Total Knee Replacement Protocol
Here at Physicare, we take the long term view and rehabilitate to a high level, with a strong emphasis on strength and safety. Strong muscles protect joints and we focus on laying a good foundation for strong legs for the rest of your life. Rehabilitation will take some time and pain and discomfort will be present initially as we try to improve joint range and stability.
Be assured that the pain and discomfort will fade eventually, and with daily dedication and consistency to your exercises, you will be able to walk better and further with less pain.
Exercise Guidelines
• Perform 10-20 repetitions of all ROM, strengthening, and strengthening exercises 3x/day.
• Build up resistance and repetitions gradually
• Perform exercises slowly avoiding quick direction change and impact loading
• Be consistent and regular with the exercise schedule
• As your pain decreases, increase the repetitions until muscle fatigue.
• Hold stretches for 30 seconds and perform 2-3 repetitions of each.
Precautions
Avoid twisting/pivoting at the knee
Avoid high impact, and contact sports
Avoid repetitive heavy lifting
Please note that this protocol is a guide.
Your Physiotherapist will use clinical judgment to adapt it according to your needs.
POST SURGICAL INFORMATION
Surgery
Total Knee Replacement (TKR) is a procedure that involves the removal and replacement of both 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.
During the knee replacement procedure, the undersurface of the knee cap may often be removed as well and 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. You will typically spend a few days in the hospital to recover. You will be out of bed the same day as your surgery. You will be working with a physiotherapist on a daily basis in hospital. Most patients are able to go directly home after discharge.
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. Additionally, you may use clingfilm/clean plastic bag with some surgical tape like Micropore, to protect the incision site. It is best to use a shower bench if possible for safety.
Physiotherapy Home Visits
You will receive home care visits from a physiotherapist after being discharged home. The physiotherapist will work with you to restore mobility, strength, and balance. While physiotherapists generally follow a set rehabilitation protocol for Total Knee Replacement, they will tailor it according to your individual presentation and needs. For optimal outcome after surgery, it is important to continue with the rehabilitation program designed by your physio.
Weight Bearing and Walking Aids
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 and strength improve, your physiotherapist will transition you to walking with a walking stick. As your balance improves, your physiotherapist may progress you to walking unaided.
Pain
Your surgeon will prescribe pain medicine for you after the operation. Adequate pain relief is an important part of your recovery as it will allow you to move around and do your rehabilitative exercises. 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 strong pain medication to simple pain relief (eg. Panadol) as soon as you are able.
Ice
You must use ice on your knee after the operation for the management of pain and swelling. Ice should be used liberally throughout the day for 10–20 minutes at a time. Typically the best time for this is after exercise. Always maintain one layer between ice and the skin, by putting a wet towel over your ice pack.
Elevation
Elevating your leg periodically throughout the day can help reduce swelling. It is recommended that you elevate your operated 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.
Recovery/Time off Work
It is very important to realize that the recovery process will take time. You must be patient, consistent and 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/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. 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.
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 strong painkillers that might make you sleepy.
Post-Operative Doctor Visits
Your first post-operative visit will be around a week after discharge. At this visit you will meet with your surgeon who will examine your knee’s range of motion and strength, the surgical incision. Should you have any cause for concern prior to your first office visit you should call your surgeon’s office for advice. Additional follow up visits to the doctor’s office will be based on your surgeon’s discretion.
TOTAL KNEE REPLACEMENT PROTOCOL
Phase 1: In Hospital
• Control pain and swelling
• Protect healing tissue
• Begin to restore range of motion (ROM) Knee flexion at least 90 degrees
• Knee extension less than or equal to 0 degrees
• Establish activation of leg muscles
• Restore independent functional mobility
Phase 2: 0-6 weeks post surgery
• Monitor wound healing
• Massage and stretches for increase ROM
• Continue to improve knee range with a goal of 0-110 degrees
• Begin to restore muscle strength throughout the operated leg, with special focus on the quadriceps
• Hip Strengthening (abductors, adductors, external rotators, extensors)
• Calf Strengthening
• Start gently on the exercise bike
• Normalize all functional mobility
• Wean all aids, emphasizing normal walking pattern
• Stair climbing: practice up with operated leg
Phase 3: 6-12 Weeks post surgery
• Start scar mobilisation
• Dry needling for residual tightness (note contraindications)
• Good patella femoral mobility
• Continue to improve knee range with a goal of 0-115 degrees
• Maximize knee ROM Aim for grade 4+/5 leg strength, especially quadriceps,
hip abductors, extensors, external rotators, adductors, plantarflexors
• Eccentric quads control
• Return to baseline functional activities
• Start resistance training
• Start balance and proprioception training
• Start endurance training (i.e. walking, pool programme 20 minutes 3x/week)
• Upgrade stair climbing (step through)
Phase 4: 12 Weeks and Beyond
• Continue to improve strength to maximize functional outcomes
• Continue endurance training (i.e. walking, pool programme 30-45 minutes 3x/week)
• Continue balance training
• Return to appropriate recreational activities
Criteria for Discharge: Non painful, independent mobility
• Normalised walking pattern
• Independent step over step stair climbing
• Pain-free range of motion
• Grade 4+/5 leg strength Normal, age appropriate balance and proprioception.
• Patient is independent with a home exercise program.
References:
SouthShoreHealth.org
Department of Rehabilitation Services Total Knee Arthroplasty Protocol
The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services.