Managing Joint Pain Before Knee Replacement Surgery
By Chris Carmichael,
Founder and Head Coach of CTS
The days are numbered for my right knee. I’ve known for a long time that I would eventually need a knee replacement. I suffered a compound fracture of my right femur in 1986, cracking it between the femoral condyles at the distal end. In the ensuing surgeries I lost an inch of leg length on the right side and over the past few decades the surgeries and the leg length discrepancy have put extra stress on my knee. Staying active has been the best medicine, but during the past year or so the pain level has increased to the point that it’s been keeping me from being as active as I’d like. At the same time, I love summers and I didn’t want to cancel some long-planned adventures, so I scheduled the surgery for January and have been focusing on pain management so I could enjoy the long summer rides. Everyone manages pain differently, but here’s what’s been working for me.
Activity
Movement is essential for keeping the synovial fluid that lubricates your joints moving so it can reduce friction. While it might seem logical to stop exercising and reduce the movement of my right knee, that’s the exact opposite of what doctors and physical therapists recommend. Personally, I have found that consistency matters more now than ever. I don’t need to ride hard or stress my knee, but some exercise each day is far better than none. I experience the worst knee pain the day after a day when I am totally inactive. That’s when it feels stiff and painful on a ride. And even during a ride, if I take a prolonged break the pain returns and then it takes about 10 minutes of easy riding until it dissipates.
Range of motion exercises
Along with consistent activity, I have been incorporating exercises to maintain my knee’s normal range of motion. On the bike my knee only moves within a prescribed range of flexion during the pedal stroke. Off the bike I make sure to include exercises that flex and extend my knee past the range of my pedal stroke. I particularly feel the benefit of this when I walk up along flight of stairs or hike on steep trails.
Cortisone
As a component of my long-term treatment plan, my doctor recommended a small number of strategically timed cortisone injections. My doctor and I discussed the fact that a knee replacement was going to be necessary within 12-18 months, and therefore he was okay with providing 2 cortisone injections – spaced out by at least 6 months – to reduce inflammation and provide some pain relief while minimizing the chance for additional damage to cartilage in my knee. They worked quite well and allowed me to continue with the two strategies mentioned above.
Although the cortisone worked, I wasn’t impressed by the results of another procedure. At the beginning of this process my doctor recommended that I try a procedure that injects platelet rich plasma (PRP) and stem cells into the joint. The idea is that the platelets signal the body that repair is needed in the area, and then stem cells get to work creating the necessary tissues. In my n=1 experience, I felt little to no pain relief after the procedure and it was quite expensive.
Pain Relievers
My doctor has prescribed me a low dose of Celebrex for a long time to reduce inflammation in my right knee. Celebrex is a prescription non-steroidal anti-inflammatory drug (NSAID), and the research on NSAIDs is clear: endurance athletes should avoid using them during training and long events, and avoid using them for prolonged periods (like for chronic pain). You can read more about the research findings and references here. In light of this, I avoid medications like ibuprofen (Advil) and naproxen (Aleve). My doctor and I discussed the risks of Celebrex for me, and we have monitored for potential side effects, but I am really looking forward to no longer taking Celebrex.
RICE
Although the scientific justification for Rest, Ice, Compression, and Elevation (RICE) as a treatment for inflammation and pain due to a chronic injury is not as strong as it is for the treatment of acute joint injuries, I include it as part of my regimen on days when I perhaps push too hard on the bike or otherwise aggravate my knee.
CBDa
Knowing that I was in for a 12- to 18-month period gradually worsening pain, one of my biggest goals was to avoid the need for opioid medications. Although opioids can be very effective for alleviating acute pain, they are not recommended for chronic or long-term pain management, in part because of the risk of addiction and overdose. I’ve previously written about these dangers here and here. Instead, and in addition to the strategies mentioned above, I decided to commit to a consistent regimen of supplementation with CBDa from Planetarie. As I wrote about in a previous blog, I’ve been impressed by Planetarie’s water-based process for extracting CBDa from hemp. There are thousands of CBD companies out there, but only one using water-based extraction instead of using harsh chemicals and/or heat. CBDa is a “raw” or less processed cannabinoid; the harsher processes convert CBDa to CBD.
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Interestingly, of all the strategies above, the CBDa is the one people question the most. It turns out that CBD skepticism is remarkably common. According to a 2021 report published by Statista, 22% of respondents didn’t trust the product or manufacturer. Another 22% didn’t believe CBD would help them. And a smaller (8%) group of respondents believed CBD would make them high. The report detailed additional misconceptions about CBD, the most striking of which was that 57% of respondents believed CBD would show up on a drug test (presumably employer or government drug testing, as the survey audience wasn’t specifically athletes). Twenty-six percent of respondents equated CBD with marijuana, which contains the psychoactive ingredient, THC, and would show up on a drug test.
These reasons for being unwilling to try CBD or CBDa echo the concerns I’ve heard from athletes I’ve talked to about my journey toward knee replacement surgery, which is unfortunate. I’m not going to oversell the benefits of CBD or CBDa. I don’t think it’s a panacea. I think consistent use of CBDa as a component of my post-exercise recovery and pain management regimen has helped me manage pain and stay more active as I wait to have surgery on my knee. For instance, since starting to use CBDa, I’ve been able to reduce the amount of Celebrex I take. This makes sense, considering that CBDa and Celebrex are both selective COX-2 inhibitors.
I also know that, of the reasons and misconceptions in the Statista report that keep people from trying CBD (or preferably CBDa), the legitimate one is distrust of the product or manufacturer. If you get it from a reputable company, neither CBD nor CBDa will get you high or trigger a positive workplace or sport drug test. However, those risks increase when the products aren’t independently tested because it’s impossible for you as a consumer to know if the product actually contains what it says on the label. That’s another reason I trust products from Planetarie and why CTS has a partnership with the company. Their products are third-party tested, a certificate of authenticity is available for every batch, and they document the entire “chain of custody” from farm to product.
Altogether, the strategies above have allowed me to have a productive and enjoyable summer riding my bike, hiking, and hanging out with the people closest to me. That said, I am really looking forward to January and the prospect of pain-free cycling and hiking once I complete the post-surgery rehab. Unfortunately, during knee surgery the surgeon can’t make my femur an inch longer to correct the leg length I lost back in 1986. I asked, but he said that’s only an option during a hip replacement, which I (thankfully) don’t need.
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Comments 18
Chris,
I had TKR 5yrs ago ( I was 73yo) due to skiing accident in 1958! and finally knee had to be replaced. Rehab is no fun. My best advice came from Bill Walton. I met him on top of Rabbits Ears Pass and asked him how was he able to ride up it with his TKR. He was riding with your group. He gave me his phone # and talked to me after the tour of Co was done. He is so awesome to share his story & time with me. He told me get get off pain meds in 5 days & go to Tylenol and get on my trainer in 7 days & to ride outside in 4 wks. I did his plan exactly because no PT will go out on the limb & prescribe that kind of activity.!!!! I’m still riding. Give Bill a call.
Thank you Chris for your suggestions. It helps a lot. Thanks
As a 54 yo physician with 2 bad knees who cannot take NSAIDs and loves cycling, running, etc … I feel what you are going thru
While I am not an ortho, I have reviewed the medical evidence — PT, ice and continued modified activity are the best. Tylenol helps but not too much if you like your post ride beer (your liver is important). steroids do help but you have to be careful about overuse. And do not forget bike fit by someone who understands knee issues (my bike fitter is a PT)!! This I cannot stress enough
Unfortunately, most data supports the idea that PRP/stem cells are really more “wallet lighteners” than actual treatments and that CBD is generally speaking is “too good to be true”. That being said,, the quality of the positive and negative data for both approaches is not good (grade “C” in the parlance of systematic review) so both are reasonable to try if you have the money (The oral CBD promoted herein is not cheap — $80 per month and PRP/stems cell are really expensive; I have checked and it seems to be $2 to 10K per procedure even with “professional courtesy” )!
But this is what I am really excited about. We are using injectable hydrogels as a non inflammatory tissue spacer in the areas where I operate and they perform exactly as advertised (in medicine, this is not common; almost nothing works exactly as advertised). It is now being studied for knee OA ( https://pubmed.ncbi.nlm.nih.gov/30148430/)– think of it as putting a contact lens over the knee joint to provide a new “cushion” effect. For those of you like me who are close to a TKR but not quite there, I would try to hold out for this. its usually 3 to 5+ years for trials like this to mature to clinical practice.
Good luck with your surgery, my 80 yo dad had his knee replaced 6 months ago and he is back on the bike and walking 18 holes!
Chris
Great honest commentary on what you are going through.
Roll on 22
Chris
Great honest commentary on what you are going through.
It’s motivating that even the best have issues
Roll on 22
Best of luck Chris. I’m about 6 months ahead of you having had my right knee replaced in July. I didn’t want to miss the winter waves in Maui so sacrificed some of my MTB season. As Karey mentioned, the first two weeks are rough. I’m at 9 weeks now and still not able to get full extension. Had 3 prior knee surgeries and just a lot of old scar tissue I’m trying to deal with. Able to get 130 degrees on flexion with a personal goal of getting to 140 which is max that the replacement they install can do. Flexion is important to me for the water sports I do. Best advise I can give ya is be prepared for your new knee to behave like a new born – it will be happy at times but often will be grumpy and screaming at you. You will have no clue why it’s grumpy, what you did to make it grumpy or how to make it happy. They keep telling me “it will be great in 2 more months”, heard that ever couple weeks now :o).
Steven
It’s been two months, how’s the knee now? I’m scheduled for tkr next month.
Todd
I suppose it comes to us all… ! Do continue to keep us informed. Thanks!
Hey Coach C, I am right there with you. Knee replacement (left) scheduled for January as well. I look forward to comparing/discussing recovery and comeback notes and modalities.
I had a left hip replacement 2 years ago, as well as a low back fusion 3 years ago. The Bionic cyclist is the new trend :). Been doing Cortisone shots every 3 months now for last year (in both knees). Seem to help for about 30 days, then it’s back to the pain cave. Also, Celebrex (Meloxicam), but it tends to wig me out, so mostly I do Ibuprofen. Also, have done Hyaluronic acid gel shot procedure.
I’m going to get one more round of C shots to go for the 90 day limit before surgery in January. I need to look into the CBDa supplement.
Haven’t been able to ride outside much, as it is really hard to come out of the saddle, so I’ve been doing indoor stationary cycling as well as recumbent and Elliptical. Lot’s of strength training, pre-hab, mobility and flexibility and modified yoga. Taking swim lessons as well (I am a sinker) Also, got a pair of Activator trekking poles (urbanpolling.com). Great for incline walking outside, they are allot more joint friendly than everyday trekking poles.
All in all, I’m looking forward to getting back on both the road and mountain bike.
Thanks for sharing your journey. Look forward to keeping in touch.
My knees suffered with Ibuprofen , ask your doctor. Paracetamol is best, again, check with your doctor and other people in the same condition to see what works best.
I just had my right knee replacement surgery on Aug 6th, the first two weeks were not fun at all, I am on week 5 now and have 115 ROM and can straighten my knee as well, I am two weeks ahead of schedule plus I can do a full revolution on the trainer, make sure you start going back wards on the trainer at first, it is easier. My main reason for commenting is I also took CBD, and a liquid collagen. I also had Baker Cysts develop behind my knee which didn’t help the osteoarthritic joint in my knee at all. I highly recommend what you are doing but I also recommend the liquid collagen, I will continue to take it for the lubrication of my knee joints in the years to come. I have been cycling for over 26 years now and have been following you and had your books in the early years. Thanks for all that you do. Karey Lee from Sweet Riders, Alberta, Canada.
Carey, what is liquid collagen? Brands?
Chris, are you using CBD topically for your knee pain? I have arthritis in my thumbs which bothers me riding increasingly and haven’t tried CBD topically yet but might consider it. For now I take it orally at night for improved sleep.
Steve: Yes I do use a muscle rub topically on my knee! I normally apply 15-20minutes before I ride and afterwards while stretching out post-training. Here is what I use:
https://planetarie.com/collections/online-retail/products/cbda-muscle-rub
Chris Carmichael
On 1 July, half of my right knee was replaced. The pain from bone on bone was no longer tolerable, and injections did not help. Later that month, I celebrated my 78th birthday.
The surgery went well and rehab began at week two. Before PT sessions, I’d walk to warm up the knee in preparation for the therapist. When I was able to climb stairs, that was added to the equation. Kneading the quads helped getting the knee warmed up for PT. Kneading also helped to relax the connective knee tissue that was ‘moved’ during surgery.
However, every morning after getting out of bed, the tightness in the connective knee tissue had to be stretched out. During the day at home, if I sat, the knee had to be stretched out to stand. If I stood for any length of time, the knee had to be slowly bent to sit down.
The adage ‘Pain is weakness leaving the body’ is very true; you will have pain. Getting the knee to bend 120° is the goal, 135° is achievable. And there will be pain.
By week 3, I was able to do 360s on a stationary bike at PT and light workouts at home with virtual rides. Progress was slow at first and pain was a good indication of overdoing the workouts. At week 6 my Orthopedic Surgeon and Physical Therapist were very happy with my progress, ‘keep doing what you are doing.’
Later this month, I’ll be in Santa Ynez for a real ride with my brother. The 8 hour drive to get to Santa Ynez will be the hard part.
We may not be as fast as we once were, but we will still get to the top of the mountain. We can compare notes at the top of the Fig at the 2022 Fig Fondo.
Have as much “fun” with your total knee replacement as possible. I do hope it provides you complete relief from the pain you are experiencing. I also hope you are one of the people that “fly” through recovery and rehab of the total knee. It’s an adventure just as in training for any athletic event. I had a total knee in 2018 and unfortunately I have scar tissue that has come back twice now, which impedes my ranch of motion. Biking is a real mind over matter for me because fo the scar tissue. So, I’m trying to figure out if it is my body repelling the joint replacement due to the very small amount of nickel in the make up of that joint replacement device, or, who knows. You, Chris Carmichael, will have a great surgery and recovery!! Continue to enjoy your life!!!
Chris — As an old fart with rickety knees who doesn’t do NSAIDs, I feel your pain — literally. I’d just like to say that PRP DID work for me, probably because my knees aren’t quite ready to be replaced. (I figure I’m a couple years away.) I got immediate relief which improved over about a month and the benefit has lasted (so far) five months. The nice thing about PRP is that you can do it again and again, if necessary, unlike steroids. Good luck on the operation!
Best of luck with your knee surgery, Chris. I look forward to seeing you on the bike pain free next year.