As knee replacement technology improves post-surgical rehab is less extensive and cyclists are getting back sooner and better than before.
The first total knee replacement surgery was in 1968, and in the early 1970s, biomechanical engineers developed the modern total knee implant called the total condylar knee. There were significant technological design advances before I began practicing Physical Therapy in 1997, but the decision-making factors to consider for my active patients were limited.
The prevailing wisdom of surgeons and therapists was to advise the athlete suffering from knee pain, usually of arthritic origin, to “put it off as long as you can.” The artificial knee prosthesis had a finite lifespan of approximately 15 to 20 years back then. Impact and excessive weight-bearing activity sped up the timeline, and surgeons advised against it for the most part. The options were limited and did not include resuming pre-surgical athletic activity.
Not Riding, and Not Riding Well Is NOT an Option
That was not an option for Neal Fleenor. “I timed the procedure on the L’Etape du Tour de France,” states Neal, who is riding in the 2022 event scheduled for July 10. The Richmond, Virginia Husband and Father of a teenage daughter will be tackling the same route as stage 12 of the Tour de France, covering 170 km with more than 4,700 meters of climbing. All with a brand new knee.
A recent study of 109 professional cyclists revealed that 58% experienced an overuse injury over the previous year, with 23% of the injuries involving knee pain. Most cycling injuries are overuse injuries that develop gradually due to repeated movement patterns. In the general patient population, a percentage of the almost one million replacement surgeries each year is due to traumatic injury.
Many Cyclists Fall Into the Knee Replacement Category
In August 2017, Neal Fleenor fell into that category after taking a misstep from a 20-foot platform. The impact caused significant skeletal injury to his lower leg, including displacement of several ankle bones and one sheared off entirely. “What my doctor didn’t diagnose at the time,” reports Neal, “was the damage to the menisci in my knees.”
Recent data has shown that as many as 47% of people surveyed have delayed seeking relief from their joint pain due to concerns with the post-operative process. Neal’s right knee progressively worsened in the three years since the accident and when walking up and down stairs became a painful chore, he went to see an orthopedic surgeon.
Riding became a problem for Neal, who admits, “trying to push a maximal effort got to be tremendously painful.” The surgeon discovered that the meniscus in his right knee had worn away, and his knee bones were rubbing together, causing the pain. “A partial knee replacement was going to be needed,” concedes Neal.
Knee Replacement Surgery Has Come a Long Way
The tremendous technological advancement in prosthesis design and process, including robotic-arm-assisted surgery, has opened the door for athletes seeking to resume an active lifestyle without putting off treatment. The prostheses last longer, and the surgery is becoming less invasive, decreasing post-surgical recovery intervention. Cyclists with arthritic knee pain have more options than ever. “My last outdoor event was in October, so I got it done right after that,” Neal declares.
Neal was introduced to cycling when he started competing in triathlons, but “after the fall, running was out, and swimming became laborious because of the lack of ankle motion when I tried to kick and even get out of the pool.” Check out Neal’s Strava profile here.
Neal could not bear weight on his left leg for twelve weeks after the accident and spent three months in physical therapy. “By the time I could bear weight,” explains Neal, “I lost a tremendous amount of muscle and the use of my lower leg.” Regaining ankle mobility and leg strength was a challenge and prevented him from riding outdoors.
Virtual Cycling Gave Him His Riding Freedom Back
Things changed for Neal in January 2018 when a bike shop owner friend showed him the direct-drive trainers he was selling and how they worked with the Zwift app. “I quickly recognized that this setup would get me riding again without fear of falling over when stopping because my injured ankle would not unclip fast enough,” Neal recalls excitedly. “I could start riding again and go for as long as I liked, giving me back some of my freedom to start doing activities again.” Find Neal’s ZwiftPower profile here.
Riding on Zwift opened Neal’s eyes to social interaction absent from his outdoor cycling. “I’m fascinated to share experiences with other riders and relate to their recovery from injury and surgery,” offers Neal, “and there’s a lot of encouragement.” The interaction helped build Neal’s confidence and reassured him that the recovery and return to activity and training would go well. “One of my ZRL teammates had a total knee replacement at the start of last summer, and I was amazed and encouraged that in 3 months, he was back to riding near the same effort level and distance he had before his procedure.”
The Surgery - October 26, 2021
Neal underwent right unicompartmental total knee arthroscopy on October 26, 2021. The surgery went well, and he was discharged home after a short stay in post-op recovery. “I was weight-bearing out of the hospital but a bit groggy from the painkillers,” admits Neal. Neal experienced a good deal of pain and discomfort the next two days.
Neal walked with the aid of a single crutch for five days. The day after surgery, physical therapy focused on improving knee mobility and activating his quadriceps muscles. “Those first two days post-surgery were very frustrating because my quad and hip flexor muscles were not responding,” notes Neal, “yet the leg could bear weight, but I could not lift or flex it voluntarily.” Neal will receive 18 physical therapy treatment sessions.
On the way home a few hours post-surgery!
Back on the Trainer in 12 Days and Racing in 5 Weeks
Twelve days after the surgery, Neal was back on the trainer. “Forward pedaling did not go well at first,” Neal professes, “but backpedaling was not a problem, and after doing that for a bit, I could pedal normally.”
Three days post-op!
At fourteen days post-op Neal took his first ride. “I logged into Zwift and virtually rode for around 20 yards,” he notes in excitement. The next day Neal increased the distance to half a mile, and on the third day, he rode over a mile. Neal’s progress was consistent, and he rode continuously for 90 minutes five weeks after surgery, “and I even added a few sprints.” In addition, Neal goes to the gym twice a week to continue the strengthening and balance program he started in physical therapy.
Two weeks post-op!
The virtual cycling community has profoundly affected Neal’s post-surgical recovery. “I’ve had many conversations with other riders who have had the same experience,” says Neal, “and I was pretty surprised to learn that several of them had their partial knee replacement within days of my procedure.” In sharing his experience, Neal notes, “some supportive riders admonish my hard efforts, but also encourage patience on me.”
Four weeks after surgery!
Virtual Cycling Community is Essential to Recovery
The encouragement Neal finds essential to his mental and physical recovery was evident during a recent group ride led by Mark Cavendish. “I rode with a world champion coming back from a crash who suffered from broken ribs, and he was keeping his effort at a very reasonable 2.1 w/kg for the whole ride,” Neal remarks. “Mark didn’t try to sprint. He didn’t try to push to the front. He rode his recovery effort and spent the whole ride chatting with other riders.”
While on that ride, Neal learned about many other riders recovering from recent injuries, including fractures, recent surgery, or will have a major surgery within weeks. “That’s not the kind of typical outside group ride experience,” Neal insists excitedly.
Forty days after the surgery!
Conclusion - Riding, and Riding Well is the ONLY Option
Neal’s knee replacement pre-and post-surgical experience is typical, however. A lot has changed in the 25 years I have been practicing physical therapy. Cyclists have many options, and not enjoying the sport we love as we used to isn’t one of them. It wasn’t for Neal, who will be competing in the upcoming ZRL season and meeting his benchmarks in preparation for the L’Etape du Tour de France in July.
The decision to undergo knee replacement surgery requires considerable thought, research, and preparation, but the cyclist shouldn’t avoid it purely for fear of never riding again. Knee replacement is major surgery, and the rehabilitation is extensive and demanding. Still, when you have explored all other options, it quite possibly may be the best decision you could make. It was for Neal.
Have you had a total knee replacement or are giving it some thought? What is your experience? Comment below. Your fellow virtual cyclists want to know.
For more helpful cycling-specific information on the treatment and prevention of injury check out the Virtual Case Studies page of The ZOM!
Semi-retired as owner and director of his private Orthopedic Physical Therapy practice after over 20 years, Chris is blessed with the freedom to pursue his passion for virtual cycling and writing. On a continual quest to give back to his bike for all the rewarding experiences and relationships it has provided him, he created a non-profit. Chris is committed to helping others with his bike through its work and the pages of his site.
In the summer of 2022, he rode 3,900 miles from San Francisco to New York to support the charity he founded, TheDIRTDadFund. His “Gain Cave” resides on the North Fork of Long Island, where he lives with his beautiful wife and is proud of his two independent children.
You will read him promoting his passion on the pages of Cycling Weekly, Cycling News, road.cc, Zwift Insider, and Bicycling. Chris is co-host of The Virtual Velo Podcast, too!