Table of ContentsView AllTable of ContentsCausesDiagnosisTreatmentNext in Knee Replacement Surgery GuideInfection After Knee Replacement Surgery

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Table of Contents

Causes

Diagnosis

Treatment

Next in Knee Replacement Surgery Guide

Some people experience pain after knee replacements, which are among the most commonly performed and highly successful orthopedic surgical procedures. A knee replacement is done when the knee joint has worn out, most often as a result ofosteoarthritis, a common diagnosis that affects some 32 million people in the United States.

Duringknee replacement surgery, damaged bone and cartilage are removed and the joint is reshaped with metal implants to allow for smooth, pain-free movement. Yet up to 20% of people are dissatisfied with surgery and continue to experience pain and mobility issues.

This article explains some of the reasons for why there may be so much pain after knee replacement, includinginfectionor a bone fracture around the replacement. It explains how persistent pain around the newly replaced joint is diagnosed and treated.

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Physical therapist and patient working on knee exercises

The most important step in finding a solution to persistent discomfort is to first determine the cause of the pain. Without this information, it is very difficult to find an appropriate treatment. The most common causes of pain after knee replacement include:

Other issues that can cause persistent pain includebursitisandcomplex regional pain syndrome.

Can Metal Implants Cause Allergies?Some people are hypersensitive to metals used in making implants; nickel, cobalt, and chromium are the most common allergens.This can lead to knee pain. Ask your healthcare provider about patch testing before surgery if you’re concerned about metal sensitivity.

Can Metal Implants Cause Allergies?

Some people are hypersensitive to metals used in making implants; nickel, cobalt, and chromium are the most common allergens.This can lead to knee pain. Ask your healthcare provider about patch testing before surgery if you’re concerned about metal sensitivity.

Knee Replacement and Metal Allergies

Your surgeon will take several steps to evaluate your pain. The first step simply involves talking with you and discussing your pain. Pain can have many different qualities, and the type of pain described can help your doctor make an accurate diagnosis.

Start-up pain (pain when rising to stand up) usually resolves within a few months, but other types of pain may suggest a more serious condition. In some cases, the location and timing of the pain can help a healthcare provider pinpoint the underlying cause.

Common Diagnostic Signs

These signs can aid your healthcare provider in a diagnosis. Symptoms and their causes can include:

Your surgeon will then want to examine the knee. A physical exam can help identify infection,stiffness, and alignment issues. Ensuring that the mechanics of the knee replacement are sound is important. Just like having the proper alignment in your car, it is important that the knee replacement is properly aligned and balanced.

Reasons to Seek Immediate CareNotify your healthcare provider right away of increasing pain in the lower leg or foot below the knee replacement, or inflammation (redness, warmth) that may suggest blood clots. Any difficulty breathing, or fever and signs of infection should be reported. So should sudden changes at the knee, like instability or pain.

Reasons to Seek Immediate Care

Notify your healthcare provider right away of increasing pain in the lower leg or foot below the knee replacement, or inflammation (redness, warmth) that may suggest blood clots. Any difficulty breathing, or fever and signs of infection should be reported. So should sudden changes at the knee, like instability or pain.

Knee Replacement Risks and Complications

Imaging

X-raysand other studies can assess alignment and loosening. Subtle loosening may not show up on a regular ​X-ray, and a bone scan ormagnetic resonance imaging(MRI) scan may be performed. In addition, there are specialty imaging studies that can be performed specifically to assess for problems related to the knee replacement.

X-rays performedfluoroscopically(in real-time) and stress radiographs to evaluate ligaments are sometimes performed. MRI is better suited for soft tissue injuries and can be particularly useful if there is infection or inflammation related to bursitis or tendonitis.

What Is The Difference Between Arthritis and Bursitis?

Lab Tests

Laboratory studies that are sometimes performed include markers of inflammation such aserythrocytesedimentation rate (ESR) and aC-reactive protein(CRP) tests. Elevations of these markers of inflammation can indicate an infection or other inflammatory medical conditions.

One of the most commonly performed procedures for a painful knee replacement isarthrocentesis(joint aspiration).This involves the insertion of a needle into the knee joint to obtain some fluid from around the implant.

The fluid, called synovial fluid, can be analyzed in the lab to look for signs of infection or abnormal crystallization around the knee joint. Tests commonly performed on synovial fluid include a white blood cell count (WBC), bacterial gram stain, and bacterial cultures.

According to a 2021 study from France, infection occurs in between 1% and 3% of knee replacement surgeries.These cases may require knee revision surgery (another repair procedure).

Treatment for pain after knee replacement is based on the cause. Medications andphysical therapymay be a first step but they don’t always resolve the underlying problem.

If loosening, infection, or alignment issues are suspected, a revision knee replacement may be necessary. The revision surgery may be minimally invasive or require removing the implanted knee and starting over.

There are situations where the source of pain cannot be identified. In such instances, it is best to treat the condition conservatively since revision surgery is unlikely to lead to an improvement.​​ If in doubt, seek a second opinion.

Sometimes the decision to treat pain after knee replacement is urgent, while, at other times, giving the new knee time to adapt may be more appropriate. Your surgeon can help to guide you on the most appropriate treatment for the cause of your pain.

How Long Do Knee Replacements Last?

Summary

While the vast majority of knee replacement surgeries lead to relief of pain, there are some people who do not find relief, and sometimes the pain can even be worse than it was before surgery.

Causes of pain linked to knee replacement include infection, alignment problems, metal allergy, and more. A healthcare provider will diagnose your pain on the basis of your symptoms and test results.

While situations that cause so much pain after knee replacement are unusual, they can be frustrating. Seek a careful and extensive expert evaluation before making decisions about your knee replacement pain and further treatment options.

Outpatient Therapy After a Total Knee Replacement

11 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Arthritis Foundation.Osteoarthritis patient education & resources.Pua YH, Poon CL, Seah FJ, Thumboo J, Clark RA, Tan MH, et al.Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.Acta Orthop. 2019;90(2):179-186. doi:10.1080/17453674.2018.1560647Mcdowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-26. doi:10.1016/j.ocl.2015.09.008Lum ZC, Shieh AK, Dorr LD.Why total knees fail-A modern perspective review.World J Orthop.2018;9(4):60-64. doi:10.5312/wjo.v9.i4.60Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W,et al.Degree of coronal alignment correction can’t predict knee function in total knee replacement.BMC Surg. 2021;21(1):383. doi:10.1186/s12893-021-01372-3Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH.Literature review of the causes of pain following total knee replacement surgery: Prosthesis, inflammation and arthrofibrosis.EFORT Open Rev. 2020;5(9):534-543. doi:10.1302/2058-5241.5.200031Desai MM, Shah KA, Mohapatra A, Patel DC.Prevalence of metal hypersensitivity in total knee replacement.J Orthop. 2019;16(6):468-472. doi:10.1016/j.jor.2019.05.005Piscitelli P, Iolascon G, Innocenti M, Civinini R, Rubinacci A, Muratore M, et al.Painful prosthesis: Approaching the patient with persistent pain following total hip and knee arthroplasty.Clin Cases Miner Bone Metab. 2013;10(2):97-110.Christus Health.Pain after knee replacement? Learn what’s normal and what’s not.Cedars-Sinai.Arthrocentesis and Arthrography.Picart B, Lecoeur B, Rochcongar G, Dunet J, Pégoix M, Hulet C.Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital.Orthop Traumatol Surg Res. 2021;107(3):102851. doi:10.1016/j.otsr.2021.102851Additional ReadingCercek R, Bassett R, Myerthall S.Evaluation of the painful total knee arthroplasty.J Knee Surg.2014;28(02):113-118. doi:10.1055/s-0034-1396081Cyteval, C and Bourdon, A.Imaging orthopedic implant infections.J Radiolog Diagnos Intervention.2012;93(6):547-557. doi:10.1016/j.diii.2012.03.004McDowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-326. doi:10.1016/j.ocl.2015.09.008

11 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Arthritis Foundation.Osteoarthritis patient education & resources.Pua YH, Poon CL, Seah FJ, Thumboo J, Clark RA, Tan MH, et al.Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.Acta Orthop. 2019;90(2):179-186. doi:10.1080/17453674.2018.1560647Mcdowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-26. doi:10.1016/j.ocl.2015.09.008Lum ZC, Shieh AK, Dorr LD.Why total knees fail-A modern perspective review.World J Orthop.2018;9(4):60-64. doi:10.5312/wjo.v9.i4.60Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W,et al.Degree of coronal alignment correction can’t predict knee function in total knee replacement.BMC Surg. 2021;21(1):383. doi:10.1186/s12893-021-01372-3Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH.Literature review of the causes of pain following total knee replacement surgery: Prosthesis, inflammation and arthrofibrosis.EFORT Open Rev. 2020;5(9):534-543. doi:10.1302/2058-5241.5.200031Desai MM, Shah KA, Mohapatra A, Patel DC.Prevalence of metal hypersensitivity in total knee replacement.J Orthop. 2019;16(6):468-472. doi:10.1016/j.jor.2019.05.005Piscitelli P, Iolascon G, Innocenti M, Civinini R, Rubinacci A, Muratore M, et al.Painful prosthesis: Approaching the patient with persistent pain following total hip and knee arthroplasty.Clin Cases Miner Bone Metab. 2013;10(2):97-110.Christus Health.Pain after knee replacement? Learn what’s normal and what’s not.Cedars-Sinai.Arthrocentesis and Arthrography.Picart B, Lecoeur B, Rochcongar G, Dunet J, Pégoix M, Hulet C.Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital.Orthop Traumatol Surg Res. 2021;107(3):102851. doi:10.1016/j.otsr.2021.102851Additional ReadingCercek R, Bassett R, Myerthall S.Evaluation of the painful total knee arthroplasty.J Knee Surg.2014;28(02):113-118. doi:10.1055/s-0034-1396081Cyteval, C and Bourdon, A.Imaging orthopedic implant infections.J Radiolog Diagnos Intervention.2012;93(6):547-557. doi:10.1016/j.diii.2012.03.004McDowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-326. doi:10.1016/j.ocl.2015.09.008

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

Arthritis Foundation.Osteoarthritis patient education & resources.Pua YH, Poon CL, Seah FJ, Thumboo J, Clark RA, Tan MH, et al.Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.Acta Orthop. 2019;90(2):179-186. doi:10.1080/17453674.2018.1560647Mcdowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-26. doi:10.1016/j.ocl.2015.09.008Lum ZC, Shieh AK, Dorr LD.Why total knees fail-A modern perspective review.World J Orthop.2018;9(4):60-64. doi:10.5312/wjo.v9.i4.60Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W,et al.Degree of coronal alignment correction can’t predict knee function in total knee replacement.BMC Surg. 2021;21(1):383. doi:10.1186/s12893-021-01372-3Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH.Literature review of the causes of pain following total knee replacement surgery: Prosthesis, inflammation and arthrofibrosis.EFORT Open Rev. 2020;5(9):534-543. doi:10.1302/2058-5241.5.200031Desai MM, Shah KA, Mohapatra A, Patel DC.Prevalence of metal hypersensitivity in total knee replacement.J Orthop. 2019;16(6):468-472. doi:10.1016/j.jor.2019.05.005Piscitelli P, Iolascon G, Innocenti M, Civinini R, Rubinacci A, Muratore M, et al.Painful prosthesis: Approaching the patient with persistent pain following total hip and knee arthroplasty.Clin Cases Miner Bone Metab. 2013;10(2):97-110.Christus Health.Pain after knee replacement? Learn what’s normal and what’s not.Cedars-Sinai.Arthrocentesis and Arthrography.Picart B, Lecoeur B, Rochcongar G, Dunet J, Pégoix M, Hulet C.Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital.Orthop Traumatol Surg Res. 2021;107(3):102851. doi:10.1016/j.otsr.2021.102851

Arthritis Foundation.Osteoarthritis patient education & resources.

Pua YH, Poon CL, Seah FJ, Thumboo J, Clark RA, Tan MH, et al.Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.Acta Orthop. 2019;90(2):179-186. doi:10.1080/17453674.2018.1560647

Mcdowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-26. doi:10.1016/j.ocl.2015.09.008

Lum ZC, Shieh AK, Dorr LD.Why total knees fail-A modern perspective review.World J Orthop.2018;9(4):60-64. doi:10.5312/wjo.v9.i4.60

Zhu S, Zhang X, Chen X, Wang Y, Li S, Qian W,et al.Degree of coronal alignment correction can’t predict knee function in total knee replacement.BMC Surg. 2021;21(1):383. doi:10.1186/s12893-021-01372-3

Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH.Literature review of the causes of pain following total knee replacement surgery: Prosthesis, inflammation and arthrofibrosis.EFORT Open Rev. 2020;5(9):534-543. doi:10.1302/2058-5241.5.200031

Desai MM, Shah KA, Mohapatra A, Patel DC.Prevalence of metal hypersensitivity in total knee replacement.J Orthop. 2019;16(6):468-472. doi:10.1016/j.jor.2019.05.005

Piscitelli P, Iolascon G, Innocenti M, Civinini R, Rubinacci A, Muratore M, et al.Painful prosthesis: Approaching the patient with persistent pain following total hip and knee arthroplasty.Clin Cases Miner Bone Metab. 2013;10(2):97-110.

Christus Health.Pain after knee replacement? Learn what’s normal and what’s not.

Cedars-Sinai.Arthrocentesis and Arthrography.

Picart B, Lecoeur B, Rochcongar G, Dunet J, Pégoix M, Hulet C.Implementation and results of an enhanced recovery (fast-track) program in total knee replacement patients at a French university hospital.Orthop Traumatol Surg Res. 2021;107(3):102851. doi:10.1016/j.otsr.2021.102851

Cercek R, Bassett R, Myerthall S.Evaluation of the painful total knee arthroplasty.J Knee Surg.2014;28(02):113-118. doi:10.1055/s-0034-1396081Cyteval, C and Bourdon, A.Imaging orthopedic implant infections.J Radiolog Diagnos Intervention.2012;93(6):547-557. doi:10.1016/j.diii.2012.03.004McDowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-326. doi:10.1016/j.ocl.2015.09.008

Cercek R, Bassett R, Myerthall S.Evaluation of the painful total knee arthroplasty.J Knee Surg.2014;28(02):113-118. doi:10.1055/s-0034-1396081

Cyteval, C and Bourdon, A.Imaging orthopedic implant infections.J Radiolog Diagnos Intervention.2012;93(6):547-557. doi:10.1016/j.diii.2012.03.004

McDowell M, Park A, Gerlinger TL.The painful total knee arthroplasty.Orthop Clin North Am.2016;47(2):317-326. doi:10.1016/j.ocl.2015.09.008

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