By Chris Carmichael,
CTS Founder and Chief Endurance Officer
The more I talk with athletes in my age group (60+), the more apparent it is that we don’t talk enough about recovery from orthopedic issues for aging athletes. Hip and knee replacements are becoming more common. Nevertheless, aging athletes struggle to find recovery and return-to-training protocols meant to restore peak performance. Although I am only an n of 1, I have more than 30 years of experience as an endurance coach, so I want to share details of my knee replacement surgery, recovery, and return to cycling training.
Please note, I am not a physician nor a registered dietitian. I have been an endurance athlete for more than 50 years and professional endurance coach for more than 30. I followed my orthopedic surgeon and physical therapist’s directions. In the process I applied proven principles of training and sports nutrition to my recovery, and experienced remarkable results. Although everyone and every surgery is different, I hope sharing my experience can inform and enhance yours.
Background: Why I needed a knee replacement
If you have followed my story, you may already know I had my hip replaced in December of 2021. You can read about my hip replacement recovery and return-to-training here. A cross-country skiing accident resulting in a broken femur was the root cause for both the hip and knee replacements. When I broke my right femur, it split between the medial and lateral epicondyles. The resulting surgeries cost me an inch of leg length on my right side. Although I returned to professional cycling, I never fully regained my previous form and retired a few years later.
The injury occurred in 1986. Over the next 35 years, I worked, worked out, and rode my bike, usually about 8,000 miles per year. I used a lift on the right side in all my shoes. For cycling shoes, I eventually moved to custom Rocket 7 shoes with a built-in lift in the right sole. But 35 years with a significant leg length discrepancy took its toll.
In my late 50s, the right knee pain progressed. But as I prepared for knee replacement during the fall of 2021, the pain in my left hip superseded the pain in my right knee. It turned out, the imbalance between my right and left legs put so much strain on my left hip that I’d worn away all the cartilage in the joint and was down to bone-on-bone.
Working with Dr. Eric Jepson of Colorado Springs Orthopedic Group, we decided to replace the hip first (December 2021) and then schedule the knee replacement for September 2022. The hip replacement went well, and I was back to unrestricted training and better than pre-op performance by mid-March (about 3.5 months).
Arthogenic Muscle Inhibition
Although my recovery from hip surgery progressed very well, my pain in my right knee was still getting worse. I was experiencing progressively greater swelling in the knee, which meant I struggled to train effectively on the bike during the summer of 2022. I confirmed with my physicians and physical therapists that I was experiencing arthogenic muscle inhibition (AMI). Essentially, it is an inability to neurologically engage the musculature surrounding an injured joint. My central nervous system partially inhibited my quadriceps and hamstrings to protect what was left of the knee joint.
The problem with arthogenic muscle inhibition, in my case, was that I experienced muscle atrophy in my right leg at the same time I was rehabbing and rebuilding muscle on my left side. Our initial plan was to space out the surgeries by 9 months to provide time for acute recovery from the hip surgery and training time to build up strength and function on my left side. Selfishly, it was also because I wanted to have the summer to ride my bike.
Training and Timing Between Surgeries
In retrospect, and as a recommendation for other athletes considering multiple joint surgeries, I should have shortened the interval between surgeries from 9 months to 5 or 6. My hip and left leg were back to unrestricted, pain-free training about 10 weeks (3.5 months) post-surgery. But with the knee getting progressively worse, my summer training was ineffective. The AMI caused muscle atrophy on the right leg, which is particularly worrisome for aging athletes.
Older athletes fight an uphill battle against sarcopenia (loss of muscle mass). As we get older, muscle protein synthesis becomes less efficient and bioavailability of ingested protein declines. Once lost, muscle mass is more difficult for older athletes to regain, compared with younger athletes. Between the surgeries, my ability to train was so limited that I continued to lose ground rather than rebuild. As a result, the lesson from my experience is to schedule surgeries closer together to minimize the total recovery time.
The Knee Replacement Surgery
Due to extensive damage from splitting the femoral condyles and 35 years of subsequent use, Dr. Jepson recommended a total knee replacement (TKR) as opposed to a partial knee replacement. This meant removing the damaged surfaces of both the femur and tibia and replacing them with metal tibial and femoral implants, separated by a medical grade plastic spacer that mimics the smooth cartilage that had eroded over time. Finally, another implant was placed on the underside of my patella (kneecap) to interface with the new joint.
Surgery and Immediate Post-Op
Dr. Jepson performed my knee replacement surgery at Colorado Springs Orthopaedic Group’s Orthopaedic and Spine Center of Southern Colorado. There were no complications during the surgery or my subsequent overnight stay. As with the hip surgery, one of my top post-op priorities was to minimize opioid-induced constipation (and to get off the opioid painkillers as soon as possible).
I was more successful at minimizing opioid-induced constipation this time around because I increased my fluid and fiber intake days before the surgery instead of waiting until after surgery. My pre- and post-op diet was high in protein and vegetables. I wanted the protein for recovery and the fiber from the fruit and vegetables for regularity. Along with a mild laxative in the days after surgery, this regimen worked well.
For the three days I took opioid pain killers every four hours, as prescribed. After that I managed the pain with acetaminophen, Celebrex, and CBDa soft gels from Planetarie. I was also instructed to take Aspirin for the first 6-8 weeks, to reduce the risk for blood clots.
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Knee Replacement Training Plan
There were two phases to recovering from my total knee replacement: convalescence and training. During the convalescent phase, the focus was on reducing the swelling around the joint and regaining range of motion with very little force through the joint. Wound care was also important because the incision was on the front of the knee joint.
Compared to the hip surgery, the convalescent phase after the knee replacement was more painful and prolonged. It took considerably longer for the swelling to subside, and the knee would swell again if I overworked it. And the tension on the skin, particularly from trying to flex my knee and regain range of motion, caused some pain and made wound care more challenging.
Throughout the 14 weeks described below, I managed pain and swelling primarily with CBDa softgels from Planetarie and a Hyperice X contrast therapy device. One of my athlete, Dale, recommended the Hyperice X and I found it more convenient for applying heat and cold than traditional ice packs and heat pads.
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My surgery was on Monday, September 12, 2022. Starting September 13, I used a short-crank, portable “pedal exerciser” (their terminology, not mine). It’s literally just a crankset mounted to a lightweight frame you can put on the floor, bed, or couch. There’s no resistance because range of motion is the goal, not force or power output. I “rode” the spinner for 2 minutes, slowly, 2-3 times a day for during the first week post-surgery. Beyond walking around the house, I got outside for walks of about half a mile starting three days post-surgery.
I continued to progress by increasing the duration of intervals on the spinner from 2 minutes to 5 minutes three times per day. In addition to two physical therapy appointments, I increased my walking to about one mile per day. The range of motion improved throughout the week, as I was working on flexion with the spinner and extension with straight-leg quadriceps contractions.
I got back on a bicycle on Sunday of Week 2 (13 days post-surgery). I used a stationary bicycle and raised the saddle about 2 centimeters higher than my normal saddle height to accommodate the limited flexion on my right knee. Prior to surgery I had about 135 degrees of flexion in my right knee (see image for reference, source). By the time I got back on the stationary bike, I had about 125-128 degrees of flexion. I spun my legs lightly for 10 minutes with minimal resistance. The joint felt good and the only discomfort was from the swelling and skin tension.
My goal for Week 3 was to engage in 2-3 activities per day and to increase the duration of pedaling movements. I ended up pedaling for just over 3 hours for the week, mostly in 20-minute periods on the stationary bike. As the range of motion improved, I gradually lowered the saddle height on the stationary bike 1-2 millimeters at a time. During long periods of sitting, I still used the spinner for 5-10 minutes at a time. And my walks increased to about two miles per day.
Sunday of Week 3 (20 days post-surgery) was the first time I slept through the night without waking from pain or stiffness. The sleep disturbance was worse after the knee replacement compared to the hip replacement, but I found that Planetarie’s CBDa soft gels were helpful for improving the restfulness of my sleep following both surgeries.
During Week 4 I kept my cycling hours constant (3 hours for the week) and increased my walking duration, along with my physical therapy exercises. I moved from mostly flat paved and gravel walks to more climbing and descending and unstable surfaces and increased the distances to about 3 miles per day (15 miles total for the week). On the stationary bike I was still riding 20-minute periods with very light resistance. By the end of the week, I had the saddle back down to my normal cycling saddle height.
Looking back, I’d say the generalized pain from surgery, convalescence, physical therapy, and exercise started to subside significantly in Week 4. In comparison, the generalized pain from the hip surgery only lasted about two weeks.
Week 5: End of Convalescent Phase
Week 5 was a combination of a recovery and travel week. I had the surgery in Colorado Springs and after 5 weeks of convalescence and in-office physical therapy, my partner Sarah and I headed to our home in Santa Ynez, California. I continued with PT exercises, the spinner, and walking during the week, but only rode the stationary bike twice for a total of one hour and forty minutes.
Sunday of Week 5 (34 days post-surgery), I rode my Canyon Endurace road bike outdoors in California! I did not change the saddle height, having worked over the preceding weeks to regain the necessary range of motion to pedal over top-dead-center and through the bottom of the pedal stroke. There was still muscle and skin tightness, so I pedaled gingerly, but Sarah and I covered about 9 miles on that first ride.
One thing I noticed immediately was that my right leg felt stable throughout the pedal stroke. Before the replacement, my right knee had some lateral instability from the deterioration within the joint. That increased stability was also evident when holding myself in a plank or standard pushup position.
Weeks 6-8: Beginning of Training Phase
Now that my range of motion for the right knee was back to 135 degrees of flexion and I had regained normal extension, it was time to start training again! My mileage in Week 6 was about 50 miles over 5 short rides. I increased this to 80 miles over 4 rides in Week 7 and 80 mile over 3 rides in Week 8. The intensity for these rides was essentially recovery or easy endurance pace.
The AMI-induced atrophy in my right leg became apparent as I started to increase the duration of rides. I needed to consciously focus on managing my left-right pedaling balance so I didn’t rely too heavily on my stronger left leg. I did not do much isolated pedaling work with my right leg, however. When I did, I was trying to focus mentally on recruiting as much muscle on the right side as I could. I had become so accustomed to using my right leg less that I needed to remind myself to engage it more fully.
I continued to increase my weekly cycling volume during Weeks 9 and 10. I jumped up from 5-6 hours to 11-12 hours on the bike, covering about 150 miles/week. Off the bike, I focused on reinforcing the range of motion gains with physical therapy exercises. I also added single leg exercises on the right side with a variety of lunges and step-ups to even out the strength discrepancy between my right and left legs.
The single-leg strength work induced a lot of fatigue in my right quadriceps, hamstrings, and glutes. As expected, this reduced my power output and energy on the bike in the short term. As a result, I focused on cycling volume at an easy endurance pace instead of focusing on increasing power output on the bike.
As I approach the end of 2022, I’m spending December focused on increasing weekly cycling volume and continuing with isolated strength work on my right leg. Going into January I intend to balance out the strength work with more bilateral movements. My cycling power is finally increasing now that I can perform sustained efforts with greater force on the pedals. For instance, on a 5-minute climb near home my power has improved by 40 watts over the four weeks ago. That’s less reflective of a dramatic change in aerobic capacity and more indicative of restored muscle strength and reduced neuromuscular inhibition.
Summary and Takeaways
Recovering from a total knee replacement took longer, was more challenging, and more painful than recovering from my hip replacement. However, I stuck to similar principles that worked after my previous surgery. I kept moving consistently, kept movements and exercises simple, focused on sleep and nutrition, and didn’t add unnecessary activities that added complexity without much added benefit.
As with the hip replacement recovery, there was absolutely some luck involved in my process. I didn’t get an infection, nor did I have any complications with the incision site. I was able to manage the pain effectively with Tylenol, Celebrex, Aspirin, and CBDa. And I had a wonderful support system with my doctors, my partner Sarah, and my teammates, kids, and staff at CTS. If you have a knee replacement in your future, I hope you can learn from my journey, have a successful return-to-training, and join me for a ride sometimes soon!
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