Total Knee Replacement Rehab Protocol: A Structured Plan for Progressive Recovery
Treatment Guidelines
Explore our total knee replacement rehab protocol for a step-by-step recovery plan, enhancing mobility and strength post-surgery.
Total knee replacements, or TKAs, are one of the most common orthopedic surgeries performed today. In some cases, patients will undergo an uncomplicated TKA, complete their first few days of rehab, then go home, never needing any further intervention. However, most patients require significant courses of rehab, both in an inpatient and outpatient setting after a TKA.
Quality post-surgical rehab can reduce pain, improve mobility, and prevent stiffness. For this reason, it is critical that patients who have undergone a TKA ensure that they complete all of their required rehab (and that they continue their home exercises after discharge). In this post, I’ll provide an overview of the TKA rehab process for caregivers, patients, and rehab specialists. I will highlight the importance of proper exercise routines and some key tips for successful return to full function.
Understanding a Total Knee Replacement Rehab Protocol
After any surgery or injury, you’ll find that many clinicians follow a rehab protocol. This means that they follow specific guidelines in order to reach well-defined outcomes. Many injuries and surgeries have well-researched protocols. This allows clinical teams to all be on the same page as they help the patient return to full activity.
For a TKA, a rehab protocol will generally promote exercises and treatments which are designed to help the patient achieve full knee range of motion, 0/10 pain, and normal gait (to name a few). While different clinicians may prefer different treatments, all of them will prescribe a program which leads the patient toward a positive clinical outcome. This consistency in protocols and goals helps patients progress safely and can prevent setbacks during recovery.
Many patients will complete rehab in an inpatient setting, and an outpatient setting, and at home. Inpatient rehab will often consist of early, basic post-surgical exercises designed to improve blood flow, healing, and activities of daily living (ADLs).
In an outpatient setting, the patient has usually returned home from the hospital, and is able to travel to the clinic for more advanced strengthening and stretching exercises.
Home care may also be an option for some patients. This is where clinicians come to the patient’s home in order to help them through the rehab process.
Phase-by-Phase Recovery Timeline
The general timeline after a TKA is as follows:
- Phase 1: Hospital stay
- Phase 2: Weeks 2-6
- Phase 3: Week 6-discharge
Let’s take a closer look at each of these phases.
Phase 1: Hospital Stay
After the surgery, most patients will spend a couple of days in the hospital. The focus of rehab during these early days is to get the joint moving, to promote blood flow, and to get the patient walking/weightbearing as soon as possible. To those outside of the rehab field, you may be surprised to learn that your hospital PT may have you walking on the same day after surgery!
The post-TKA patient will usually complete general lower body range of motion exercises such as ankle pumps, quad sets, and heel slides while in the hospital.
Phase 2: Weeks 2-6 (Early Rehab)
At this point, the patient will almost certainly be discharged from the inpatient setting. Many patients will now go to outpatient rehab, while others will receive home care. The focus of this phase of rehab is to increase the amount of weightbearing, while ensuring that range of motion is returned to normal as quickly as possible.
Some exercises seen during this phase may include straight leg raises, supported mini squats, and knee flexion stretches encouraging greater range of motion.
Phase 3: Weeks 6 and Beyond
At this point in the rehab process, the pain will hopefully be very minimal, and the range of motion should be close to normal. The therapist will now be focusing on higher level exercises which will help the patient return to normal life, such as unsupported squats, step ups, and balance exercises.
Eccentric Exercises for Strength and Control
Eccentric training is critical for improving outcomes after TKA. If you are unfamiliar with the term, eccentric exercise refers to the “negative” component of a movement. For instance, when performing a bicep curl, as you bend your elbow, you are completing the concentric or positive phase of the motion (where the muscle shortens in order to move the weight). When you lower the weight back down and slowly straighten your arm, you complete the eccentric or negative portion of the movement (where the muscle lengthens under tension).
Eccentric exercise is very helpful for improving strength and control while keeping the joint stress low. For more, check out our article on the subject: all about eccentric training.
Basic strategies for using eccentric training during knee rehab include moving very slowly on the “down” phase of a squat and slowly lowering the weight back to the starting position during a knee extension.
More advanced tools, such as the Eccentron, can help to further emphasize the eccentric portion of movements. Some research has demonstrated that the use of the Eccentron is more beneficial than traditional eccentric exercise strategies for the lower extremity. The Eccentron has also been utilized, to great effect, in TKA rehab specifically.
Simple Rehab Exercises After Total Knee Replacement
As was mentioned previously, there are a variety of exercises which are often utilized to treat a patient post-TKA. In this section, we’ll take a closer look at some of the more commonly seen post-surgical exercises for patients with knee replacements.
Patients should be careful not to overexert themselves, while still pushing the envelope and progressing each week. Thus, it is the job of the therapist to help patients progress appropriately through their rehab program using targeted exercise plans.
Quad Sets
Quadricep sets are isometric movements where the patient tightens and holds their thigh muscle in a contraction. These can be done in various positions, but usually patients will perform quad sets while lying on their back, with their knees straight.
Often patients will be instructed to perform 10 reps of 10 second holds of quad sets per session.
Straight Leg Raises
Straight leg raises, or SLR, are often used as a progression from quad sets. The patient performs a quad set then lifts their whole leg up off of the table slowly, then lowers it back down to the starting position to complete the rep.
Most patients can perform three sets of 10 repetitions of SLR to start.
Knee Extensions
The two primary motions of the knee include flexion (bending) and extension (straightening). Knee extensions strengthen the quadricep muscle, and they are typically performed seated. Patients should start by performing three sets of ten reps with no weight, quickly progressing to using ankle weights, bands, or even machines as they get stronger.
Heel Slides
Heel slides emphasize the bending motion of the knee. This move stretches the quadricep and helps the patient regain normal knee ROM. Most patients can comfortably perform 10 reps with 10 second holds to start, aiming to feel a stretch in the knee each time.
Mini Squats
Squats are a key functional movement. Mini squats are a great way to increase weightbearing through the surgical limb, cause a mild stretch in the knee, and to strengthen the quadriceps. Patients should aim to complete three sets of ten repetitions with minimal upper body support to start.
Accelerate Recovery with These TKR Rehab Tools
Clinicians use advanced rehabilitation tools like the PrimusRS and Eccentron to help patients regain strength and function following total knee replacement. With the PrimusRS patients can do a wide variety of functional exercises, from isolated joint movements to dynamic, full-body activities. Watch the video below for examples of PrimusRS knee rehab exercises.
Another advanced clinical tool, the Eccentron gradually helps patients gain leg strength and stability through gentle, progressive eccentric training. Patients exercise in a seated, closed-chain position, which is ideal for sensitive joints. These tools support an effective recovery journey following total knee replacement.
What to Watch For
While relatively rare, complications can occur after a TKA. Both patients and clinicians need to be on the lookout for red flags which indicate serious problems associated with the surgery. A few common red flags include:
- Excessive swelling
- Redness
- Pain
- Fever
- Significant stiffness
If any of these are present, prompt assessment by the surgeon is essential. This is why it is critical for patients to have their rehab overseen by a qualified PT.
Bonus Tips for Long-Term Knee Recovery Success
One of the best ways to be successful after a TKA is to be consistent with exercises. Using calendars, alarms, or apps, patients should devise ways to perform their exercises with the frequency prescribed by their PT.
Further, patients should set reasonable goals for themselves, adjusting them as they achieve them. This helps to always have something more to accomplish related to their knee issues.
Last but not least, patients need to pay attention to their nutrition and sleep. What we eat fuels our recovery, and during sleep our body begins to heal. Patients need to be sure to prioritize these items (along with exercise) to ensure a positive long-term outcome.
Support Functional Recovery with a Protocol-Based Rehab Approach
Sticking to a program overseen by a qualified PT is a must for patients after TKA. Without proper progression and adjustments, patients may struggle during their recovery. Stick to the program, and patients and clinicians will enjoy better rehab programs with fewer complications.
