Total Knee Arthroplasty (TKA) Rehabilitation Protocol

Anatomy and Biomechanics

The knee is a simple hinge joint at the connection point
between the femur and tibia bones. The smooth articular
cartilage surface of the femur sits on top of the cushioning
discs of fibrocartilage on the tibia known as the medial and
lateral meniscus. These smooth surfaces that make up the knee
joint will naturally wear down over time creating a rougher
surface with which to weight bear on. Without smooth healthy
cartilage the knee also has a hard time producing the natural
joint fluid that lubricates the knee during movement.
Collectively, these degenerative processes that happen over
time lead to the condition known as osteoarthritis. This
process happens naturally over time to everyone, but can be
more severe or develop quicker in some people.

As degenerative changes in the knee advance the joint

becomes more painful and less mobile. Osteoarthritis
typically results in stiffness in the joint and pain during
weight bearing activity. This is especially true right after a
period of immobility (ie when getting up after sitting for a
long time). The pain in the joint may subside after moving
around, but become worse again when standing or walking for
long periods of time. As the condition of the joint deteriorates
it will become more difficult to bear weight on it and
eventually the joint may lose some of its range of motion.

Treatment Options
Based on the nature and severity of the osteoarthritis in your knee your physician will work with
you to determine what the best course of treatment will be. When degenerative changes are not
severe the associated pain and dysfunction may successfully be treated with rest, anti-inflammatory
measures, activity modification and physical therapy. Injections of cortisone or joint lubricants
may provide temporary improvement in pain and function. After a thorough evaluation your
physician and their staff will recommend the most appropriate course of action to take.

Physical therapy is often recommended for treatment of pain and dysfunction associated with
osteoarthritis. The physical therapist will evaluate your mobility, flexibility and strength with the
purpose of determining any underlying deficits that contribute to increased stress on the painful
joint. You will be counseled on which activities you can safely continue and which should be
avoided. The physical therapist will teach you exercises that will help to reduce joint stress. In
most cases this will include strengthening and stretching the muscles around the hip and knee, as
well as strengthening your core.

If joint degeneration is severe and conservative measures are unsuccessful in restoring function
your physician may recommend a total knee replacement procedure.

Surgery
Total Knee Arthroplasty (Replacement) is a complex procedure that involves the removal and

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replacement of both the tibial and femoral weight bearing surfaces of the knee. First the ends of
both bones are removed. Then metal implants are inserted into the ends of the femur and tibia.
The metal implant that is used on the tibial side of the joint has a polyethylene (plastic) piece
attached to it that serves as the weight bearing surface of the new joint. Your surgeon may elect to
use bone cement to help hold these implants in place. During the knee replacement procedure the
undersurface of the knee cap is often removed as well, and is replaced with a polyethylene cap.
Some of the structural ligaments of the knee may also be adjusted during the procedure so as to
assure that the knee is stable and well aligned after surgery.

Each patient will be required to go through a pre-operative

educational class which will review in detail the typical patient
experience in the early phases of recovery. Some physicians
require an appointment with your dentist to ensure there are no
active dental problems. Issues such as dental infection may affect
the results of your surgery. Many patients will also be required to
see their primary care physician prior to surgery.

Total Knee Arthroplasty is not currently an outpatient day surgery

procedure. You will typically spend 1-2 days in the hospital to
recover. You will be out of bed the same day as your surgery.
You will be working with physical and occupational therapy on a
daily basis in the hospital. Most patients are able to go directly
home after discharge. Some more complex cases may require a
short stay in a rehab facility following their hospital stay.

Home Visits
You will likely receive home care visits from a registered nurse and a physical therapist after being
discharged home. The nurse will help monitor your medical status and the physical therapist will
help you work to restore mobility, strength and tolerance for activity. Your home care physical
therapist will work with your surgeon and their staff to determine when you are ready to attend
outpatient physical therapy. This will typically be around 3 weeks from your operation.

Surgical Incision/Dressing
You will have a dressing placed on your knee after surgery which will remain in place for 1 week.
If you have staples closing your incision they will likely be scheduled to be removed, and replaced
with steri-strips, around 10-14 days after the operation. Allow the steri-strips to fall off on their
own or to be removed at your next doctor’s office visit. If your surgeon used glue to close the
wound do not remove it and it will gradually fall off approximately 1 month after surgery.

Showering
You may shower with the post-op dressing immediately. After the dressing is removed you may
shower as long as the incision is not draining. If the incision is draining try to keep it from getting
wet during showering by using a water-tight dressing. It is best to use a shower bench if possible
for safety.

Medication
Your surgeon will prescribe pain medicine for you after the operation. Please call the doctor’s
office if you have any questions regarding medication. As time goes on you will require less and
less pain medication. Your goal should be to switch from a narcotic medication to an over the
counter pain medication as soon as you are able.

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Driving
Your surgeon will tell you when you are ready to return to driving. Commonly, you are not
permitted to drive for 6 weeks if you had your right knee replaced, and 4 weeks if you had your left
knee replaced. You cannot drive while taking narcotics.

Elevation
Elevating your lower extremity periodically
throughout the day can help reduce
swelling. It is recommended that you
elevate your operative leg 3 to 4 times a
day for 30 minutes. To elevate properly
make sure to lie flat on your back and have
your operative leg in a fully straightened
position with your foot above the level of
your heart. You may use ice and elevate
your leg at the same time.

Ice
You must use ice on your knee after the
operation for management of pain and
swelling. Ice should be used consistently
throughout the day while in the hospital.
Once home, you may taper down to
applying ice 3-5 times a day for 10 to no
more than 20 minutes at a time. Typically
the best time for this is after exercise.
Always maintain one layer between ice and the skin. Putting a pillowcase over your ice pack
works well for this. The home care physical therapist can help you customize a plan on how and
when to best apply ice to your knee.

Post-Operative Office Visits

Your first post-operative visit will be as early as 10 -14 days after the operation. At this visit you
will meet with the surgeon or the physician assistant who will examine your knee’s range of motion
and strength, the surgical incision. If staples are present they will be removed and replaced with
steri-strips. Should you have any cause for concern prior to your first office visit you should call
your surgeon’s office for advice. Your next visit will be around 6 weeks after the operation. At this
visit you may have an X-ray taken to make sure that the knee replacement components are aligned
well, and you will discuss when it will be appropriate to make an appointment to begin outpatient
physical therapy. Additional follow up visits to the doctor’s office will be based on your surgeon’s
discretion.

Weight Bearing
After surgery you are allowed to put as much weight on your operated leg as you can tolerate
(unless otherwise indicated by your surgeon). For the first several weeks after surgery you will
require the use of a walker or crutches. As your tolerance for weight bearing improves your
physical therapist will transition you to walking with a cane. Eventually, when your gait is normal
you will be able to walk without an assistive device. Many patients are able to walk without an
assistive device by six weeks after the operation. Remember, proper gait pattern must be achieved
in order to discontinue use of assistive devices.

Recovery/Time off Work

Recovering from Total Knee Arthroplasty surgery is not easy. It is very important that to realize

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that the recovery process is difficult and time consuming. You must be an active participant during
this process, performing daily exercises to ensure there is proper return of range of motion and
strength. There is a large amount of variability in the time it takes to fully recover from this
procedure. It is usually estimated that it will take at least 4-6 months for the patient to feel as
though he or she has completely returned to a pre-injury level of activity. Some cases may take as
long as 9-12 months to make a full recovery. People with desk jobs should plan to take at least 4
weeks off from work and should have an extended absence plan in place should complications
arise. People with more physical jobs that require excessive weight bearing and manual labor will
likely be out of work for at least 3-6 months. Recovery is different in each case. Your individual
time table for return to activities and work will be discussed by your surgeon during post-operative
office visits.

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 Typical Rehabilitation Continuum Time Frames Following TKA:

Outpatient PT
Inpatient Stay 3 Weeks - 12
Day 0-2 Week s

Home Care Rehab Independent

Program
3 Days - 3 Weeks
12 Weeks and
Beyond

Outpatient Discharge Criteria

You are ready for discharge from outpatient PT typically when you reach 70-80%
functional level compared to before surgery. This can vary greatly based on your prior
level of function. Some criteria may include:
 Walking normally without any assistive device
 Negotiate stairs reciprocally and safely
 Getting in/out of a car without difficulty
 Donning/doffing shoes and socks without difficulty

Being discharged from PT does NOT mean that you are exempt from you home exercise
program. For optimal outcome after surgery, it is important to continue with your specific
program designed by your PT.

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 Rehabilitation
**The following is an outlined progression for rehab. Time tables are approximate and
advancement from phase to phase, as well as specific exercises performed, should be based on
each individual patient’s case and sound clinical judgment by the rehab professional. **

Phase 1: Phase (Day 0- Hospital Discharge)

Goals
 Control pain and swelling
 Protect healing tissue
 Begin to restore range of motion (ROM)
o Knee flexion at least 90 degrees
o Knee extension less than or equal to 0 degrees
 Establish lower extremity muscle activation
 Restore independent functional mobility

Precautions
 WBAT with crutches or walker unless otherwise ordered
 Screen for sensory/motor deficits
 Screen for DVT, symptomatic orthostatic hypotension, symptomatic low hematocrit

Recommended Exercises
Range of Motion
 Passive knee flexion and extension
 Heel slides
 Active assisted knee flexion/extension in sitting
 Ankle pumps
Strength
 Quad sets
 Glut sets
 Hamstring sets
 Straight leg raises (SLR): emphasizing no lag
 Hip abduction/adduction
 Long arc quads (LAQ)
 Seated hip flexion
Functional Mobility
 Bed mobility
 Transfer training
 Gait training on level surfaces
 Stair training
 Activities of daily living with adaptive equipment (as needed)
Positioning (when in bed)
 Use a towel roll under ankle to promote knee extension
 Use a trochanter roll to maintain hip in neutral rotation and promote knee extension
 Never place anything under the operated knee

Guidelines

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Perform 10 repetitions of all exercises 3-5 times a day. Use ice after exercising for 10-20 minutes.

Inpatient Plan of Care

Day of Surgery
 Out of bed to a chair
 PT Evaluation
Post Op Day 1
 PT and OT Evaluations
 Therapeutic Exercise including ROM, Strengthening, and Functional Mobility as
appropriate
 ADL Training as appropriate
Post Op Day 2-Discharge
 Progression of Therapeutic Exercise and Functional Mobility
 Continued ADL Training

Phase 2: (Hospital Discharge-6 Weeks)

Goals
 Continue to improve ROM with a goal of 0- 110 degrees
 Begin to restore muscle strength throughout the operated leg, with special focus on the
quadriceps
 Initiate proprioceptive training
 Initiate endurance training
 Normalize all functional mobility
 Wean all assistive devices, emphasizing normal gait pattern

Precautions
 WBAT with crutches or walker, progressing to cane, then weaning devices as appropriate
 Monitor for proper wound healing
 Monitor for signs of infection
 Monitor for increased swelling

Recommended Exercises
Range of Motion
 Continue with all phase 1 ROM exercises
 Heel slide with towel
 Prone knee flexion
 Heel prop (towel under ankle) and/or prone knee hang to promote full extension
 Initiate stationary biking, starting with back and forth motion progressing to full
revolutions as able
Joint Mobilizations and Stretching
 Initiate patellofemoral and tibio-femoral joint mobilizations as indicated
 Initiate hamstring, gastroc/soleus, and quadriceps stretching
Strengthening
 Quad sets, glut sets, hamstring sets

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  Use neuromuscular electrical stimulation (NMES) to quads if poor quadriceps
recruitment is present
 SLR without lag, add resistance towards the end of this phase
 Hip abduction/ adduction/ extension against gravity, add resistance towards the end of
this phase
 Progress to closed chain exercises including terminal knee extensions, mini-squats,
step ups, and mini-lunges by the end of this phase
Proprioception
 Single leg stance
Functional Mobility
 Gait training with appropriate device emphasizing normal gait pattern
 Stair training with appropriate device

Guidelines
Perform 10-20 repetitions of all ROM, strengthening, and strengthening exercises 3x/day. Hold
stretches for 30 seconds and perform 2-3 repetitions of each. Bike daily for 5-10 minutes if able.

Phase 3: (6-12 Weeks)

Goals
 Maximize knee ROM
 Restore normal LE strength, especially normal quadriceps function
 Return to baseline functional activities

Precautions
 Avoid high impact activities
 Avoid activities that require repeated pivoting/twisting

Recommended Exercises
Range of Motion and Flexibility
 Continue ROM exercises from phase 1 and 2
 Continue biking, adding mild to moderate resistance as tolerated
Joint Mobilizations
 Continue with phase 2 activities as indicated
Strengthening
 Continue with phase 2 exercises adding and increasing resistance as tolerated
 Add resistance machines as appropriate including leg press, hamstring curl, and 4-way
hip machine
 Emphasize eccentric control of quadriceps with closed chain exercises
Proprioception
 Single leg stance
 Static balance on Bosu/wobble board/foam/etc
 Add gentle agility exercises (i.e. tandem walk, side stepping, karaoke, backwards
walking)
Endurance
 Biking program
 Begin walking program

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Guidelines
Perform ROM and stretching exercises once a day until normal ROM is achieved. Hold stretches
for 30 seconds and perform 2-3 repetitions of each.
Perform strengthening exercises 3-5 times a week. Do 2-3 sets of 15-20 Reps.
Bike daily for ROM at least 10 minutes if able.
Progress to biking/walking for at 20-30 minutes 3x/week for endurance.

Phase 4: (12 Weeks and Beyond)

Goals
 Continue to improve strength to maximize functional outcomes
 Return to appropriate recreational activities (i.e. golf, doubles tennis, cycling)

Precautions
 Avoid high impact, and contact sports
 Avoid repetitive heavy lifting

Recommended Exercises
ROM and Flexibility
 Continue daily ROM and stretching exercises
Strengthening
 Continue with all strengthening exercises increasing resistance and decreasing
repetitions
Proprioception
 Continue with all phase 3 exercises, increasing difficulty as tolerated.
Endurance
 Continue with walking, biking, elliptical machine programs

Guidelines
Perform ROM and flexibility exercises daily.
Perform strengthening and proprioception exercises 3-5x/ week, performing 2-3 sets of 10-15
repetitions.
Continue endurance program 30-45 minutes 3x/ week.

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 Time Precautions Goals Recommended Exercises
Phase 1:  WBAT with  Control pain and ROM
Day 1 – crutches or walker swelling  P/AA/AROM knee flexion and
Hospital unless otherwise  ROM: knee flexion extension
D/C ordered by MD to at least 90◦, knee  Heel slides
 Screen for DVT extension 0◦  Ankle pumps
 Screen for sensory/  Establish LE STRENGTH
motor deficits muscle activation  Quad/glut/hamstring sets
 Restore  Hip Abd/Add
independent  LAQ
functional mobility  Seated Hip Flexion
 SLR (NO lag)
FUNCTIONAL MOBILITY
 Gait training with appropriate assistive
device on level surfaces
 Transfer training
 Stair training
POSITIONING (when in bed)
 Towel roll under ankle to promote knee
extension
 Trochanter roll to maintain hip neutral
rotation and promote knee extension
 Never place anything under the
operated knee
Phase 2:  WBAT with  ROM: 0 to at least ROM
Hospital crutches or walker, 100◦  Continue with all phase 1 exercises
D/C – 6 progressing to  Normalize all  Heel slide with towel
weeks cane, then weaning functional mobility  Prone knee flexion
all devices as  Wean all assistive  Heel prop and/or prone knee hang to
appropriate devices promote full extension
 Monitor for proper  Begin to restore LE  Initiate stationary biking
wound healing strength, especially Joint Mobilizations and Stretching
 Monitor for signs quads  Initiate patellofemoral and tibio-
of infections  Initiate femoral joint mobilizations as indicated
 Monitor for proprioceptive  Initiate hamstring, gastroc/soleus, and
increased swelling training quadriceps stretching
 Initiate endurance Strengthening
training  Quad/glut/ham sets
 Use NMES to quads if poor quad
recruitment in noted
 SLR without lag, adding resistance
towards the end of this phase
 Hip abduction/ adduction/ extension
against gravity, adding resistance
towards the end of this phase
 Closed chain exercises (TKEs, mini-
squats, step ups, mini-lunges) by the
end of this phase
Proprioception
 Single leg stance
Functional Mobility
 Gait training with appropriate device
emphasizing normal gait pattern
 Stair training with appropriate device

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Phase 3:  Avoid high impact  Maximize knee ROM
6-12 activities ROM  Continue phase 1 and 2 exercises
weeks  Avoid activities  Restore normal LE Joint Mobilizations and Stretching
that require strength, especially  Continue with phase 2 activities as
repeated pivoting/ normal quad indicated
twisting function Strengthening
 Return to baseline  Continue with phase 2 exercises,
functional increasing resistance as tolerated
activities  Add resistance machines as appropriate
(leg press, hamstring curl, 4-way hip)
Proprioception
 Single leg stance
 Static balance on Bosu/wobble
board/foam/etc
 Add gentle agility exercises (i.e.
tandem walk, side stepping, karaoke,
backwards walking
Endurance
 Biking program, adding mild to
moderate resistance as tolerated
 Begin walking program
Phase 4:  Avoid high impact,  Continue to ROM
12 weeks and contact sports improve strength to  Continue daily ROM and stretching
and  Avoid repetitive maximize exercises
beyond heavy lifting functional Strengthening
outcomes  Continue with all strengthening
 Work with PT and exercises increasing resistance and
MD to create decreasing repetitions
customized routine Proprioception
to allow return to  Continue with all phase 3 exercises,
appropriate sports/ increasing difficulty as tolerated
recreational Endurance
activities (i.e. golf,  Continue with walking, biking,
doubles tennis, elliptical machine programs
cycling, hiking) Functional Progressions
 Activity/sport-specific training
exercises

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