Knee replacement complications | Pain 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.

Comprehensive Prolotherapy helps in providing knee stability by strengthening connective structures such as ligaments and tendons.

If you have questions about knee replacement options, contact us for help and more information

The debate over whether or not to have a knee replacement is not a new on. Back in 2006, the rate of knee replacement failures caused some concern that maybe everyone is NOT a candidate for knee replacement.

That was 2006, certainly things have changed. Eight years later, June 30, 2014, research in the medical journal Arthritis & Rheumatology, suggested more than one third of total knee replacements in the United States were the “inappropriate” treatment. Researchers in this study, lead by Daniel Riddle, PT, PhD of the Department of Physical Therapy, Virginia Commonwealth University, found that surgeons were sending patients to knee replacement with slight to moderate osteoarthritis.(2)

In December 2017, Dr. Riddle assessed The American Academy of Orthopaedic Surgeons (AAOS) recently published appropriateness criteria for patients with knee osteoarthritis who are being considered for total knee arthroplasty  in the medical journal Osteoarthritis Cartilage. Here are the highlights:

Defining who is at high risk for failed knee replacement and pain

Researchers at the Department of Surgery, Southern Illinois University School of Medicine offered this assessment in the medical information publication Instructional Course Lectures:

Postoperative pain, which has been attributed to poor outcomes after total knee replacement, remains problematic for many patients. Although the source of total knee replacement pain can often be described, establishing a precise diagnosis can be challenging.

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.(5)

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.(6)

Research: Patients say, compared with preoperative health problems, post  knee replacement health problems were a bigger problem than anticipated.

One 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:

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 in 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.”(8)

In the end there is no way currently to predict who will get 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 these 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 in 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 than assessed the following of having some benefits:

The doctors concluded that following guidelines presented, some patients could be shown to have pain improvement.(9)

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 about 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 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:

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? Are you getting the wrong joint operated on? Is the knee replacement wrong because it was unnecessary?

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.(13) 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) 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.” (14)

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.”(15)

We have identified the problems, now we will look at remedies and treatments for pain after knee replacement

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

These are the problems we will comment on:

Catastrophizing thoughts and central sensitization = catastrophic results and opioid dependence after knee replacement

Researchers in Canada writing in the Journal of Pain Research found pain catastrophizing reflects a patient’s anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain and a sense of helplessness regarding pain.(16)

Catastrophizing thoughts are unrealistic beliefs that only the worst can happen. A person who goes into any medical treatments believing it will not work is at a significant disadvantage. A patient should relay these thoughts to his/her doctor so that appropriate action can be taken. For some patients counseling will be effective, for some therapy, for some prayer. The patients must be made aware of options that will help them move from hopelessness to cautious optimism.

A significant problem with catastrophizing thoughts that needs to be addressed is a greater risk for opioid dependence.

Doctors in Belgium write in the Bone and Joint Journal that pre-operative pain in the knee predisposes to central sensitization (catastrophizing thoughts). Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitisation called ‘opioid-induced hyperalgesia’ painkillers increase chronic pain.(17)

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.(18) 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.

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.(19)

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.(20)

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

The research team from 2014 we just mentioned released another study (November 2017) in the British Pain Journal. Here they made these new observations:

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

High levels of depression in their knee replacement patients

“Patients may need subsequent surgeries to maximize the benefits of joint replacement”

“Many patients with hip and knee arthritis have the condition in more than one of their hip or knee joints,” said the study’s lead author Dr. Gillian Hawker. “So it’s not surprising that replacing a single joint doesn’t alleviate all their pain and disability — patients may need subsequent surgeries to maximize the benefits of joint replacement.”

The study, published in the journal Arthritis & Rheumatism (April 2013), followed a group of patients with osteoarthritis and inflammatory arthritis. Only half reported a meaningful improvement in their overall hip and knee pain and disability one to two years after surgery. What’s more, researchers found the patients who had the worse knee or hip pain to begin with but fewer general health problems and no arthritis outside of the replaced joint were more likely to report benefits.

According to the study authors, nearly 83 per cent of study participants had at least two troublesome hips and or knees.

“While demand for joint replacement surgery has increased as our population ages, physicians lack a set of established criteria to help determine what patients will benefit from surgery and at what point during the course of the disease,” said Dr. Hawker, physician-in-chief at Women’s College Hospital and a senior scientist at ICES. “As physicians, we need to do a better job of targeting treatments to the right patient at the right time by the right provider.”

Fixing Pain After Total Knee Replacement


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.(22)

In new 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).

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

A 2011 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 revision

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

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.”(25)

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:

Ironically, the number one symptom that our treatments Prolotherapy, Stem Cell Prolotherapy and Platelet Rich Plasma Injections address in pre-surgery patients is ligament instability. Post-knee replacement pain problems and instability can benefit from these treatments if the problems relate to the soft tissue and ligaments:

Knee replacement complications – references for this article

1 Ben-Galim P, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res. 2006 Jun;447:100-4. [Google Scholar]

2 Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis & Rheumatology. 2014 Aug 1;66(8):2134-43. [Google Scholar]

3 Riddle DL, Perera RA. Appropriateness and total knee arthroplasty: an examination of the American Academy of Orthopaedic Surgeons appropriateness rating system. Osteoarthritis and cartilage. 2017 Dec 1;25(12):1994-8. [Google Scholar]

4 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]

5 Ibrahim T, Bloch B, Esler CN, Abrams KR, Harper WM. Temporal trends in primary total hip and knee arthroplasty surgery: results from a UK regional joint register, 1991–2004. The Annals of The Royal College of Surgeons of England. 2010 Apr;92(3):231-5. [Google Scholar]

6 Luna IE, Kehlet H, Petersen MA, Aasvang EK. Clinical, nociceptive and psychological profiling to predict acute pain after total knee arthroplasty. Acta Anaesthesiologica Scandinavica. 2017 May 16. [Google Scholar]

7 Beswick AD, Wylde V, Gooberman-Hill R. Interventions for the prediction and management of chronic postsurgical pain after total knee replacement: systematic review of randomised controlled trials. BMJ open. 2015 May 1;5(5):e007387. [Google Scholar]

8 Pickard AS, Hung YT, Lin FJ, Lee TA. Patient Experience-based Value Sets: Are They Stable? Med Care. 2017 Nov;55(11):979-984. [Google Scholar]

9 Zajonz D, Fakler JK, Dahse AJ, Zhao FJ, Edel M, Josten C, Roth A. Evaluation of a multimodal pain therapy concept for chronic pain after total knee arthroplasty: a pilot study in 21 patients. Patient Safety in Surgery. 2017 Aug 30;11(1):2 [Google Scholar]

10 Dave AJ, Selzer F, Losina E, Usiskin I, Collins JE, Lee YC, Band P, Dalury DF, Iorio R, Kindsfater K, Katz JN. The association of pre-operative body pain diagram scores with pain outcomes following total knee arthroplasty. Osteoarthritis and cartilage. 2017 May 31;25(5):667-7 [Google Scholar]

11 Howells N, Murray J, Wylde V, Dieppe P, Blom A. Persistent pain after knee replacement: do factors associated with pain vary with degree of patient dissatisfaction? Osteoarthritis Cartilage. 2016 Aug 9. [Google Scholar]

12 Lim H-A, Song E-K, Seon J-K, Park K-S, Shin Y-J, Yang H-Y. Causes of Aseptic Persistent Pain after Total Knee Arthroplasty. Clinics in Orthopedic Surgery. 2017;9(1):50-56. [Google Scholar]

13 Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11. [Google Scholar]

14 Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11. [Google Scholar]

15 Lau RL, Perruccio AV, Gandhi R, Mahomed NN. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature.BMC Musculoskeletal Disorders. 2012;13:250. [Google Scholar]

16  Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015 Jan 5;8:21-32. [Google Scholar]

17 Lavand'homme P, Thienpont E. Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain. Bone Joint J. 2015 Oct;97-B(10 Suppl A):45-8. [Google Scholar]

18 Phillips JR, Hopwood B, Arthur C, Stroud R, Toms AD. The natural history of pain and neuropathic pain after knee replacement. Bone Joint J. 2014 Sep 1;96(9):1227-33. [Google Scholar]

19 Cremeans-Smith JK, Greene K, Delahanty DL. Symptoms of postsurgical distress following total knee replacement and their relationship to recovery outcomes. J Psychosom Res. 2011 Jul;71(1):55-7. [Google Scholar]

20 Fletcher D, Moore AJ, Blom AW, Wylde V. An exploratory study of the long-term impact of difficulty kneeling after total knee replacement. Disability and rehabilitation. 2017 Dec 4:1-6. Bristol Medical School, University of Bristol [Google Scholar]

21 Phillips JR, Hopwood B, Stroud R, Dieppe PA, Toms AD. The characterisation of unexplained pain after knee replacement. British Journal of Pain. 2017 Nov;11(4):203-9. [Google Scholar]

22. Gottfriedsen TB1, Schrøder HM, Odgaard A. Transfemoral Amputation After Failure of Knee Arthroplasty: A Nationwide Register-Based Study. J Bone Joint Surg Am. 2016 Dec 7;98(23):1962-1969. [Google Scholar]

23 Polanco-Armenta AG, Miguel-Pérez A, Rivera-Villa AH, Barrera-García MI, Sánchez-Prado MG, Vázquez-Noya A, Vidal-Cervantes F, de Jesús Guerra-Jasso J, Pérez-Atanasio JM. Risk factors for amputation in periprosthetic knee infection. European Journal of Orthopaedic Surgery & Traumatology. 2017 Apr 7:1-5. [Google Scholar]

24. Del Gaizo DJ, Della Valle CJ.Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46. [Google Scholar]

25. Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. Ligament instability in total knee arthroplasty--causal analysis. Der Orthopade. 2007 Jul;36(7):650-2.  [Google Scholar]

26. Pancio SI, Sousa PL, Krych AJ, Abdel MP, Levy BA, Dahm DL, Stuart MJ. Increased Risk of Revision, Reoperation, and Implant Constraint in TKA After Multiligament Knee Surgery. Clin Orthop Relat Res. 2017 Jun;475(6):1618-1626. [Google Scholar]

If you have questions about knee replacement options, contact us for help and more information

Our Facebook Reviews
Our Facebook Reviews
Celebrating 25 years of Prolotherapy! Are you a good Prolotherapy candidate?
How Can We Help You?
First Name:
Last Name:

Enter code:

for your symptoms

Prolotherapy, an alternative to surgery

Were you recommended SURGERY?
Get a 2nd opinion now!

★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!Come see why patients travel from all
over the world to visit our clinics.
Current Patients
Become a New Patient

Chicagoland Office
715 Lake St., Suite 600
Oak Park, IL 60301
(708) 393-8266 Phone
(855) 779-1950 Fax
Southwest Florida Office
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 303-4069 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider.
© 2017 | All Rights Reserved | Disclaimer
National Prolotherapy Centers specializing in Comprehensive Prolotherapy,
Stem Cell Therapy, and Platelet Rich Plasma.

Meet our Prolotherapy Doctors and check out our Prolotherapy research.