knee replacement

Knee Replacement Training Plan: Returning to Cycling and Sport after Total Knee Replacement

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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 But as I prepared for knee replacement during the fall of 2021, the pain in my left hip superseded the pain in my right knee.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

after knee replacement surgery

On my way home with my fiancé Sarah after total knee replacement surgery.

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.

Hyperice X

Although I have no financial interest in the Hyperice X contrast therapy device, I definitely recommend it.

Week 1

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.

Week 2

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.

knee flexion

I started out at about 125-128 degrees of flexion when I first got back to pedaling a stationary bike. My normal cycling position requires 135 degrees of flexion.

Week 3

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.

knee replacement xray

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

Week 4

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.

Weeks 9-10

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.

Weeks 11-14

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.

return to cycling after knee replacement surgery

December 13, 2022: Back on the road, feeling good, and power is coming back up!

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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Comments 38

  1. Hi Chris, thanks so much for this amazing and helpful article about your road to recovery. I had my left knee replaced on October 20 2022. I just got back on my road bike about 3 weeks ago. I am able to ride at mellow paces (15mph) for about 90 minutes or so. But I am having problems with single leg drills. I can not do a single leg rotation on its own without quite a bit of pain, but have no problems with normal pedaling. I suspect that my glutes and hamstrings are pretty weak as I dealt with pretty bad arthritis, bone on bone on the lateral side for about 20 years before having the TKR. Did you have any issues with single leg strokes? Do you have any thoughts or recommendations? Wondering how much AMI is coming into play here. I really do hope that it improves soon! ps- I am somewhere in the 120’s for degrees of flexion and have normal extension.
    Thanks so much!
    Jamie

  2. Six weeks out with similar results Chris, like I I am a cyclist as well. I can do sets of 10 one legged chair squats at week 5. Here’s the big question?
    I am 62, if I do allot of road miles and climbing over the next 10 years plus.will I wear out the joint, if so what is replaced? Have u considered this?
    Thanks

  3. I would love to hear more regarding how senior women recovered. Thanks for your story. P.S.I think one factor may be condition before procedures.

  4. It’s been a while since we last met. I have been following your CTS training emails for years. I followed both your hip and now knee replacement rehab programs. Good luck with your business and riding after 2 major joint replacements.
    Gary Klein MD

  5. I enjoyed reading your story! Now I am going to give you a short version of mine. I had my knee replaced three years ago (needed a specialist). Sence, I have completed five XC Ski marathons and many Triathlons (seven this season) including IM Florida 2021 and IM Lake Placid 2022.
    I think recovery to come back in endurance sports is all in the therapy and how hard you work to make it happen.
    I will be 76 in February and have been in Triathlon for 41years and have been Skiing forever.
    HAPPY NEW YEAR!!
    Jim.

  6. Chris, after years of climbing, mountaineering and cycling my knees were destroyed and I had to have them replaced in 2017. After working hard to gain mobility and strength I started hiking and biking again. When Covid came along I bought a Wahoo Kickr bike and have been riding a majority of rides indoors. In the last 18 months I’ve riden almost 400 days and 6,000 miles. As you highlighted it is challenging to maintain muscle mass as you age and at 75 yo I do a combination of bike, weight training and Pilates. Still able to push over 600 watts and maintain a high cadence on multiple hour rides. Training to do Mt Evans in the spring when the road opens. Great article. Keep pedaling!

    1. Bob:
      Well, you are an inspiration for me! I hope to be hitting as hard as you are when hit 75yrs old. Keep it going!
      Chris

  7. Hi Chris:
    Thanks for this article, my coach Dave Harris passed it on to me. I just had a TKR on 9/20, and my experience was similar to yours.
    A couple of questions:
    1. Did your surgeon use the robot?
    2. Did you experience muscle tightness and weakness in certain leg muscles you were not using before?
    3. Were you able to get rid of the lift in your shoe?

    Best,

    Sam

    1. Sam:
      Here are your answers:
      1. No robot, just an old fashion Orthopedic Surgeon, Dr. Jepson at Colorado Springs Orthopedics
      2. Most of this I covered in the blog but because the knee was swelling from post-trauma arthritis I experienced slight muscle atrophy
      3. No, as the surgeon wasn’t able to increase the length of my femur
      Good luck on your TKR…you will do fine!
      Chris

  8. Chris, glad to hear your recovery is going so well, especially about recovery from muscle atrophy and strength in your right leg. As a senior master athelete I continue to work hard on both my strength program and cycling workouts to try and prevent age related sarcopenia as much as possible. I am finding that upper body strength is just as important as lower body. So far I think I am doing fairly well at maintaining but would still like to be stronger. You continue to be an inspiration to me to keep riding and improving. Best wishes to you and Sarah for this holiday season and the New Year.

    1. Ken:
      you are my hero as you are killing it on the bike! I hope we can ride together again soon? Are you going to the Santa Ynez spring training camp? If so, then we will ride. I especially enjoy Manny’s ride to the beach and back.
      Happy Holidays,
      Chris

  9. Hi,I’m having a TKR in April 2023..The article is a great insight in what to expect.
    Thank you for sharing your experience.
    God speed.
    Regards and best wishes
    Rob Davenport.

  10. Laura Sophiea Rossetti

    Thanks so much for sharing your journey! I am literally 4 weeks behind you. I had my TKR on October 24th. I have been an IM athlete for 35 years and knew this was a forgone inclusion for me after a knee surgery 2016 when I had a hole in my femur bone. My DR gave me about 4 years before I would need the TKR, but I managed 6 with 2 1/2 IM this past summer and DNF both at St. George and Kona !M due to knee pain!
    My first 4 weeks post surgery was pretty easy. I thought this was not bad in both the pain arena and exercise. I got to a 120 bend and a 3 extension all while walking and riding my tri bike on the trainer @ 3 weeks. But thens week 5 it was like someone else took over my body and I stopped sleeping due to the crazy pain. I am beginning week 8 and the pain did lessen but I lost both the the extension and bend. Super frustrating !! I am now up to 14 hrs a week with biking inside on trainer, walking 4 miles daily, and PT work and weights. What I have learned is they really don’t or are unable explain how things will work pain and exercise wise. Everyone is different.
    I was happy to read about the arthogenic muscle inhibition as now i see what was going on before surgery! Thanks again for al of your great insight. Good luck and continued success on your TKR journey!!

    1. Laura:
      Good luck as you begin coming back to triathlons! I sure you will soon see less pain from the TKR and be back to training. Happy holidays!
      Chris

  11. I also had Total knee replacement – 5 years after right hip replacement. The knee takes 2-3 times longer to heal!
    I got back to biking short distances at 3 months without cleats. At 4 months I could use Mountain bike pedals with my road bike – they have more rotation to clip in and out than my road bike pedals.
    At 6 months I can ski but not at the level I could ski before surgery. I am much more cautious and have found out that it’s not easy to get up if I fall.
    Now I have to take off both skis to stand up due to limited flexion in operated knee. It will improve👍

    1. Barbara:
      I had the same experience that the TKR is a longer comeback than a hip replacement. I needed both and feel pretty good these days.
      Chris

  12. Wow, awesome recovery! Thanks for great motivation. SO I am 67, had LTKR in January 2021 and RTKR in March. (decided to get both done instead of waiting to be time efficient to get my life back AND back on the bike). Also like you I had Hip Replacement in 2019. Its been a fun journey and I’m looking forward to the 2nd half of the game! You really got your flexion back quickly. I followed a similar comeback pattern of indoor cycling and PT (as well as endless heel slides). It’s been a year coming up in Jan and I’m at 125 degrees flexion and still working to get more back. I found modified yoga with all the support toys (I live for child’s pose while measuring my progress) , mobility, ROM and strength training, as well as stationary cycling, fairly high resistance standing climbs (60-70 rpm) with flat seated flats with higher rpm’s will get me back on the bike outside ASAP.
    Good luck to you, as we Active Aging Athletes pursue greatness, no matter what the wear and tear.

    1. Paul, thanks for sharing your experience as well. It is remarkable how our bodies can heal. Best of luck!
      Chris Carmichael

  13. Chris, That was a great read how you managed rehab after muscle loss in your left leg! As well as your direct comparison of hip to knee replacement / rehab. Were you able to reduce your leg length discrepancy with the knee replacement?
    As you know I had a total hip replacement nearly 10 years ago, immediately after a freak crash. Couldn’t risk 6 months muscle loss in a wheel chair hoping a plate might heal. My experience was really fortunate, zero opioids or pain killers of any kind after the first day. It just never hurt that badly compared to a regular hard crash…
    Looking forward to riding together again soon. Best, Wayne

    1. Wayne, yes it has been a long road with 2 joint replacements in less than year but grateful be back on the bike.

      I do look forward to riding together but take it easy on me ☺️

  14. I had hip replacement surgery a number of years ago. I was lucky that I started spinning two weeks after surgery. My first ride 6 weeks after surgery was 17 miles. I recovered quickly because of my riding prior to surgery. I’m still riding years later and this year did over 5000 miles. In 2021, I rode 7400+ miles including a 228 mile one day ride.

  15. Chris,
    I’ve been working with Dr Jones at CSOG, but we haven’t gotten serious about TKR – yet. If triathlon was your thing, would the replacement have enabled you to continue running?

    1. Bob, good question on running. I did ask Dr. Jepson on hiking and he said the knee would hold up well. Good luck on the TKR!

  16. You summed it up really well, thank you! I had my first TKR in Feb 2016 after a massive injury to my right knee playing tennis – after about 35 years of recurring injuries due to patellar dislocation. The TKR provided the best comprehensive solution. I was 50 at the time and in excellent physical shape. Recovery was slow but steady and I was back at playing league tennis about 8 months later. Earlier I this month, on Dec 7th I just had my left knee TKR… I’m now 57 and while I like to think I’m still in good shape it’s clear the older me is having a bit tougher time…despite this, 15 days out I’ve had no complications, staples came off yesterday and I have been walking unassisted for about 5 days. There’s still a little bit of swelling in the knee but I elevate as much as possible. I’m walking about 1.5 miles cumulatively per day and will try the stationary bike later today! Sleeping has been challenging…will try the CBD gummies….(I also got off the opiates super early on, day 4).

    Thank you for sharing your journey.

  17. Thanks Chris for the report. It keeps one motivated. I had a partial knee done at age 60 and am so grateful to my surgeon I’ve had to cut out racket ball this year and switch to pickle ball but still train and do the 104 mi Ga Six gap Not bad for a 77 year old.So important to have goals and keep moving
    Joe

  18. Big Kudos to Sarah… I know she was there with you all the way and doing it solo would have probably been a lot harder!

  19. Long story short, I had a traumatic knee injury in Jan 91 which eventually led to TKR in Nov 2015. I rode a lot that summer to get as strong as possible prior to surgery. It must have worked, as I was back in spin class 4 weeks post op. (Santa Fe Century, RtR, Glacier to Y’Stone with The Cycling House, 2 weeks riding in Luberon Valley incl Mt Ventoux!) You’ve done quite well. Good on ya.

    1. Doug, absolutely feel free to share with other who would find this blog helpful. Enjoy the holidays!
      Chris Carmichael

  20. Enjoyed your patient perspective. As an orthopedic surgeon it is hard to guide the masters athlete as there goals and desires are much higher than most. Congratulations on a rather speedy knee recovery. They are much more challenging to recover from than a hip. I tell patients ” the hip is a sprint, the knee is a marathon.”

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