The pain that did not go away after knee replacement

Prolotherapy knee replacement

Ross Hauser, MD

Can we help you with continued knee pain after knee replacement surgery? In this article, we will address post-surgical problems that can be successfully treated with comprehensive Prolotherapy. See our main page, Prolotherapy for knee pain to learn more about our regenerative treatments for knee pain.

Doctors are looking for the causes of pain after knee replacement and it is challenging

Researchers at the Department of Surgery, Southern Illinois University School of Medicine offered this assessment in the medical information publication Instructional Course Lectures to guide doctors trying to help patients with pain after knee replacement.

Point #1 Establishing a precise diagnosis of where the pain is coming from can be challenging.

This is what doctors need to look for in trying to find the source of knee pain after knee replacement:

Patients at greater risk? Women, older people, sufferers of depression and anxiety

In a study out of London, researchers writing in The Annals of The Royal College of Surgeons of England sought to uncover various predictors of a successful (or unsuccessful) outcome in a total knee replacement. Looking at 1,991 total knee replacement patients over a three-year period, they discovered that females and older people had worse functional outcomes following the replacement surgery.(2)

In a 2017 study from the University of Copenhagen in Denmark, pre-operative widespread pressure pain hypersensitivity and pain catastrophizing are predictive of moderate-severe post-total knee replacement pain. Also interesting in this study was the impact of fear of hospitals and hospital stay anxiety.(3)

Post knee replacement health problems are a bigger problem than anticipated

Prolotherapy vs SurgeryOne of the problems we see in patients who are having problems post-knee replacement surgery is the thinking that knee replacement works for everyone, how come it didn’t work for them?

When these patients are presented with research complied from patient outcomes, they are somewhat surprised to see that they are not so unique after all, many patients have reported problems with expectations and complications of their knee replacement(s).

Knee replacement is considered one of the great innovations in musculoskeletal care. It is said to be the only known cure for knee osteoarthritis. Orthopedist surgeons routinely tell patients of the great success of the procedure. Yet, it was not until doctors started to perform outcome questionnaire studies that the medical community started to realize what patients had already.

Knee replacement is not as successful as everyone thinks.

In 2016, Doctors at the University of Bristol in the United Kingdom wrote in the British Medical Journal that the problem of post-surgical pain in knee replacement patients had reached a point of significance and that researchers should prioritize their studies to help people with pain. They wrote:

Doctors in the United Kingdom search for answers for “Mystery Pain” after Knee Replacement

Here are findings released (November 2017) in the British Pain Journal. 

One in four patients with pain after knee replacement had no clear reasoning for their pain

In this study, the doctors also made this remarkable observation

What patients want from their knee replacement:

In the November 2017 edition of the journal Medical Care, a combined research team from the University of Illinois at Chicago, China Medical University Hospital, and National Taiwan University Hospital published their findings on what concerned patients before knee replacement and the type of pre-existing conditions these patients had.

Before the surgery concerns about successful surgery circled around these factors:

  1. anxiety/depression
  2. The ability to take care of themselves immediately after the surgery.
  3. The ability to move and have mobility after the surgery.
  4. The ability  to be able to perform their own usual activities,
  5. The amount of pain and discomfort during recovery and post-op.

After the surgery, researchers found patients had to alter their recovery and post-surgery strategy to account for new health problems and problems of mobility

  1. The amount of pain and discomfort in recovery and post-op became the greatest impact of post-surgical patient non-satisfaction.
  2. Compared with preoperative health problems, postsurgical health problems were associated were a bigger problem than anticipated.
  3. Significant differences in thinking before surgery and surgical outcomes were observed including
    1. Greater problems than anticipated in:
      1. Mobility,
      2. Not being able to perform usual activities,
      3. anxiety/depression.

It is important to know that the purpose of this research was to assign a set of values to these patient problems in order to be able to come up with a formula that would better help the patient with their expectations before and after the surgery. The researchers had to conclude in the end that:

“Our systematic review highlights a lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement.”(6)

In the end there is no way currently to predict who will benefit and who will get worse from knee replacement surgery and patients should be counseled that there is no guarantee that knee replacement will work for them.

Patients should be counseled that there is no guarantee that knee replacement will work for them


Research: 10% to 34% of patients are not satisfied with knee replacement

In August 2017, doctors at the University Hospital Leipzig in Germany opened their published research in the medical journal Patient safety in surgery with this statement:

What this paper deals with is an ever-growing population of people for whom knee replacement did not work.

In their paper the Leipzig researchers were looking at effective means to help the patient with pain after knee replacement, a brief summary of their findings is presented here:

“The treatment of patients with chronic complaints after total knee replacement is a challenging task. Therefore, an adequate therapy is only possible due to an interdisciplinary team of experienced orthopaedic surgeons with great knowledge in the field of endoprosthetics (knowledge of hardware failure and misfit), qualified physiotherapists (patients with problems after knee replacement often suffer from various stage of depression) and pain therapists.” (The patients are in pain, sometimes more so than before the surgery.)

The researchers then assessed the following of having some benefits:

The doctors concluded that following guidelines presented, some patients could be shown to have pain improvement.(7)

Harvard Medical School’s findings surrounding the phenomena of continued pain following total knee replacement

Here are some more quick facts surrounding the phenomena of continued pain following total knee replacement from researchers at Brigham and Women’s Hospital, Harvard Medical School.

In this 2017 study published in the medical journal Osteoarthritis Cartilage, the doctors found:

Research: “Patients with persistent pain after knee replacement are dissatisfied”

That is an obvious statement, but what are the patients dissatisfied with and how can we help them? Here is the study that statement came, 2016 research in the journal Osteoarthritis Cartilage:

In the most dissatisfied knee replacement patients:

In patients who were dissatisfied on a lesser level,

Studies have demonstrated that poor management of acute pain after total knee replacement is strongly associated with the development of chronic pain

In March 2017, a team of Korean doctors went further, writing in the medical journal Clinic in Orthopedic Surgery they announced:

With nowhere else to go, doctors suggest another knee replacement.

Patients had knee pain after knee replacement because after the fact, it was determined that knee replacement was the wrong surgery. The knee was not the problem and the patient was inappropriately rushed to surgery

Are you getting a knee replacement because of undiagnosed back and hip pain? Above we spoke about doctors looking for knee pain that was actually coming from the spine, hip, ankle, and feet. The knee was perhaps not the problem and the patient was inappropriately rushed to surgery

Doctors warn that in the case of chronic knee pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the truth is that the source of pain is often missed and treatment then will present a significant challenge with less than desired results.

One study sought to understand why up to 20 percent of patients who undergo total knee replacement still have persistent pain and why secondary surgery rates are on the rise.(11) Forty-five patients were studied. What the researchers found was somewhat shocking. The pain was not originating in the knee – here is what they said:

Patients may still be undergoing knee replacement for degenerative lumbar spine and hip osteoarthritis

“Patients may still be undergoing knee (replacement) arthroplasty for degenerative lumbar spine and hip osteoarthritis. . . We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

In other words, patients received a knee replacement when the cause of pain came from the hip and spine.

In the journal Modern rheumatology, Japanese doctors wrote:

“We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain.” (12)

In the case of chronic joint pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the sad truth is that the source of pain is often missed because of misinterpretation of MRI and other imaging scans. Please see our article on MRI accuracy.

Despite the warning about knee replacement complication risks being higher when performed at local low-volume hospitals – patients still choose the local – higher risk option. In fact, the researchers called these patients the “vulnerable group.”

In 2012, doctors writing in the journal BMC Musculoskeletal Disorders, warned patients not to go to low-volume knee replacement hospitals because the risk of complication was greater due to lack of expertise. (Yes we say the same thing about Prolotherapy – go to a high volume Prolotherapy practice).

Despite this warning about knee replacement complication risks being higher when performed at local low-volume hospitals – patients still choose the local – higher risk option. In fact, the researchers called these patients the “vulnerable group.”(13)

Knee replacement complications in former athletes

In a recent paper, doctors from NYU Langone Medical Center, Hospital for Joint Diseases suggest that total knee arthroplasty (replacement) is often the best answer for end-stage, post-traumatic osteoarthritis after intra-articular (inside) and periarticular (around) osteoarthritic fractures the knee.

However, total knee replacement in the setting of post-traumatic osteoarthritis is often considered more technically demanding surgery and the surgical outcomes are typically worse for these patients. The goal of the NYU paper was to create a new classification label for post-traumatic osteoarthritis patients and improve medical documentation and improve patient care.

In a similar study, doctors at Duke University also recognized that Total Knee Arthroplasty as an important treatment for post-traumatic arthritis. However, these researchers also found complications that should not be expected in a mostly healthy patient population.

This included:

The patient problems after knee replacement surgery are many. At Caring Medical we can address many of these problems, we cannot address all, especially when the problem of the knee replacement is caused by hardware failure and hardware placement failure

Problem: Neuropathic knee pain after surgery – nerve damage caused by the surgery

A 2014 study from doctors in the United Kingdom published in the Bone and joint journal suggests that it is neuropathic pain that cause problems after knee replacement. That is damage to the nerves that usually occurs in surgery.(16) Neuropathic pain is an underestimated problem in patients with pain after total knee replacement. It peaks at between six weeks and three-months post-operatively. Currently, doctors believe the best choice recommendations for neuropathic knee pain is pharmacologic management. For a discussion on Prolotherapy and nerve damage see our article on Neurofascial Prolotherapy.

The same research team had more to say in a 2017 study that will be discussed below.

Problem: Post-surgical stress following knee replacement

Post-surgical stress: the demands of recovery and possible out of pocket expenses cause a great deal of stress in patients. In research published in the Journal of psychosomatic research that followed total knee replacement patients who reported pain and other difficulties, doctors found that “A significant percentage (20%) of patients undergoing total knee replacement reported noteworthy levels of postsurgical stress 1 and 3 months following surgery.”

Further, this distress was associated with a more difficult recovery following (the knee replacement), characterized by more severe pain and greater functional limitations. There was a significant impact of psychological processes on the postoperative recovery.(17)

Problem: Difficulty in Kneeling

Most people had difficulty kneeling because of pain or discomfort in the replaced knee. Many patients described how this limitation affected their daily lives, including housework, gardening, religious practices, leisure activities and getting up after a fall. Patients often adapted to these limitations by finding alternatives to kneeling, assistance from others or home adaptations. Many patients had accepted that they could not kneel, however some still expressed frustrated. Few patients had consulted with healthcare professionals about kneeling difficulties, and unmet needs included the provision of information about kneeling and post-operative physiotherapy.(18)

Problem: Fixing Pain After Total Knee Replacement may include Amputation

Three in 1000 patients will need to have their leg amputated.

The causes of the amputation were:

In 80% of the cases, there were more than 2 of these factors for amputation.(19)

In research from April 2017 doctors writing in the European journal of orthopaedic surgery and traumatology wrote:

Treatment for prosthetic knee replacement is becoming more common. Infection is an arthroplasty-related complication leading to prolonged hospitalization, multiple surgical procedures, permanent loss of the implant, impaired function, impaired quality of life and even amputation of the limb.

The purpose of this study was to identify risk factors for amputation in periprosthetic infected knee through a case-control study, analyzing patients treated from January 2012 to November 2016 in a hospital with a high incidence of this diagnosis. We included 183 patients with periprosthetic knee infection; 23 required amputation as definitive management (cases).

One place we can help: The often overlooked and ignored cause of pain after knee replacement – the Knee Ligaments.


Post-surgical pain and knee instability may be from the surviving ligaments

A  study in the journal Orthopedics from Rush University Medical Center researchers identified the problems of knee instability as a cause of pain in knee replacement patients. Here is a summary of their findings:

Ligament instability was the primary reason for repair surgery

Doctors writing in the German medical journal, Der Orthopäde said:

Put the ligaments back where you found them

The summary statement of this research is extraordinary in its simplicity

“Correct anatomical positioning of the components and balanced ligaments in the different extension and flexion positions are important for good clinical results, a stable joint, good function and longevity.”(22)

In other words, put the ligaments back where you found them.

Previous ligament reconstruction surgery – higher risk for complications after knee replacement

Doctors at the Mayo Clinic have published findings in Clinical orthopaedics and related research which they suggest that patients who had previous multi-ligament reconstruction surgery were at high risk for:

Pain after knee replacement – find the cause, make a realistic assessment of the situation

We may be able to help you with your pain after knee replacement. If you have questions about knee replacement options, contact us for help and more information


1 Manning BT, Lewis N, Tzeng TH, Saleh JK, Potty AG, Dennis DA, Mihalko WM, Goodman SB, Saleh KJ. Diagnosis and Management of Extra-articular Causes of Pain After Total Knee Arthroplasty. Instructional course lectures. 2015;64:381-8. [Google Scholar]

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