Spontaneous Knee Bleed

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dwhist

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Dec 30, 2011
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131
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Elmhurst, IL
I had a mechanical Aortic valve put in coming up on 8 years. I am on Warfarin with a goal of 2.5 to 3.5. Also baby aspirin.

7 Weeks ago I was watching tv and my left knee swelled up in a matter of about an hour. I went to doctor next morning who sent me to ER. They said my knee swelled up due to bleeding caused by the blood thinner. Normally they would drain, but being on blood thinner, it would just fill up again. Was very painful and I saw an orthopedic doctor who did an MRI and confirmed the bleeding. After talking to cardiologist, I reduced my INR to as close to 2.0 as we could for 3 weeks. Orthopedic doctor said he sees this occur in both the knee and the shoulder. My cardiologist says this is only the second time he has seen it. I am know doing rehab, but still unable to raise leg. Therapist said we need to rebuild the knee as if the knee joint had been replaced as the blood did a lot of damage.

My cardiologist has arranged for me to get home monitor and we are going to try to keep range of 2.5 to 3.0, which we know can be hard.

So, the question I have, is has anybody else gone through this, and if you have , what treatment was done and did it reoccur?
 

tom in MO

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Jan 17, 2012
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MO USA
I have never heard or read about that type of thing happening.

Warfarin alone generally won't cause you to bleed, there must have been something else that started the bleeding. For example, if I am on my feet all day, I'll get some blood spots on my lower legs. The doctor said that this is normal little veins popping and I can see them because they bleed a little more since I'm on warfarin. I've gotten a big bruise on my knee when I fell, but that's all. My range is 2-2.5.

Good luck.
 

pellicle

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Hi
curiously I would occasionally get small knee bleeds in my 20's when motorcycling (lengthy rides or just harder dirt bike riding), I eventually decided that this was due to posture (meaning angles of usage of the joints, orientation of rotation of the thigh, 5h1t like that .. ask your physio this exact question and see how happy they are you grasp the idea).

So this was some 20 years before I was on warfarin. Since I've been on warfarin (well and for the last 20 years anyway) I've not had that. However I've had some tendon injury on a trampoline a couple of years back and my friends gave me the due sympathy of "what, you were doing that and hurt your knee, how old did you think you were?"

So I can't blame warfarin for that one either ;-)

I guess that the INR 3.6 did not help the issue, but being on warfarin does not cause bleeds, it just makes what happens more apparent. So you still need to look at the cause.

It could have been as simple as getting up "wrong" and placing undue strain on the parts which are already getting older (I see you do "biking" but don't now what type. If cycling then it could also be your leg style / seat position / (if you use cleats) cleat adjustment.

Knee injurys are a PITA for sure ... I hope it gets better soon.

RICE : Rest, Ice, Compression, and Elevation is good for knee pain caused by a minor injury or an arthritis flare. Give your knee some rest, apply ice to reduce swelling, wear a compressive bandage, and keep your knee elevated.​

Best Wishes
 

dwhist

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Joined
Dec 30, 2011
Messages
131
Location
Elmhurst, IL
Hi
curiously I would occasionally get small knee bleeds in my 20's when motorcycling (lengthy rides or just harder dirt bike riding), I eventually decided that this was due to posture (meaning angles of usage of the joints, orientation of rotation of the thigh, 5h1t like that .. ask your physio this exact question and see how happy they are you grasp the idea).

So this was some 20 years before I was on warfarin. Since I've been on warfarin (well and for the last 20 years anyway) I've not had that. However I've had some tendon injury on a trampoline a couple of years back and my friends gave me the due sympathy of "what, you were doing that and hurt your knee, how old did you think you were?"

So I can't blame warfarin for that one either ;-)

I guess that the INR 3.6 did not help the issue, but being on warfarin does not cause bleeds, it just makes what happens more apparent. So you still need to look at the cause.

It could have been as simple as getting up "wrong" and placing undue strain on the parts which are already getting older (I see you do "biking" but don't now what type. If cycling then it could also be your leg style / seat position / (if you use cleats) cleat adjustment.

Knee injurys are a PITA for sure ... I hope it gets better soon.

RICE : Rest, Ice, Compression, and Elevation is good for knee pain caused by a minor injury or an arthritis flare. Give your knee some rest, apply ice to reduce swelling, wear a compressive bandage, and keep your knee elevated.​

Best Wishes
Thanks for replies.

I did some research on line and this bleeding tends to happen in hemophiliacs. These people have a lack of clotting of the blood. I had been sitting in chair for at least 2 hours before the bleeding became noticeable and happened very quickly.

Also, see if link works, https://www.belmarrahealth.com/hemarthrosis-causes-bleeding-knee-treat/
It references warfarin as possible issue.

My cardiologist says what happened is very rare and I was hoping somebody else on the forum had this happen to them. I am hoping it does not happen again. At this point I am in week 6 of rehab for knee and still cannot lift leg. I am told it will take a while for the quad to start working again.
 

gerrychuck

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173
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Moose Jaw, SK, Canada
My mother in law experienced a very similar spontaneous knee bleed a couple of years ago. She was on warfarin prophylactically after a stroke 20 years ago. In her case they decided ongoing anticoagulation carried more risk than benefit at that point and they took her off the medication. No issues since.
 

Protimenow

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California
You weren't specific enough about your 'knee bleed' for me to compare it to what I've experienced - and written about here a few times.

If this bleed is actually BEHIND your knee, it's probably the same thing that I've experienced a few times over the last four or five years. (One of these put me in the hospital for a few days last year).

What you may have had is called a 'Bakers Cyst.' It's also known as a Popliteal cyst. Fluid forms behind the knee, and you get a bulge that is filled with fluid, dried blood, and blood. It's hard to bend your leg all the way back. Occasionally, the thing pops, causing significant pain, and the fluids drip down the leg, creating some really beautiful (or ugly) bruises. At least, this is what I had a few years ago.

I used crutches for a few days. My orthopedist was no help.

Last November, I was sitting in a cardtable chair with my legs folded under me, playing Othello with a 99 year old nun. When I got home, I felt a cyst behind my left knee. It got worse as time went on. I called my orthopedic surgeon, he was of no help, it wasn't an emergency, and he really didn't care.

The next morning, my entire left calf was stiff, filled with fluid (I guess), and extremely swollen. He told me that he'll see me in two weeks.

He told me that he couldn't drain the cyst because there were nerves behind my knee that he didn't want to injure.

I called a rheumatologist. He was concerned about the turgidity of my calf. He could drain the fluid, but didn't want to until he saw an ultrasound of the knee and lower leg to see what was going on.

The lab I went to for the MRI was across the street from a hospital. They didn't have my appointment. Using a crutch, and stopping a few times to deal with the pain, I walked across the street to the hospital's emergency room. I asked for a wheelchair - I couldn't stand any longer.

In the hospital, they did an ultrasound of the veins in my leg. The E.R. doctor had me admitted - he was concerned that I may have 'compartment syndrome.' (Compartment syndrome can result in death of tissue and, in some cases, loss of the leg).

In the hospital, they had me sitting upright in the hospital bed. The swelling didn't resolve much. The hospital claimed (and I'm not sure if it's accurate) that my INR was 6.1. I take my INR weekly, but missed for a few weeks, and didn't test it after starting hyaluronic acid. So, it's possible that a higher INR contributed to the free flow of fluid into the synovial cyst, and the leakage of fluid into the lower leg.

I was in considerable pain for weeks (I know, if your suffering, this isn't good news), but it was releived by extractions of the fluid from the cyst, by the rheumatologist. He explained that Orthopedic surgeons aren't especially interested in things that aren't surgical. The Rheumatologist was able to extract the fluid. He also ordered an MRI -- revealing that when I had a fall a few months earlier, I'd torn some ligaments in my knee - completely missed by the Orthopedic surgeon - and, in his words, I'll need a knee replacement.

I ignored that advice. But once or twice a week, the rheumatologist drained the fluid behind my knee - offering almost immediate reduction in pain. I also made sure that my INR stayed below 3 (he didn't want to drain the fluid if my INR was higher, because it took longer to stop the bleeding).

Physical therapy helped a little. Going to the gym and building up the muscles around my knee seemed to help even more.

Keeping my INR below 3.5 is probably one of the ways to reduce the risk of another cyst forming. Making sure that I don't sit with legs behind me for more than 30 minutes or so, then walking around also helps.

If I were you -- I'd see a rheumatologist to assess your knee problem. If it's a cyst like I had, he or she may help relieve some of the swelling behind the knee.

---

Now, another, somewhat related thing: I'm sitting here in a fair amount of pain. Last week at the gym, I overused one of their machines. This machine was designed to strengthen abdominal muscles. I kneel on it, knees together, body bent back further than it should be, and move my trunk from side to side, with weights causing restricted movement. Somehow on that damned machine, I either overstretched a ligament between my lower leg and my knee, or a popped a blood vessel.
My INR last night was 3.2 - well within range.
The large bruises on the inside of my leg, just below the knee are big and painful. The collected blood is distributing down to the lower calf, so I'm expecting to have a nice, big bruise on my lower calf in the next few weeks.

The point of this part is that I've got to be more careful with my knew found flexibility - folding my lower leg behind or close to the upper leg is a no no.

---

So this is a long answer to a fairly short question.

You probably don't need knee surgery. You probably don't need a knee replacement (and if you do, you may be able to delay it). If your muscles above and below the knee are weak, you should try to strengthen all the muscles in your leg. You should watch your INR, keeping it in a safe range (for myself, 2.5-3.5 is fine).
And you shouldn't bend your lower leg under your upper leg, if you can avoid it, and certainly not for more than 30 minutes at a time.
 

pellicle

Professional Dingbat
Joined
Nov 4, 2012
Messages
6,162
Location
Queensland, OzTrayLeeYa
Hi

I did some research on line and this bleeding tends to happen in hemophiliacs. These people have a lack of clotting of the blood. I had been sitting in chair for at least 2 hours before the bleeding became noticeable and happened very quickly.

Also, see if link works, https://www.belmarrahealth.com/hemarthrosis-causes-bleeding-knee-treat/
It references warfarin as possible issue.
interesting ... reading through that I spotted:

Medications: Anticoagulants such as warfarin have the potential to lead to joint bleeds.​


I underlined the bit that also needs to be understood (and also warfarin sort of makes you an induced hemophiliac). However (as I read it) the point above it is important in that context:

Haemophilia: Those who suffer from this hereditary condition, which impairs blood-clotting mechanisms, are more likely to get hemarthrosis.​

which ties into what I wrote initially: "but being on warfarin does not cause bleeds, it just makes what happens more apparent. "

This is what I understand them as meaning "more likely to get". Its also important to look at that site and note that this is not a medical site but a site intended to flog a product which has ads on it to make money. Accordingly they'll use "non accurate" language (AKA Dumbing it down and throwing precision to the wind like an aircraft throwing radar chaff out to distract that incoming missile) which will be different to what you'll read in a journal (or your cardiologist may use).

The point I made on my earlier motorcycling days was (probably inadequately described) that I got bruising appear some time later as the blood lost by tissue rupture (of unknown cause) spread surrounding tissue to become apparent.

My cardiologist says what happened is very rare and I was hoping somebody else on the forum had this happen to them.
sure, its an excellent question to ask, but if it does happen again you will need to look more into why it happened and do some examinations (perhaps MRI) and look for possible causes ... it could be for instance a bone spur.

Either way I hope you get a resolution (and hope more though that it doesn't happen again).

Best Wishes
 

dwhist

Well-known member
Joined
Dec 30, 2011
Messages
131
Location
Elmhurst, IL
You weren't specific enough about your 'knee bleed' for me to compare it to what I've experienced - and written about here a few times.

If this bleed is actually BEHIND your knee, it's probably the same thing that I've experienced a few times over the last four or five years. (One of these put me in the hospital for a few days last year).

What you may have had is called a 'Bakers Cyst.' It's also known as a Popliteal cyst. Fluid forms behind the knee, and you get a bulge that is filled with fluid, dried blood, and blood. It's hard to bend your leg all the way back. Occasionally, the thing pops, causing significant pain, and the fluids drip down the leg, creating some really beautiful (or ugly) bruises. At least, this is what I had a few years ago.

I used crutches for a few days. My orthopedist was no help.

Last November, I was sitting in a cardtable chair with my legs folded under me, playing Othello with a 99 year old nun. When I got home, I felt a cyst behind my left knee. It got worse as time went on. I called my orthopedic surgeon, he was of no help, it wasn't an emergency, and he really didn't care.

The next morning, my entire left calf was stiff, filled with fluid (I guess), and extremely swollen. He told me that he'll see me in two weeks.

He told me that he couldn't drain the cyst because there were nerves behind my knee that he didn't want to injure.

I called a rheumatologist. He was concerned about the turgidity of my calf. He could drain the fluid, but didn't want to until he saw an ultrasound of the knee and lower leg to see what was going on.

The lab I went to for the MRI was across the street from a hospital. They didn't have my appointment. Using a crutch, and stopping a few times to deal with the pain, I walked across the street to the hospital's emergency room. I asked for a wheelchair - I couldn't stand any longer.

In the hospital, they did an ultrasound of the veins in my leg. The E.R. doctor had me admitted - he was concerned that I may have 'compartment syndrome.' (Compartment syndrome can result in death of tissue and, in some cases, loss of the leg).

In the hospital, they had me sitting upright in the hospital bed. The swelling didn't resolve much. The hospital claimed (and I'm not sure if it's accurate) that my INR was 6.1. I take my INR weekly, but missed for a few weeks, and didn't test it after starting hyaluronic acid. So, it's possible that a higher INR contributed to the free flow of fluid into the synovial cyst, and the leakage of fluid into the lower leg.

I was in considerable pain for weeks (I know, if your suffering, this isn't good news), but it was releived by extractions of the fluid from the cyst, by the rheumatologist. He explained that Orthopedic surgeons aren't especially interested in things that aren't surgical. The Rheumatologist was able to extract the fluid. He also ordered an MRI -- revealing that when I had a fall a few months earlier, I'd torn some ligaments in my knee - completely missed by the Orthopedic surgeon - and, in his words, I'll need a knee replacement.

I ignored that advice. But once or twice a week, the rheumatologist drained the fluid behind my knee - offering almost immediate reduction in pain. I also made sure that my INR stayed below 3 (he didn't want to drain the fluid if my INR was higher, because it took longer to stop the bleeding).

Physical therapy helped a little. Going to the gym and building up the muscles around my knee seemed to help even more.

Keeping my INR below 3.5 is probably one of the ways to reduce the risk of another cyst forming. Making sure that I don't sit with legs behind me for more than 30 minutes or so, then walking around also helps.

If I were you -- I'd see a rheumatologist to assess your knee problem. If it's a cyst like I had, he or she may help relieve some of the swelling behind the knee.

---

Now, another, somewhat related thing: I'm sitting here in a fair amount of pain. Last week at the gym, I overused one of their machines. This machine was designed to strengthen abdominal muscles. I kneel on it, knees together, body bent back further than it should be, and move my trunk from side to side, with weights causing restricted movement. Somehow on that damned machine, I either overstretched a ligament between my lower leg and my knee, or a popped a blood vessel.
My INR last night was 3.2 - well within range.
The large bruises on the inside of my leg, just below the knee are big and painful. The collected blood is distributing down to the lower calf, so I'm expecting to have a nice, big bruise on my lower calf in the next few weeks.

The point of this part is that I've got to be more careful with my knew found flexibility - folding my lower leg behind or close to the upper leg is a no no.

---

So this is a long answer to a fairly short question.

You probably don't need knee surgery. You probably don't need a knee replacement (and if you do, you may be able to delay it). If your muscles above and below the knee are weak, you should try to strengthen all the muscles in your leg. You should watch your INR, keeping it in a safe range (for myself, 2.5-3.5 is fine).
And you shouldn't bend your lower leg under your upper leg, if you can avoid it, and certainly not for more than 30 minutes at a time.

Yes for the first few weeks there was a lot of pain and I had to use crutches. Still sore 8 weeks later. In my case the Synovial capsule that surrounds the knee joints and lubricates them is what filled up with blood. Per the orthopedic doc, I was able to reduce, with cardiologists ok, my INR to a range of 1.8 and 2.0 for 2 weeks. Required daily testing. I thought he would drain, but he didn't. I have been doing rehab for 6 weeks now. Still cannot raise the leg. Therapists says the quad will not fire. Seems to be neurological. I see ortho again on Monday and may get a second opinion as the fellow I see only spends about 5 minutes with me.

They did an MRI the first week and it showed a lot of arthritis, so I am going to check into seeing a rheumatologist.
 

dwhist

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Joined
Dec 30, 2011
Messages
131
Location
Elmhurst, IL
Hi



interesting ... reading through that I spotted:

Medications: Anticoagulants such as warfarin have the potential to lead to joint bleeds.​


I underlined the bit that also needs to be understood (and also warfarin sort of makes you an induced hemophiliac). However (as I read it) the point above it is important in that context:

Haemophilia: Those who suffer from this hereditary condition, which impairs blood-clotting mechanisms, are more likely to get hemarthrosis.​

which ties into what I wrote initially: "but being on warfarin does not cause bleeds, it just makes what happens more apparent. "

This is what I understand them as meaning "more likely to get". Its also important to look at that site and note that this is not a medical site but a site intended to flog a product which has ads on it to make money. Accordingly they'll use "non accurate" language (AKA Dumbing it down and throwing precision to the wind like an aircraft throwing radar chaff out to distract that incoming missile) which will be different to what you'll read in a journal (or your cardiologist may use).

The point I made on my earlier motorcycling days was (probably inadequately described) that I got bruising appear some time later as the blood lost by tissue rupture (of unknown cause) spread surrounding tissue to become apparent.



sure, its an excellent question to ask, but if it does happen again you will need to look more into why it happened and do some examinations (perhaps MRI) and look for possible causes ... it could be for instance a bone spur.

Either way I hope you get a resolution (and hope more though that it doesn't happen again).

Best Wishes
Thanks,

They did an MRI the first week and did not note a bone spur, What I read on other sites, is that the blood that sat in there could cause damage to the ligament's. As mentioned to Protimenow I may follow up with a Rheumatologist.
 

Protimenow

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I got no relief from an orthopedic surgeon. The rheumatologist (who doesn't do surgery, but CAN work on symptoms and drain some of the fluid) did a lot better for me. Without the fluid drainage for about a month, I'd have been in pretty bad shape. BTW: He was four or five cysts behind my left knee.
 

charlottekaye

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Kinda off the subject, but - may I ask how long you have been on warfarin/coumadin, and how long have you been on the coumadin/baby aspirin combination? Thanks
 

pellicle

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Kinda off the subject, but - may I ask how long you have been on warfarin/coumadin, and how long have you been on the coumadin/baby aspirin combination? Thanks
So that the person you're asking knows that you're asking them, its better to either quote some of their post (by clicking reply where the above is filled in), or mention their username starting with first typint @ and then as you type more letters you see their name appear in a list, select that.
like @dwhist (assuming it was him you you asking)
 

dwhist

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Joined
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Messages
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Elmhurst, IL
Kinda off the subject, but - may I ask how long you have been on warfarin/coumadin, and how long have you been on the coumadin/baby aspirin combination? Thanks

If I am the one you were asking. I have been on warfarin and baby aspiring since valve replaced 7 1/2 years ago. I was on baby aspirin for years before that. Cardiologist says the baby aspirin makes the blood a bit slippery. Family history of heart problems, so I have been seeing cardiologist for 20 years.

Also, like others I am learning this new board, so I appreciate Pellicle's input on how to respond. I was on board when I had the surgery and fell off over the years, but trying to get more involved now.
 

charlottekaye

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Messages
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georgia
So that the person you're asking knows that you're asking them, its better to either quote some of their post (by clicking reply where the above is filled in), or mention their username starting with first typint @ and then as you type more letters you see their name appear in a list, select that.
like @dwhist (assuming it was him you you asking)
 

Duffey

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Far side of the moon
If I am the one you were asking. I have been on warfarin and baby aspiring since valve replaced 7 1/2 years ago. I was on baby aspirin for years before that. Cardiologist says the baby aspirin makes the blood a bit slippery. Family history of heart problems, so I have been seeing cardiologist for 20 years.

Also, like others I am learning this new board, so I appreciate Pellicle's input on how to respond. I was on board when I had the surgery and fell off over the years, but trying to get more involved now.
We all learn eventually, with or without help. I believe the most important element is your involvement. From my vantage point it looks as though you’re doing a fine job.
 

Protimenow

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Messages
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FWIW - I've been on warfarin for 27 1/2 years. I'm not sure if I'm who you were asking.

I'm suffering again, on my right leg -- probably not a popliteal cyst (Baker's cyst), possibly a large pool of blood, behind the inner part of my right leg, around the knee. I can't afford an MRI to determine what's there, but I think that I may have injured a tendon or torn a muscle at the gym.

I know that it takes longer for the blood to clot, and takes a long time to resorb the blood, so I was waiting for this stuff to stop. It seemed to get worse, so I saw my rheumatologist....without an MRI, we're treating it as if it's a pool of blood - applying heat to it.

I know -more information than you asked for.
 

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