It is now almost five weeks since I had my total left knee surgery from Dr. Christopher Hanosh, of the Lovelace system using a Mako Total Knee procedure utilizing advanced robotic technology for its precision.
My surgical journey started with a CT scan of my left knee weeks before surgery to create a 3D model, allowing for personalized surgical planning and execution by Dr. Hanosh. During surgery, the Mako robotic arm assisted Dr. Hanosh in accurately positioning the implant based on the results of the CT scan. He made an incision down the front of my left knee, removed damaged cartilage and other soft tissue, and prepared my left knee for the implant. The robotic system provided real-time feedback to ensure the optimal placement of the implant. The knee implant was inserted by the robotic arm and and Dr. Hanosh checked for proper alignment and stability before closing the incision along the front of my knee.
Many of you who have known me over the years, know that I do not advocate surgery as the first choice in treating chronic musculoskeletal pain and other symptomatology. Sometimes it is warranted and is your only choice especially after a traumatic experience as I had in 1971 while training for the 1972 Olympics. Surgery was done then because of a fall injuring my left medical meniscus, medial collateral ligament, and anterior cruciate ligament.
I finally chose to have this Mako Total Knee done in March because I was no longer able to walk for my fitness nor go up and down stairs without experiencing knee pain. Knee pain that was now affecting both knees from the compensation over the years to my injury and surgery in 1971. Prior to this surgery in March 2026, I did try hyaluronic acid injections to both my knees for the osteoarthritis called viscosupplementation.
Hyaluronic acid is a substance naturally found in the body’s joint fluid which is injected into the knee joint to restore lubrication and cushioning diminished by a diagnosis of osteoarthritis. The diagnosis of osteoarthritis for both my knees was confirmed by x-ray images with the left knee looking much more severe than the right. Thus, I decided to do just my left knee with this most recent surgery.
It should also be noted I contemplated having stem cell injections before the hyaluronic acid injections where stem cells, the body’s master cells, are injected into the joint. Stem cells are the body’s master cells because all other cells of the body arise from stem cells. Stem cell injections are a form of regenerative medicine utilizing the stem cells to promote healing and repair of the body’s soft tissues. Stem cell injections involve the introduction of stem cells into damaged tissues such as cartilage of the knee which can differentiate into various cells and and can help in reducing inflammation and stimulate healing. However, I decided to go the route of the hyaluronic acid injections.
While getting the hyaluronic injections which are usually done in a series over several weeks, I noticed immediate improvement with my right knee while my left knee was slow to respond. During this time, I continued to work on my strength and endurance as well as the alignment of my lower extremity kinetic chain involving my feet, ankles, knees, hips, and pelvic girdle. I did this because the osteoarthritis shown in the x-ray images was due to the poor alignment of my left lower extremity kinetic chain and compensation after my surgery in 1971. The poor alignment altered the fluid dynamics of the joint synovial fluid to my left knee leading to the degenerative changes seen on the x-ray images. My right knee was also compensated, but not to the degree of my left.
I have to say the hyaluronic acid injections helped my left knee, but to a much lesser degree than on my right. Therefore, I continued to struggle with walking long distances and going up and down stairs and finally made the decision to have my left total knee.
At five weeks, I am doing amazingly well achieving full range of motion and exercising daily. I am walking about a half mile a day and gradually increasing the distance using my hiking sticks. I use my hiking sticks not for balance, but to focus on my reciprocal gait pattern with my arms. That is because my gait has been compensated over the years due to the poor alignment of my lower extremity kinetic chain and pain. I am also riding my recumbent exercise bike 10 minutes a day and will gradually increase to about twenty minutes a day. In addition, I do exercises to increase my lower extremity strength and range of motion as well as stretching for my flexibility. Of course, I finish up with stair work and balance. I am happy to say I am now walking and going up and downstairs without pain even with my right knee.
I did go to physical therapy for two visits with an old colleague of mine, Sledge Morgan at Mountainview Physical Therapy here in town releasing me after two visits. On my last visit, he asked me how I was able to recover so fast from the surgery. My answer was simply, “overcoming fear and pain!” I am not talking about “no pain, no gain,” but by understanding where my pain was coming from diminished my fears after surgery that allowed me to work with my tightened soft tissues around my left knee immediately even though I was experiencing the usual post surgical pain.
I have to thank Dr. Hanosh and his staff for monitoring and preventing any possible infection which was a real fear of mine. I felt an infection would be the only thing to prevent me from a fast and full recovery. Prior to surgery, my blood work was positive with a pre-surgical staphylococcus screening culture. Therefore, Dr. Hanosh convinced me to stay overnight in order to administer antibiotics by IV as a precaution. Thanks to his professional expertise and decision I was able to avoid any infection.
When I talk about fear and pain, I have an advantage over most of you since I have already experienced orthopedic surgery in 1971 to my left knee and bilateral shoulder surgery due to falls while training and competing in sport of nordic ski jumping. In addition, I have forty-four years of physical therapy experience in hospitals and private clinics dealing mostly with chronic musculoskeletal pain and other symptomatology. On top of that, I remember when my left knee surgery was done, the post operative management involved putting my left leg in a straight leg cast for three months and was non-weight bearing causing significant compensation never allowing my left knee to work biomechanically and functionally correct.
So when I awoke from surgery on March 30, I was bound and determined to move my left knee. At first, I just actively moved my left knee in flexion and extension for several minutes every hour I was awake even though I had pain. I also got up that day and walked with a walker. Once at home, I used a Knee Works Model 300 from Motion Restore every other hour on my flexion and extension range of motion. In addition, I consistently during the day would manually work on my soft tissues to the areas of tension around my left knee with vibration, infrared light therapy, as well as deep manual pressure. I also used an ice machine and my prescribed pain and anti-inflammatory medication and tylenol for pain management. I gradually eliminated the pain medication and anti-inflammatory.
In order for me to work my left knee as I did immediately upon awakening from surgery, I had to have a good understanding of what the pain I was experiencing was and wasn’t. Initially, my pain was primarily due to the trauma of my soft tissues from surgery. I often describe surgery to my clients as induced trauma. But I also was experiencing what I refer to as dysfunctional pain. It is pain which is typically associated with the increased tension of the body’s soft tissues causing a loss of movement, stiffness, and stagnation of circulation. With dysfunctional pain, the pain occurs at the end range of a restricted movement and the pain decreases when moving away from the end range of a restricted movement.
To successfully rehabilitate from any surgery, it is my belief you have to have a good understanding and knowledge about pain. Most people think that pain is an input to your nervous system when it is actually an output.
When your nervous system elicits an output of pain, you should think of it as a positive output, even though today thinking of pain in such a manner is still misunderstood.
But with the research done on pain neuroscience today, these groundbreaking findings should change how pain is managed, even as we hang onto some of the old ideas regarding pain. I know pain neuroscience, or neurobiology has exploded with new findings on pain since I was in P.T. school in the early 1980’s and especially since 1995. One finding that stands out to me is when you experience pain, we no longer should feel like it is an input to our nervous system. We hang onto pain being an input because as children, we were kind of acculturated into this world of whenever you feel pain, it is because you have injured or hurt yourself. Therefore, you tend to associate pain and especially musculoskeletal pain with an injury or trauma. You also tend to associate musculoskeletal pain as something you feel in the periphery and not experienced by your brain. But modern pain neuroscience has completely reversed that way of thinking. When you really understand pain and you understand how it is created by your brain and used by your brain, all of sudden, your options for helping yourself expand exponentially.
You first have understand that your brain is first and foremost concerned with your survival through movement or a motor output. Therefore, your brain is always worried about a danger or a threat to you and the safety and well-being within you.
Your brain is constantly monitoring your internal and external environment for a threat and danger generating a constant balancing act within your central nervous system involving your sympathetic and parasympathetic systems of your autonomic nervous system. If your brain feels or perceives something is dangerous or threatening to your survival, its job is to protect you causing the sympathetic nervous system or the output of “fight or flight” to be facilitated.
Simply if your brain senses danger or a threat to your survivability, it will take action to change your environment or change your behavior so that you are safe and out of harm’s way. However if your brain perceives a danger or a threat and feels the need to protect you, it has different motor outputs or actions that it can choose.
Keep in mind that your brain has many tools it can utilize to protect you from a danger or threat with pain being the first tool it uses.
Think about it. Whenever you injure yourself, your brain usually tells you it is a bad idea to keep moving. I am sure many of you have sustained a sprained ankle feeling a pop and immediate pain making it difficult to walk. That pain and getting the weight off your ankle and foot is an output and safety mechanism from your brain in that moment. Your nervous system is trying to prevent you from walking or running on that ankle that could cause even more soft tissue damage.
But let’s look at another example to describe other outputs. Again, you feel a pop of your ankle and experience immediate pain with the output of pain being a primary safety mechanism protecting you at that moment. But what if you heard the pop of your ankle while walking across a street with a bus coming directly at you. At that moment, your brain probably would say the output of your pain is secondary at that moment because the primary danger to your survivability now is not from your injured ankle, but foremost from the bus coming right at you.
When pain is considered as a behavioral tool or output of change as just described rather than an input, it is something that doesn’t need to feared, but rather an output your brain can use to alter your behavior. Again, the pain you experience is brain generated based on an evaluation by your nervous system of the safety and danger to your survivability.
But when talking about pain, realize it also involves changes in your immune system, sympathetic nervous system, and endocrine system revealing the reality that your brain has multiple options of action or outputs to chose from for your protection and well-being from a perceived threat or danger. However, nobody can deny that pain is usually is the primary output that gets your immediate attention.
Back in the 1600’s pain used to be defined by a Cartesian model believing that if you did something like getting your foot too close to a fire, you would get sensory input from your foot to the brain. The sensory input would go up through your peripheral nerves to the spinal cord, and finally reach a part of the brain that would light up and you would experience pain. Unfortunately, many people today including many health professionals still think of pain in this antiquated manner utilizing the Cartesian model. You need to understand that with the brain output of pain, you brain has many other factors to look at in order to decide on a motor output or action to remove you from a threat or danger.
However, the first priority of your brain of course is evaluating how dangerous or a threat a situation at that moment is from reading the sensory input coming from your peripheral nervous system.
Remember with any sensory input your brain receives, you have interpretation, decision, and output loop occurring at the brain level. The sensory input plays a major role in evaluating what is a dangerous and threatening situation to your survivability. But your past experiences can also impact the output from your brain and assessing whether your situation of the moment is a danger or threat. I will use my own personal experience to explain.
When I was training and competing in nordic ski jumping, I took thousands of rides on jumps without feeling or experiencing a sense of danger or threat to my survivability. That is until I took serious fall in 1975 flipping in the air and landing on the back of my shoulders traveling at about 70 mph. After that, I had a significant sense of danger or threat whenever on top of a jump. It took me about two years to overcome that fear of danger and a threat to my survivability every time I took a jump. Along with past experiences, understand cultural factors matter and can play a major role in determining what is a threat or danger to you and the output from your brain.
So ultimately what I’m trying to say is that neuroscience has discovered some clear facts we now know about pain at this point in time that refute what we have been taught in the past. First and foremost, the neuroscience has shown that the pain you experience doesn’t exist in your periphery, but pain in fact is an opinion of your brain about what is happening with your internal and external environment. Pain is not an input, but rather an output of your brain when it senses a threat or danger to your survivability generating a behavioral change or output. The output of pain from your brain is from the summation of sensory inputs regarding your internal and external environment, previous experiences, and cultural factors.
I mentioned the fear I experienced while training and competing in nordic ski jumping after a severe fall. Fear is also a brain generated output that is closely associated with the output of pain. It is your brain’s emotional response to a real or perceived threat or danger to your survivability. Fear as pain is a survival tool. Therefore, the brain output of fear is related to pain causing increased muscle tension and heightened pain perception. This can generate a negative feedback loop where pain triggers fear, which in turn exacerbates the pain.
The anxiety of experiencing pain has become a well-documented predictor of chronic pain. Individuals who fear pain usually avoid any physical activity, leading to physical deconditioning and an exacerbation of their pain. Fear can intensify and reinforce the perception of your pain through sensory pathways.
Fear as does pain produces universal biochemical changes within your nervous system, an evolutionary development for your survivability that is an automatic response of your autonomic nervous system known as the fight-or-flight response of your sympathetic nervous system. This response is your body’s preparation to confront a threat or danger to your survivability or run away.
The body’s sympathetic nervous system plays a crucial role in your muscle function and fascial health. The sympathetic nervous system is known to increase your muscle tone and contraction that generates tension throughout your body ensuring a rapid response during stressful situations. Chronic activation of the sympathetic nervous system due to the outputs of fear and pain can lead to increased tension and stiffness of the fascia and myofascia reducing the vagal nerve tone and the parasympathetic nervous system know for “digestion and relaxation.”
Therefore knowing how fear, pain, and the sympathetic and parasympathetic nervous systems affect the fascial and neuromyofascial systems, I constantly focused my attention on the soft tissue tension at and around my left hip, knee, lower leg, ankle, and foot. From experience in the clinic, I knew healthy fascia and myofascia is flexible and glides smoothly for unrestricted movement. However after surgery, the fascia and myofascia stiffen developing adhesions called myofascial trigger points. These myofascial trigger points are also called Ashi points in Traditional Chinese Medicine (TCM).
Myofascial trigger are small, hyperirritable, tender spots, tight knots located in a tight band of skeletal muscle usually located in the muscle belly. They can cause localized and a referred pain pattern.
Myofascial trigger points actually become an accumulation of tension from the compensation that involves your myofascia and fascia, manifested as hypersensitive myofascial reflex points. But in addition, to myofascial trigger points there are Ashi trigger or tender points I usually find at the tendon attachments of muscles and especially at its origin where a muscle meets a tendon. Although in TCM Ashi points are also described along the muscle muscle belly as well similar to myofascial trigger points. But I find these tender areas or Ashi points most commonly at a muscle’s origin or a “binding point,” especially around major joints of your skeletal structure which are common spots for chronic tension.
I think that more than anything, working on these areas of accumulated tension through myofascial trigger points and ashi points in and around my left knee after surgery, is what allowed me to progress as well as I have. I have continued to work on these myofascial trigger points and ashi points as well as acu-points affecting the acupuncture meridians to enhance my recovery from left total knee surgery.
I hope what I shared with you regarding my surgical journey will help you learn more about your own body because I feel having that knowledge can have an tremendous impact on your fear and pain and the management of your acute/chronic musculoskeletal pain and other symptomatology.
I want to thank all of you for your thoughts and prayers for my full recovery and look forward to seeing you soon.
Terry