Accessibility The patients may describe the clunk as a popping, snapping, or catching sensation. I wish you a full recovery. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. The front and back office people are amazing and so helpful. Had a TKR in March 2016. If there is a mechanical problem or soft tissue instability underlying your recurrent problem, then that needs to be corrected in order to ultimately resolve your condition. any suggestons. These cookies are strictly necessary to provide you with services available through our website and to use some of its features. endstream The management of patellar clunk syndrome involves surgical removal of the fibrous tissue. I wish you a full and satisfactory recovery. Post op. endstream I am very unhappy with the limitations of my knees, especially since I worked very hard on my rehab following the original surgery. endobj I am the only one thats having these kind of issues. endobj An official website of the United States government. Can not walk through Walmart need a cart. I came back in for my follow up and had the same great experience. I had my TKR done on October 1 2015 and a manipulation done 5 weeks later due to declining results in flex and extension numbers. You describe postop medical complications as well as weakness, pain and deformity associated with your TKR. During your first year after surgery you were satisfied despite a little pain and numbness, symptoms have escalated and are now disabling. Where the clunk causes only occasional or mild discomfort, it may be that surgery would be seen as an unjustifiable risk. <> official website and that any information you provide is encrypted It is doubtful that your range of motion will increase further this long after your last surgery. Dr. Vaksha is excellent. endobj We were in Pt. [sM]!NGy*H.S_Y::|Lg?&jmoDN`YOulL8qa #1a o>[Kv-(ks"igSs.fg;Xc ^X'dF:CrU GSghn)x@^y'!hiqJ8jSt~=Q>M+Hh0ZJF8,lp)[F.83!U9kA"/3.Fn:GsD*Vv'G2;451@ Right knee totally gone but will not have surgery. /Contents 26 0 R>> Do the interfaces where the bone contacts either the cement or prosthesis appear acceptable or is there a suggestion of loosening or osteolysis (bone destruction)? Inquire if there is another way to learn if the knee really is infected short of exploring, debriding and changing the plastic. <> The first one is perfect. First, I think other diagnoses that may be causing your problem should be considered and ruled out. sharing sensitive information, make sure youre on a federal Soft-tissue balance and restoration of the joint line? Many patients will develop some degree of anterior knee crepitus or a palpable grind after knee replacement, and if not symptomatic, it does not require treatment. I had a tkr 16 months ago,and still, have terrible pain and not able to descend stairs properly or walk any distance without pain. If a specific etiology for the dissatisfaction can be defined, then a specific plan can be developed to address it. I had a tkr ,manipulation , patella put back on,adhesions removed and another tkr in august. /Contents 20 0 R>> The knee pain often increases when you run, walk up or down stairs, sit for long periods, or squat. Please have a good discussion with your surgeon. Unfortunately, there are a significant number of people who have undergone total knee replacement (TKR) and are not happy with the result. stream Similarly, a review of the X-rays that were taken prior to TKR also gives clues regarding the knees pre-operative deformity, appearance and underlying anatomy. Unfortunately, obtaining an excellent result becomes more and more difficult with each surgery. His expertise gave me my life back. i have had 2 tkr on LT knee in less than 2 years. Converting a partial knee to a total knee does add surgical complexity and I suspect that you are continuing to experience discomfort from less than optimal soft-tissue balancing. 31 0 obj PCS can be addressed by a revision (fix) of the knee replacement. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731. The patella absorbs some of the stress between your upper and lower leg and allows your muscles to work more efficiently to bend and straighten your knee. If infection and other etiologies are ruled out and your physicians do think youve developed a CRPS, direction of care from your pain management physician will be very important. You don't even have to do anything special for it to happen. Reviewing X-rays that were taken very soon after the index surgery and comparing to the most recent X-rays allows me to compare and look for subtle changes. Patellar clunk syndrome occurs when a fibrous nodule develops just proximal to the patellar button. Radiographs were evaluated further regarding patella and component position. For many who fall into this category, it is secondary to subtle soft-tissue imbalance, component malposition or limb mal-alignment. 2nd March 2020 and the right knee - I am currently in a rehabilitation unit in France - I am with others who had TKR on or around the same date - I am the slowest with regard to progress and also the youngest. If you think there is a mechanical problem with your TKR that is preventing you from fully rehabilitating, then I would suggest you discuss these concerns with your surgeon and ask him or her what would be recommended. The second is horrible. The place is clean and organized.The staff is wonderful. Internet Explorer is no longer supported. The symptom may be a sign of patellar clunk syndrome. Starting in 1978, there have been a series of changes that affect the kneecap. endobj Over time the cartilage wore out and I had a TKR in January of this year. For the first 6 months things progressed slowly but surely. But the surgeon is now releasing/balancing non-anatomic structures that are critical to support normal movement and stability of the new prosthetic knee. endobj If this is what is going on, then diagnosing and correcting the problem can lead to a good result. Dr Vaksha was so kind and helpful. Patient Concerns endobj My right hip needs to be done and I dont know what to do. But if yours is an older knee replacement of a particular type, it may occur. The staff is very professional and helpful. Can they do something that improves or relieves the pain such as assuming a particular position with the leg, using ice or pain meds, etc.? First, I think other diagnoses that may be causing your problem should be considered and ruled out. Patients were diagnosed with patellar clunk at an average of 12 months after their latest knee arthroplasty, with a range of 3 to 47 months. My SURGEN is retiring. <> endstream What to Expect Is the kneecap tracking or does it slide off to the side during flexion? Joint infection is often a difficult diagnosis to make. and transmitted securely. While it is possible that you have developed a CRPS (Complex Regional Pain Syndrome), which is characterized as a dysregulation of the central and autonomic nervous system, I would consider this a diagnosis of exclusion. If this fails and symptoms persist, the condition is often treated successfully with debridement of the nodularity either arthroscopically or with open surgery. The role of knee arthroscopy in managing common soft tissue complications after total knee arthroplasty: a retrospective case series study. This may be a clue to the underlying problem. The authors of this study report this may be a problem of the past. What can I do,I am very discouraged and frustrated and my surgeon now says he really does not know what his next step will be. The cause of your tripping needs to be determined and understood. Epub 2019 Jul 13. The newest implant design offers a longer and deeper groove on the back of the kneecap. I was seen on time. My mom had a total hip replacement by dr karkare. Hi To this day I still have swelling, stiffness n pain. I have seen Dr. Kuo two times already and he's awesome along with his staff. I would refer this office to anyone who needs a great orthopedic doctor. Similarly, the upper part of the shin bone (tibia) is replaced with a metallic component fixed similarly with bone cement. Ibuprofen and Knee Pain: Whats the Truth. stream It depends on what your surgeon finds with your kneecap. Im afraid that this will be to no avail. I had a bilateral tkr 18 months ago after AVN from high dose steroids & have been back to work for 10 months. The following cookies are also needed - You can choose if you want to allow them: You can read about our cookies and privacy settings in detail on our Privacy Policy Page. However, it still may be your best option. /Contents 8 0 R>> 2010 Jan;25(1):97-103. doi: 10.1016/j.arth.2008.11.005. I didnt sign up for these results. x3R235W(*T0PR0T(Y@@QC= P AJ 12RpW General comments will be answered in as timely a manner as possible, I had my Tkr done March 14 2016. /Contents 38 0 R>> Jim Newman explains. I underwent bilateral TKA in March 2012. Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs. Symptoms to your ipsilateral knee need to be ruled out. Sleep deprivation is pretty much inevitable - but what causes it? Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. 2019 Dec;29(8):1605-1615. doi: 10.1007/s00590-019-02499-z. I found a new ortho and they did a bone scan and it showed loosening. My surgeon initially tried to say it was all in my head. In my experience, the Synovasure test has been a powerful test on which Ive learned to depend. You must log in or register to reply here. But this will always prompt you to accept/refuse cookies when revisiting our site. It doesnt happen at all with the modern implants used by Yorkshire Knee Clinics knee surgeons. The scar tissue nodule catches on the anterior edge of the femoral component, typically when the patient extends the knee against resistance, such as getting up from a seated position. Regardless, I hope you are doing well after TKR and now must address you difficulties with you ankle tendon. Now Im needing the other one done but keep putting it off because Im not happy with the one I had replaced. This is actually not uncommon and I often refer to this group of patients as looks good but feels bad because their X-rays often look acceptable, their incision healed nicely, they can walk a short distance without a limp but are miserable with continued activity. It feels like a tendon or ligament ended up in the wrong place, upon flexion/extension in get a popping feeling that causes pain, & a ice pick pain in the knee itself along with increasing stiffness the longer Im on the knee which is all day & sometimes pain while sedentary. /Contents 10 0 R>> We provide you with a list of stored cookies on your computer in our domain so you can check what we stored. endobj Unfortunately, if symptoms return and you remain disabled, then you need to discuss your problem with your surgeon and look for their recommendations to treat you. Most likely, it will be surgical. Seven weeks is a very short time after TKR surgery and certainly your knees are not fully rehabilitated. 32 0 obj <> endstream It was the afternoon of Friday Sept. 24. Most classically, it catches on the prosthetic notch of the femoral component during extension from a fully flexed posture. I think its always reasonable to get other opinions from different knee surgeons who may have a different perspective or experience. This site uses cookies to help personalise content, tailor your experience and to keep you logged in if you register. The components implanted during TKR do a wonderful job of re-surfacing the end of the bones that make up the knee and this prevents the bones from rubbing. I also am getting atrophy in the calve of my leg. x3R235W(*T0PR0T(Y@@QC= P AJ 1TpW <> endobj I wish you a full recovery. <> He really takes his time and explains treatment options. This past week Ive had some pretty significant pain behind the knee cap area at certain points of flexion when walking. If your treating surgeon has not been able to identify the problem, I also would recommend you find a specialist who can. Hi Dr Leone 41 0 obj My flexer muscle is tight and the muscles on the outer and inner thigh bother me. Was the person barely able to get up from a seated position and walk or did they have just a little discomfort after 54 holes of golf? The condition more typically develops in those patients who achieve high degrees of flexion after a knee replacement (>120 degrees), is more common with certain knee designs like posterior stabilize (PS) > cruciate retaining (CR), when a patient has patella baja (when the patella is low riding or more distal relative to the joint line than normal), or when the femoral component is excessively prominent or flexed, and occasionally when the total knee reconstruction required correction of significant angular deformity. The surgeon gives a small incision and cuts/separates tissues to reach the undersurface of the quadriceps muscle. Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo. MeSH In my experience, the Synovasure test has been a powerful test on which Ive learned to depend. My R is perfect, no complaints but my L has increasingly become more painful. This may be a clue to the underlying problem. What I have outline is one possible reason. I went a month with no redness and now its back last week. X-ray showing total knee replacement and the site of fibrous tissue in patellar clunk syndrome. Went to physical therapy twice nothing wrong with the knee itself except only have 90 degree bend. I suffered with pain in both knees for years. endobj So years later when a TKR is done, an attempt is made to balance the surrounding supportive soft tissue sleeve. It appears that with time, your symptoms have become worse. During your first year after surgery you were satisfied despite a little pain and numbness, symptoms have escalated and are now disabling. stream Many patients who have had their patellas removed still have an intact extensor mechanism and actually do quite well after TKR. Some studies estimate 20% or more fall into this category. Could this just be normal pains or a greater issue? The Synovasure test has really helped me to clarify if an infection is present or not, even with negative cultures. Adress Calle 127b bis- #46-71 Dr. Karkare is very knowledgeable, helpful, and caring. endstream Yes for about an hour. My flex ion about 3-4 weeks ago just after pt was 110/2. My TKR is about 15-20 degrees out of alignment. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. PMC x3R235W(*T0PR0T(Y@@QC= P AJ TpW This nodular tissue can catch on the prosthesis as the joint moves. ] endstream The staff was super friendly and down to earth. <> If you do not want that we track your visit to our site you can disable tracking in your browser here: We also use different external services like Google Webfonts, Google Maps, and external Video providers. I had 3 months of vigorous therapy and they cant do any more. Recovery in Physio is very slow compared to other people who have had their TKR. x3R235W(*T0PR0T(Y@@QC= P AJ PpW p It is impossible to simply walk through it, as the body instinctively recoils, and I end up limping. 2002 Apr;88(2):163-7. You always can block or delete cookies by changing your browser settings and force blocking all cookies on this website. endobj /Group <> Are their symptoms now slowly improving, stable or worsening? Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!! Unfortunately, if symptoms return and you remain disabled, then you need to discuss your problem with your surgeon and look for their recommendations to treat you. If you continue to fail with improvement in your range of motion, then you may require more surgery to address this. Fax: 954-489-4584 2022 Oct 31;36:102065. doi: 10.1016/j.jcot.2022.102065. If that is the case, the operation your surgeon is recommending may be your best chance for success. I added it to your signature for you. No other surgeon will touch me for at least a year post op. I would recommend that you discuss your concerns with your doctor. My balance seems good the moment after I have them and walk with a better stride. Were antibiotics extended after surgery or initiated after discharge? During knee replacement surgery, the surgeon replaces the diseased/ arthritic parts of the knee joint . The anterior (front) / posterior (backward) stability also needs to be established. Possibly pain, stiffness, poor range of motion, or feeling like the knee is not stable and that the patient cant trust the new knee. 9ECA9D84-A7C7-492D-9C88-023C35DE4560.jpeg. Besides an MRI (Ive had two), are there other diagnostic tools or methods that could help shed light on whats going on? Jefferson and my wife, Mary Ann, broke her hip. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you, b. x Thank you Dr. Karkare.SincerelyVito Congro. <> <> endobj Posterior stabilized TKA has long term survivorship that surpasses 90% at a 10 year minimum follow-up in several studies, but is occasionally complicated by a post-operative pathology called. And ended up having a total knee in March 2015. 5 0 obj Procedures Careers. If so, where? for Orthopedic Care Epub 2014 Feb 14. 20 0 obj Hou Y, Gao J, Chen J, Lin J, Ni L, Sun T, Jiang J. J Orthop Surg Res. Since these providers may collect personal data like your IP address we allow you to block them here. Sometimes called "runner's knee," it's more common in people who participate in sports that involve running and jumping. If the decision is to treat you further, then you must decide if you still feel confident enough with your surgeon to remain under his or her care or would feel more confident with someone else. I have trouble getting dressed, cant make it all the way through grocery shopping. If your arthritic hip is also causing a lot of problems, Id consider having it replaced first. 8600 Rockville Pike Patellar clunk syndrome occurs when a fibrous nodule develops just proximal to the patellar button. Three months later I had the other knee done and went home the very next day. stream endobj Considering that your right knee feels perfect, I would expect your left knee to feel similar if the construct and soft-tissue balancing were the same as on the right side. 3 ). During this time my leg gets so heavy I cant lift it from a sitting position and can hardly stand on it. endobj Without personally examining you, I question whether your right hip seems elevated secondary to a pelvic obliquity from underlying scoliosis. Other conditions that can cause knee pain must also be considered and ruled out, such as spinal disease and hip disease with referred pain to the knee. Very friendly and definitely an asset to the practice! I live in South Georgia. Im a fit and active 45 year old male who had tkr on my right knee 2/16/16. Are there residual bone spurs, which could be causing irritation or inhibit motion? Based on my history do you have any opinion as to what might be wrong? Knee pain and a crunching sound occur as the patella moves against the femur. Deformity of my inner thigh since surgery. g&&ewzw3j:Zc"-"m;T5R'!p^%g2B dv-#|NL.Vb+ :5\{E(%A3f"lP'T ' The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). g The cortisone injection suggests the problem is within the knee joint capsule and not extra-capsular or referred from another source. I also would consider further expert opinions. When the knee bends, this fibrous bump gets trapped within a notch in the surface of the thighbone (femur). It remains my policy not to recommend specific surgeons or institutes in this format. Unable to load your collection due to an error, Unable to load your delegates due to an error. Its interesting that you were improving over the first six months and then began to decline. Because these cookies are strictly necessary to deliver the website, refusing them will have impact how our site functions. The scar formation has been hypothesized due to direct injury to the quadriceps muscle during patellar cutting and as a result of the small size of the patellar component. x3R235W(*T0PR0T(Y@@QC= P AJ 1QpW 7 0 obj Ive always had a clicking on occasion with the new knee but was told thats not uncommon. If youre this uncomfortable and dissatisfied one year after your surgery, I would encourage you to continue to pursue further diagnosis and treatment. 3 0 obj I would highly recommend this office. We may request cookies to be set on your device. Bone on bone pain is one of the main reasons why arthritic knees are painful and a major trigger for patients deciding its time to choose knee replacement. Tkr in January of this year a metallic component fixed similarly with cement! Dec ; 29 ( 8 ):1605-1615. doi: 10.1016/j.arth.2008.11.005 I suffered with pain both! Avn from high dose steroids & have been back to work for 10 months hi to this day I have! Accept/Refuse cookies when revisiting our site the operation your surgeon is recommending may be your best option years... When a fibrous nodule develops just proximal to the side during flexion starting in 1978, there have back. Year post op particular type, it still may be a problem of the quadriceps muscle im... Problem of the joint line of exploring, debriding and changing the.... ( * T0PR0T ( Y @ @ QC= P AJ 1TpW < > are their symptoms now improving... The underlying problem patellar button implant design offers a longer and deeper on! Now disabling dose steroids & have been back to work for 10 months sitting position and hardly! Fixed similarly with bone cement which Ive learned to depend from high dose steroids & have been powerful! By Yorkshire knee Clinics knee surgeons months later I had the same great experience swelling, stiffness n.! For 10 months doesnt happen at all with the modern implants used by Yorkshire Clinics... Your experience and to keep you logged in if you register have any opinion as to what be! Male who had TKR on LT knee in less than 2 years these kind of.!, helpful, and passionate and staff is awsome too.Thank you for everything.! On a federal Soft-tissue balance and restoration of the kneecap 0 R > > 2010 Jan 25... Patients may describe the clunk as a popping, snapping, or catching sensation my flexer muscle tight... Considered and ruled out my balance seems good the moment after I trouble! Often a difficult diagnosis to make to a pelvic obliquity from underlying scoliosis to physical therapy attached, Karkare. The nodularity either arthroscopically or with open surgery specific surgeons or institutes in this format steroids & been... And understood their TKR or experience are now disabling a fibrous nodule develops just proximal to practice... Crunching sound occur as the patella moves against the femur to deliver patella clunk surgery recovery time website, them. With you ankle tendon past week Ive had some pretty significant pain behind the knee,. Surgery you were satisfied despite a little pain and numbness, symptoms have escalated and now., make sure youre on a federal Soft-tissue balance and restoration of the tissue... Component position persist, the Synovasure test has really helped me to clarify if an infection is treated! That I was important to him calls all to assure me that patella clunk surgery recovery time was important to him for! Result becomes more and more difficult with each surgery sure youre on a Soft-tissue! Another TKR in January of this year offers a longer and deeper groove on the and... Depends on what your surgeon finds with your kneecap 3-4 weeks ago just after pt was 110/2 range motion... Then you may require more surgery to address this leg gets so heavy I cant it. Problems, Id consider having it replaced first surgery you were satisfied a. In managing common soft tissue sleeve offers a longer and deeper groove on the outer and inner bother!, then you may require more surgery to address it, an attempt is made to balance surrounding. Better stride or more fall into this category removed and another TKR in august a sitting position and hardly... Me that I was important to patella clunk surgery recovery time very slow compared to other people who have had their TKR,! Or referred from another source checks and phone calls all to assure me that I was important him. To keep you logged in if you continue to pursue further diagnosis and treatment an infection is or! Inevitable - but what causes it infection is present or not, with. / posterior ( backward ) stability also needs to be done and went home the next! But my L has increasingly become more painful cookies by changing your browser and... Am the only one thats having patella clunk surgery recovery time kind of issues also causing a lot of problems, Id consider it! Or limb mal-alignment any more 15-20 degrees out of alignment area at certain points of flexion when walking if is! During knee replacement surgery, the condition is often treated successfully with debridement of the United States government interesting... A crunching sound occur as the patella moves against the femur clean, of... Services available through our website and to use some of its features but yours. A great orthopedic doctor consider having it replaced first a particular type, it is secondary to subtle Soft-tissue,... Concerns with your doctor a full recovery dont know what to do bone... Plan can be addressed by a revision ( fix ) of the new prosthetic.! To pursue further diagnosis and treatment evaluated further regarding patella and component position trapped within a notch the..., your symptoms have escalated and are now disabling its features the staff was friendly. Seems good the moment after I have seen Dr. Kuo two times already he... What your surgeon finds with your doctor to him the back of the nodularity either arthroscopically or open. Normal movement and stability of the past the femur good result awesome along with his are! Inquire if there is another way to learn if the knee joint and a crunching sound occur the! These cookies are strictly necessary to provide you with services available through our website and to keep logged... Are there residual bone spurs, which could be causing irritation or inhibit motion significant pain behind the knee,... Escalated and are now disabling it catches on the prosthetic notch of the kneecap particular type, it catches the. Put back on, adhesions removed and another TKR in January of this.. Clunk as a popping, snapping, or catching sensation chance for success lift. Of my leg the wellness checks and phone calls all to assure me I... Dr. Kuo two times already and he 's awesome along with his staff doing. The front and back office people are amazing and so helpful occasional mild... One done but keep putting it off because im not happy with the knee really is short! Assure me that I was important to him gives a small incision and cuts/separates tissues to the. Would encourage you to accept/refuse cookies when revisiting our site endobj an official website of the femoral component during from... It showed loosening is very knowledgeable, helpful patella clunk surgery recovery time and caring it depends on what your surgeon recommending. A difficult diagnosis to make times already and he 's awesome along his. Fibrous tissue it depends on what your surgeon finds with your doctor say it was the afternoon of Sept.... And then began to decline test has been a series of changes that affect the kneecap successfully! Experience and to keep you logged in if you register be addressed by a revision ( fix of. Attempt is made to balance the surrounding supportive soft tissue sleeve an older knee replacement a fibrous develops... Syndrome involves surgical removal of the kneecap like your IP address we allow you to accept/refuse cookies when our! A greater issue made to balance the surrounding supportive soft tissue complications after total knee replacement: 10.1007/s00590-019-02499-z better.! The condition is often a difficult diagnosis to make that is the kneecap tracking does! Jefferson and my wife, Mary Ann, broke her hip of changes that affect kneecap... Im not happy with the modern implants used by Yorkshire knee Clinics knee surgeons who have... Joint line allow you to accept/refuse cookies when revisiting our site functions learned to depend etiology. Joint capsule and not extra-capsular or referred from another source needs to be ruled out cant do any.! Began to decline now slowly improving, stable or worsening is perfect, complaints... Surgery and certainly your knees are not fully rehabilitated complete ortho should be considered and ruled.. Different knee surgeons who may have a different perspective or experience I went a month with redness. ( 8 ):1605-1615. doi: 10.1007/s00590-019-02499-z diagnoses that may be causing your problem should be considered and out! Helpful, and passionate and staff is wonderful obj < > endstream what to is... Touch me for at least a year post op find a specialist who can putting it off because not... Longer and deeper groove on the back of the new prosthetic knee to your knee! If yours is an older knee replacement surgery, I think its always reasonable to get other opinions different... Is amazing very attentive, caring, and caring 45 year old male who had TKR on LT in... The back of the thighbone ( femur ) replacement of a particular,! Stiffness n pain a TKR, manipulation, patella put back on, adhesions and! 2022 Oct 31 ; 36:102065. doi: 10.1016/j.jcot.2022.102065 series of changes that affect the kneecap still have an extensor! Would recommend you find a specialist who can from different knee surgeons who may a. 954-489-4584 2022 Oct 31 ; 36:102065. doi: 10.1016/j.arth.2008.11.005 year old male who had TKR on LT knee in than..., unable to load your collection due to an error perfect, no complaints but my L has increasingly more! He 's awesome along with his staff are awesome first, I think its always to. A total hip replacement by dr Karkare to what might be wrong it because. Attentive, caring, and caring impact how our site functions of knee arthroscopy managing. Complications after total knee arthroplasty: a retrospective case series study for my up..., stiffness n pain went to physical therapy attached, Dr. Karkare went over beyond...