Total Knee Replacement Rehabilitation Protocol

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone a Total Knee Replacement (also known as Total Knee Arthroplasty).  It is by no means intended to replace or substitute the clinical decision making process of the clinician assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol they should contact the treating surgeon or qualified team member.  

 

*This protocol applies to Primary Total Knee Replacement and is not applicable to Revision Total Knee Replacement procedures or scenarios in which surgical or post-operative complications have occurred. 

 

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

 

*A word about “pain” and management of anticipated discomfort following Total Knee Replacement…

Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  



Phase 1-Early Post-surgical Phase (Days 0-5)

 

The goal of physical therapy intervention during the early post-operative phase is to decrease swelling, increase range of motion, enhance muscle control and strength in the involved lower extremity, and maximize the patient’s mobility with a goal of functional independence. Physical therapy interventions are directed towards identifying sensorimotor or systemic conditions that may influence a patient’s rehabilitation potential.  Routine use of Continuous Passive Motion (CPM) machines is no longer a standard of care and insurance policies will not cover the expense of use.  

 

Goals: 

  1. Perform transfers with minimal assistance from others and advance to full weight bearing ability on the operative extremity
  2. Ambulate 25-100 ft continuously 
  3. Maintain passive Range of Motion (ROM) equal to or greater than 75 degrees of flexion and maintain passive extension to less than -10 degrees from zero 
  4. Perform independent Straight Leg Raise (SLR)
  5. Verbalize and demonstrate understanding and appropriate use of assistive devices (ie. walker, cane, knee immobilizer, wheelchair, bedside commode, etc)
  6. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

 

Assessment by Therapist:

  1. Assess surgical wound for drainage, bleeding, blistering, or dehiscence
  2. Assess pain using 1-10 scale or visual analog scale
  3. Ensure patients have taken oral pain medications 30-60 min prior to therapy session
  4. Assess patellar mobility, pre-treatment AROM/PROM, efficiency/safety/necessity of ambulatory assistive devices
  5. Assess for signs of DVT (Homan’s sign, calf circumference, Well’s Criteria), PE (pulmonary embolism), Nerve palsy/dysfunction 

 

Therapeutic Exercises:

  1. Isometric quadriceps, hamstring, and gluteal exercises
  2. Straight leg raises (flexion and extension only)
  3. Closed chain exercises using upper extremity support means as necessary to prevent increased fall risk 
  4. Assess balance, gait pattern, and weight transfer 
  5. Ensure neutral hip motion and address any postural deficiencies from pelvic or lumbar spine etiology

 

Precautions:

  1. WBAT (Weight Bearing As Tolerated), initially with assistive device and wean use as patient demonstrates sufficient locomotor proficiency
  2. Avoid weights or resistance bands
  3. Avoid rotational torque and/or twisting of the knee while weight bearing
  4. Avoid kneeling or direct pressure on the incision/anterior knee
  5. Avoid placing supports behind the surgical knee to facilitate obtaining full extension

 

*Patient may progress to Phase II when able to demonstrate sufficient quadriceps activation, independent SLR, Active ROM 10-80 degrees flexion or greater, adequate pain control, ability to transfer independently, and ambulate greater than 100 ft with appropriate assistive devices.  



Phase II (Post-op Day 5 Through 6 Weeks)

Goals:

  1. Improve AROM with a goal of 0-110 degrees
  2. Continue strengthening exercises of knee flexors and extensors.  May begin resistance exercises as tolerated when goals of Phase I are met
  3. Address any deficiencies or weaknesses of upper extremities, back/neck, or contralateral (non-operative) lower extremity
  4. Continue proprioceptive training and gait training (Encourage early discontinuation of assistive devices when appropriate)
  5. Demonstrate ability to perform ADLs unassisted
  6. Decrease swelling/inflammation
  7. Return to work for primarily sedentary professions

 

Assessment by Therapist:

  1. Monitor wound for signs of infection, dehiscence, or complications of skin closure devices (Dermabond, Zip-line, sutures, staples)
  2. Monitor for signs/symptoms of DVT/PE
  3. Monitor for signs of dehydration (skin turgor, orthostasis, etc)
  4. Assess use of narcotic and non-narcotic analgesics
  5. Assess pre-treatment PROM/AROM 

 

Therapeutic Exercises:

Week 1-4

  1. Encourage AROM flexion stretching exercises 
  2. Begin stationary bike with minimal or no resistance if flexion >90 degrees
  3. Patella mobilization 
  4. Continue isometric quadriceps, hamstring, and gluteal exercises
  5. Supine Heel Slides and seated Long Arc Quad (LAQ)
  6. Begin SLR in all planes (flexion, extension, ADDuction, ABDuction)

Week 4-6

  1. Continue week 1-4 exercises
  2. NMES of quads based on necessity (lack of appropriate activation).  May progress NMES from isometric to isotonic and functional activity
  3. Front and Lateral step up/down
  4. Decrease sit-to-stand (get up and go) times
  5. Begin shallow lunge (25% depth)
  6. Continue stationary bike, may incorporate low resistance seated rowing exercises if flexion >100 degrees.  
  7. Consider aqua therapy if wound healed and available access to safe entry/exit pool 

 

Precautions

  1. Wean assistive devices only when the patient is supervised by a therapist and the patient is able to demonstrate minimal compensatory gait. There is no mandatory time frame for use of assistive devices and duration of time before weaning is based on multiple factors including patient apprehension/concern, fall risk, gait pattern kinematics, pre-operative need for such devices, and muscle activation/performance
  2. Monitor for increase in edema/swelling with increased activity levels, consider graduated compression stockings if accepted/indicated

 

*Patient may progress to Phase III after achieving AROM 0-110 degrees or greater, adequate quadriceps activation, and able to ambulate > 500 ft uninterrupted without assistive device or significant gait disturbance



Phase III (Week 6-12)

Goals:

  1. Progressive increase in flexion 0-120 degrees or greater
  2. Increased patellar mobility
  3. Complete daily activities without pain and light recreational activities (walking, aquatherapy, etc) with minimal discomfort
  4. Return to work for professions not requiring manual labor, heavy lifting, climbing stairs, shifts requiring standing > 4 hours without breaks or steps > 5-10K per day

 

Therapeutic Exercises

  1. Continue Phase II exercises and progress resistance, strengthening, and repetitions as tolerated
  2. Lunge depth 50%
  3. Begin open chain exercises if patient agreeable
  4. Initiate and progress balance and proprioceptive exercises as appropriate
  5. +/- NMES 

 

*Patient may progress to Phase IV when able to complete Phase III without pain and quad strength 4+/5



Phase IV (Week 12-16)

Goals:

  1. Return to work unrestricted most professions 
  2. Return to recreational sports/activities as indicated/desired (golf, cycling, pickleball, doubles tennis, outdoor hiking, etc)
  3. Pain free gait, including stairs 
  4. Transition from formal physical therapy to Home/Gym Exercise Program