By Chris Carmichael,
CTS Founder and Chief Endurance Officer

One year after a total knee replacement surgery on my right leg, and 21 months after surgery to replace my left hip, I am finally feeling strong and durable as a cyclist again. As I near my 63^rd birthday, I know I am one of many athletes in my age group who have had or will need joint replacement surgeries in the coming years. I have shared the stories of my old injuries and recent surgeries in previous posts (The Hip Replacement Training Plan: Returning to Cycling and Sport after Total Hip Arthroplasty and the Knee Replacement Training Plan: Returning to Cycling and Sport after Total Knee Replacement) and receive messages every week from athletes sharing their joint replacement stories and asking questions about their return to sport. As I’ve learned firsthand, there isn’t much information available for athletes who want to return to endurance sport training or competition following hip and knee replacements. That’s why I felt it was important to provide an update to my story on the one-year anniversary of my knee replacement.

Quick background summary

The articles linked above describe my surgeries, the injuries that necessitated them, and the rehabilitation work I completed to return to active training. The short version is this: In 1986 I broke my femur in a back-country ski accident, splitting the femoral condyles. In the resulting surgery I had a rod inserted into my femur and lost about 1 inch of length in my right leg. Over the next 35 years, I wore a lift in my right shoe off the bike and stacked cleats or had custom cycling shoes, but the injury eventually led to excess wear in my right knee.

My left hip compensated for my shortened right leg, and it too wore out. By 2021, the constant pain in both my hip and knee affected my daily activities, including my ability to ride my bike. Although I initially planned to have the knee replacement first, my hip deteriorated rapidly in the fall. As a result, I had my hip replaced first, in December 2021, and then my knee replaced in September 2022.

X-ray of my replaced knee three weeks after surgery.

Comparing Hip and Knee Replacement Recoveries

Compared to my hip replacement, the recovery from my knee replacement was more painful, much slower, included more setbacks, and required more modifications to lifestyle behaviors, exercise routines, and equipment. If you’re heading for any joint replacement – and particularly a knee replacement, my advice is to be patient, be diligent and consistent with physical therapy, and approach your recovery like a training plan.

One Year Post-Knee Replacement: Lessons Learned

Lesson 1: Give Yourself a Full Year for Recovery

My orthopedic surgeon (Dr. Eric Jepson of Colorado Springs Orthopedic Group) told me it would take a full year to get over the surgery. Naturally, I didn’t believe it would take that long. I’ve been an athlete all my life, and call it ego or arrogance or life experience, I figured a full year was a conservative estimate. Surely, I could recover faster…

Nope, the doctors were right on the money. The pain in the knee joint and from the trauma of surgery lasted significantly longer than I anticipated. Within a few weeks the swelling around the knee joint subsided, but not completely. The residual, minor swelling was persistent. And because it was around the knee joint, even minor swelling diminished my right knee’s range of motion. The tension and stretch on the skin limited knee flexion and caused pain, and it took months for my right knee to even look normal.

I have only recently turned the corner, so to speak, and experienced a significant improvement in my right knee. In August 2023, nearly a year after the knee replacement, the residual pain and stiffness in my right knee diminished enough that it was no longer hindering my performance on the bike. Over the course of three weeks, my power output jumped up by 20-40 watts on climbs lasting 5 to 20 minutes. Those improvements were too large and rapid to be caused solely by training volume or time-at-intensity. The cardiorespiratory fitness was already there. The gains came from finally being pain free and hence able to effectively produce force – and therefore power – through my right knee.

Lesson #2: Commit to Physical Therapy Like It’s a Training Plan

Not self-advocating for more physical therapy was probably the biggest mistake I made throughout my entire hip and knee replacement journey. I recovered quickly from the hip replacement surgery and I found that physical therapy was downplayed for hip replacement patients. If you’re relatively healthy and active going into the surgery, doctors mainly recommend walking and a few weeks of physical therapy visits. (see hip replacement article above for details on my walking progression and exercises) My error was dropping the PT exercises after a few weeks, once I was back on the bike.

The decision to stop PT exercises, or strength training and significant walking/hiking, doomed my recovery from the knee replacement nine months later. The knee replacement was so debilitating that although I could walk a mile after two weeks, I struggled to extend those walks for around 6 weeks post-op. In contrast, I was walking within days of the hip replacement, progressed to mile-plus walks by 5 days post-op, and I was back to training – not just riding – on the bike in 3.5 months.

I should have focused more on strengthening my left hip and left leg before the surgery to replace by right knee. But because I didn’t, my left leg atrophied significantly due to inactivity following the knee surgery. Instead of being able to rely on my left side to compensate for the recovering right leg, both sides were weak. That led to strange compensations in how I stood, walked, and rode my bike.

Note: I wouldn’t change the spacing or separation between my hip and knee surgeries. Longer recovery time from the hip surgery wasn’t the problem. The problem was not strengthening my left leg sufficiently in anticipation of a prolonged period of diminished activity.

Lesson 3: Get a Post-Knee Surgery Bike Fit

Although I’ve probably done or supervised thousands of bike fits over the past 30 years, my riding position in early 2023 was essentially the same as it was when I was a professional bike racer. The stem was a bit higher, but saddle position, stem length, and bar width hadn’t changed. Following the knee surgery, I got back to riding pretty quickly and within six months my power outputs were just 10-15% below what I was capable of about a year before the hip surgery (i.e. before the pain really started diminishing performance).

With the pain and stiffness in my right knee diminishing, and despite some persistent swelling, I felt like I could push forward with my cycling training workload. I increased my weekly training volume to about 15 hours per week. My right knee would swell between rides and gradually get better as I rode, but the extent of the swelling got progressively worse over a period of weeks. Eventually the swelling contributed to developing bursitis, primarily driven by ramping up volume and the repetitive motion of cycling too aggressively.

Shorten crank length after knee surgery

I found a physical therapy practice that specializes in treating cyclists and other athletes, Revolutions in Fitness, in Mountain View, California. A bike fit with Curtis Cramblet was a key component of my recovery. The idea of transitioning to shorter crank arms is not new. It’s been popular in triathlon for several years, and of course shorter crank arms are common in velodrome events. I’ve ridden 172.5mm crank arms for decades. What I hadn’t considered was that shortening my crank arms to 165mm could lessen knee flexion at the top of the pedal stroke, where I was having trouble with skin tension due to inflammation.

I had been trying to alleviate that tension by raising my saddle, which caused too much knee extension at the bottom of the pedal stroke and calf cramps from using my lower leg muscles in a new way. A key consideration after shortening crank length was following up by lowering the saddle height, a piece of the equation that’s often missed.

Raise your stem

I am guilty of holding on to “bike racer” ideas of what my road and gravel bikes should look like. I was far from having a slammed stem, but I’ve tried to keep the stack of spacers under my stem reasonably small. Following the hip surgery, I got back to my normal riding position pretty quickly. Following the knee surgery and in conjunction with the shorter cranks, raising my stem was an effective means for opening up my hip angle and further reducing tension on my right knee.

Lesson #4: Focus on Building Strength Before and After Surgery

Strength training is important for aging athletes. Sarcopenia causes a gradual loss of muscle mass as we get older and muscle protein synthesis to build and repair muscle becomes less efficient at the same time. I made the mistake of not doing enough strength training between my hip and knee surgeries. The result was evident when I returned to training after the knee surgery. My left/right power balance was 45L/55R in early 2023. Despite the more recent knee surgery, my left hip side was the weaker one! In late August 2023, I did a 60-mile ride in Santa Ynez, California with 5-minute efforts up Drum Canyon. I achieved my 4^th fastest time and 3^rd highest power output for the last ten years. And my left/right power balance was 49L/51R. A 10-point spread, which had reduced to a six-point spread in the spring, is now back to normal.

Lesson #5: Work with medical professionals who understand athletes

From the beginning, I chose Dr. Eric Jepson and Colorado Springs Orthopedic Group because of their experience with athletes. What I learned in the year after my knee surgery was that I needed a team that included physical therapists, a bike fitter experienced with joint surgeries, and access to orthopedic surgeons for questions and conversations. I am particularly thankful for physical therapy guidance from Dr. Juliet St Germain and bike fit from Curtis Cramblet at Revolutions in Fitness and to fellow cyclist and orthopedic surgeon Dr. Douglas Tice.

Differentiate skeletal vs. soft tissue problems

Have a meaningful conversation with your orthopedic surgeon about the difference between a skeletal issue (e.g., joint replacement, fractured bone) and a soft tissue problem (e.g., torn anterior cruciate ligament, torn meniscus). Once the surgery and acute recovery were complete, my knee was stable. Yes, there was inflammation and trauma from surgery that needed to heal, but it was important for me to know I wasn’t going to damage to anything by moving. Pain was the limiting factor in how much I could move or exercise and moving would accelerate healing (up to a point, which I exceeded…). However, an ACL or meniscus injury takes considerably more time to rehabilitate. You need to be more cautious on how quickly you advance because you can tear soft tissues.

Absorb advice and trust yourself

Through 50 years of being an athlete and coach, I’ve learned a lot about how adaptable the human body is. I think I’m pretty good at manipulating stress and recovery to improve cardiorespiratory performance, strengthen muscles, and even remodel bone tissue. I understand how to utilize nutrition to support recovery and performance. But I needed specialized guidance from medical professionals, physical therapists, and bike fitters to recover from two joint replacements in less than two years.

At the same time, I also needed to trust myself and the skills and mentality that have served me through nearly 63 years on this planet. My doctors were concerned I’d crash if I rode outdoors too soon. That’s a valid concern, but I was more apt to trip and fall walking. And when it came to the volume of riding I could handle, I used the medical advice to differentiate between pain and harm. Pain I could handle, so long as I wasn’t risking harm.

When should you have joint replacement surgeries?

Mobility is longevity and independence. As I get older and see my peers and older role models age, it’s clear that restricted mobility contributes to a cascade of progressively detrimental health consequences. That’s important when considering joint replacement surgeries. All the advice I received before surgery was to keep my “original equipment” as long as possible. And I think that’s good advice.

You never know what will happen in surgery, so keep what you have until it’s really impacting normal function. I tried stem cell therapy to extend the time before needing surgery. Results vary, but my personal experience I found it expensive, not covered by insurance, and only mildly effective at reducing knee pain for about a month. I had reached the point the knee and hip were affecting my mobility and starting to affect my overall health. So, it was the right time to get them replaced.

How I plan to get 20 years out of my new joints

Hip and knee replacements generally happen to people in their 50s, 60s, and 70s. The surgeries themselves are hard to recover from, and I was a healthy, active person with a long exercise history. But I was also a one trick pony, a cyclist who really only rode bikes. The prolonged periods of diminished activity and losses of muscle mass and range of motion were wake up calls. The losses didn’t happen all at once or just from the surgeries. I’d been losing muscle and flexibility and range of motion for years, but so slowly that I barely noticed.

Cycling obscures some of the losses because you have great aerobic fitness and big rides provide the perception of great athletic capacity. Even with decades of coaching experience and a good grasp on the science, I’ve been surprised by how much I need to do to combat process of losing muscle mass and preserving flexibility in my 60s. My cardiovascular fitness is great, as is my strength in the specific movements of cycling, but in other aspects of life I’m vulnerable.

You can gain strength at any age, but it gets harder to build and maintain muscle mass as you get older because of inefficient muscle protein synthesis and hormonal changes. The doctors say I can probably get 20 years out of my new knee. That’s great, but to be around in 20 years to get another one I have committed to the steps my coaches and I have long recommended for others, including strength training 2-3 times per week year round, a flexibility/range of motion program, and increased protein intake (up to about 1.8-2.0 grams per kilogram of bodyweight per day, consumed throughout the day).