joint, such that the repaired knee can undergo undesirable changes, and unrelated changes could also have taken place. It could be that something has loosened in the replaced knee parts, but it could just a likely be some other structure, tendon, muscle or other structure, that could be the source of this new pain. This needs investigating! 

Until you have an exam and get a diagnosis from your orthopedic MD, avoid the positions that create immediate or delayed pain in the affected knee. Poses like Child’s pose include Hero pose, Thunderbolt pose (as well as poses that have just one leg in the deep flexion fold at the knee joint), front knee in Pigeon pose variations, the front knee in deep drop knee lunges, and any Lotus preps or full and half Lotus pose. Even some simple seated poses like Sukasana (Seated Crossed Legs) can be worth avoiding until you know what you have going on. Once you get a clear picture of what is happening, I’d suggest setting up a private session with an experienced yoga teacher or yoga therapist to design a home practice that can address your unique situation.

—Baxter

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Menu Part 4 A Fourth List of Publications for Potential Posting

First, two updates on previously published items:

Avastin Update: Medicare not Likely to Cover its Use

Following posting of the original article – Avastin: A New Hope for Treating AMD, I found an online article that clarifies the Medicare position on “off-label” usage of this drug.

Inlays, Onlays, Rings & Things - Part 2

The original article was written in 1990. Following the 2000 ASCRS meeting, I updated my findings on these types of devices.


As part of my coverage of both the AAO and ASCRS annual meetings, I sat in on the technical presentations and also spent several days walking the vast exhibit halls, gleaning information on new developments in both lasers and other ophthalmic technologies.

Customized Ablation/Custom Cornea: Wavefront Driven LASIK (WFL)

Before presenting my reports on several of these meetings, I would like to showcase two important technologies that I was among the first to write about: Customized Ablations (or Wavefront Driven LASIK), and LASEK, the technique of pushing aside the epithelium and performing PRK on the surface of the cornea – as opposed to first making a flap with a microkeratome or laser, and then zapping the cornea to reshape it.

Here, in chronological order, is a series of writeups on these techniques:

1. I’ve Seen the Future....and its Custom Cornea, OSN, June 15, 1999.

I first learned about custom ablation at the 1998 AAO meeting, but it was at the 1999 ASCRS meeting that I came to realize that it was the future of refractive surgery.

2. Customized Ablation: the Future is Close, OSN, February 15, 2000.

My first encounter with wavefront and ray tracing diagnostics as a pre-cursor to customized ablation.

3. Customized Ablation: Getting Closer Yet, OSN, August 1, 2000.

At the 2000 ASCRS meeting I learned first-hand of the early results on the initial human clinical trials using wavefront combined with LASIK.

4. Customized Ablation: The Wave Moves Forward.....but Keep an Eye on a Newly Developed Technique....LASEK!, OSN, January 1, 2001.

My first exposure to LASEK – laser epithelial keratoplasty, as I explained it in detail.

5. AAO Report: LASEK, Customized Ablation Draws Interest, OSN, January 1, 2002.

More results from ongoing custom LASIK trials and a new technique for performing LASEK.

6. AAO Refractive Pre-Meeting Focuses on LASIK, LASEK, OSN, January 15, 2002.

An overview of what was reported at the RSIG pre-AAO meeting.

7. ASCRS Report: Customized Ablation, Hyperopia & More, OSN, August 1, 2002.

An overview from the 2002 ASCRS meeting.

8. An AAO 2002 Update: Classic vs. Custom LASIK -- The Battle Continues, OSN, January 1, 2003.

And finally, my last report for OSN, reviewing the latest developments occurring at the 2002 AAO meeting.

9. Custom Ablation #9: Questions......and Answers (May 5, 2006)

An update and answer on the question – Custom vs Classic Lasik.