Total knee replacement surgery is an effective way to relieve arthritis pain when non-operative measures have failed. A substantial portion of the outcome, however, is based on adequately rehabilitating after surgery. The most important part of the rehabilitation program is regaining normal range of motion. This is easier said than done. At the time of a properly performed knee replacement surgery, the soft tissues are balanced and the range of motion should be full. That is: all the way straight, to all the way bent. This is something we test during surgery. Then the incision is closed and the healing process begins. Initially, there could be some swelling and acute surgical pain from the incision/surgical approach. Soon this acute pain subsides and stiffness begins. The stiffness is experienced by many patients as pain, especially when moving against the endpoint. In a prior posting I discussed the tissue planes that need to glide to allow proper motion. Each day that passes after knee replacement surgery, more healing occurs. This process can create connections, or adhesions, between these tissues. After about 6 weeks, enough scar tissue has formed, that most patients are unable to obtain more range of motion by stretching. In other words, at around 6 weeks from surgery no more progress with regard to range of motion is possible. The trouble is, in order to regain excellent function, adequate knee range of motion is necessary. Most patients are anxious to walk, ride a stationary bike, and are often quite focused on regaining strength. While these are fine things to do, and I certainly understand this desire, redirecting the focus to stretching appropriately remains my priority during the first 6 weeks postoperatively. Once range of motion is reestablished, all of these activities will be possible. Because we have a limited time to regain this range of motion this needs to be the priority early on. Thankfully these stretches are simple. Gently and progressively force the knee straight. And then gently and progressively force the knee bent. Simple! Except when it's not. Sometimes, and fortunately it is rare, a patient really struggles to regain range of motion after their total knee replacement. This can be a very frustrating situation for the patient and surgeon alike. I recommend stretching early, often, gently, but progressively. It is better to regain motion early than to attempt to catch up when stiffness is setting in. The simplest stretches are shown below: ![]() This is one of the easiest stretches for extension. Place your ankle on a pillow. Relax your muscles to allow your knee to sag down. Then attempt to push the back of your knee down. This is a side view of my knee. It is important to note that my kneecap and toes are pointing straight up. This stretch can be held for minutes, gradually relax your muscles more and more, allow gravity to do the work. The longer the stretch the more the viscoelastic tissues will elongate. ![]() This is the wrong way to stretch. This is a view of my knee from above. There is a natural tendency to externally rotate as your hips relax. Our goals are not being accomplished if this is allowed to happen. If you find this happening, simply place additional pillows or folded blankets along the outside of your foot and thigh to hold your toes and kneecap pointing up. ![]() Now we are working on regaining flexion. In this example we are working on gaining flexion in my right knee (in the back ground of this photo). Here I have placed my left leg in front of my right ankle. I am using my left leg to help bend my stiff right knee more. This works best when done progressively over a period of minutes as opposed to seconds. Use your hamstrings in both legs to try to flex both knees further. ![]() For deeper flexion than the previous stretch, this position utilizes a step-stool to provide deeper knee flexion. As shown, leaning forward and applying pressure with your hands can increase the stretch. ![]() This is a stretch that can achieve extreme flexion. This time I am lying on my back. My knee is pointing up toward the ceiling. Flexing the hip relaxes the quadriceps. The hands are used to to pull the leg toward your body. The effect is increased hip and knee flexion. Please note: if you have a total hip replacement, be very careful with this position as it can produce significant hip flexion. These stretching positions should take care of 90% of total knee replacement patients. These stretches should be done everyday, ideally multiple times per day, with no days off. The longer the stretches can be held, the better. Remember to relax as much as possible while stretching and remember that a little pain is normal an expected. If no pain is encountered, I would recommend pushing a little bit harder. As always, if you have any specific questions about your particular case, discuss with your surgeon.
Occasionally we encounter a patient that has a very difficult time regaining motion. I have a few additional recommendations in these cases and will address that situation in an upcoming posting.
30 Comments
Michael Rogers
10/26/2018 09:50:54 am
Dr. Gorczynski,
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10/26/2018 10:22:40 pm
Tourniquet use remains routine for many orthopedic procedures. It makes the surgery a little easier for the surgeon to perform, but paradoxically may actually increase total blood loss. Like many things in medicine there are trade-offs. At this point, I recommend you use plenty of ice, continue to work on gentle progressive range of motion exercises and I am sure you will do very well.
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David Roberts
4/3/2020 12:45:38 pm
After having simultaneous bilateral total knee replacements, I’m in week four.
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4/4/2020 12:50:18 am
This is a good technique to help regain a functional range of motion. Throughout this website, I provide some examples of more passive methods of stretching. The more you are able to stretch passively (not requiring you to exert force with your legs) the better.
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Susan Macaulay
5/9/2020 02:01:42 am
I am 7 weeks post-TKR (left knee). Because of the COVID-19 situation, my surgeon recommended that I attend physical therapy 2X/week for the first four weeks, and do the rest on my own at home. I suspect I may not have stretched enough during that time, because my knee is very tight, and stretching can be very uncomfortable. I've also started walking outside, and find that if I do much more than about 1/4 mile, my whole leg becomes really sore. I'm going to try to step up my stretching routine, and will keep doing the other PT exercise I was given, but am probably going to keep the walks to 1/4 mile unless I'm in less pain. (Not happy about that - I really want to begin to take the long walks I used to before osteoarthritis really took hold). Does this seem like a reasonable approach? Any other suggestions? My left leg (ankle to hip) is still noticeably larger than my right, so I'm guessing that that isn't helping things either.
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5/11/2020 06:55:54 pm
Yes, this seems reasonable. Stretching is much more important than walking long distances early after total knee replacement. Walking is good, but should improve gradually with time Focus on range of motion and keep in close contact with your surgeon who should be monitoring your progress (even remotely via telemedicine).
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Patricia Carver
6/20/2020 05:15:35 am
I am 5 weeks out From TKR and have flexion of 105 and 2 degrees from being straight. I have ankylosing spondylitis and prone to stiff joints. I also had damage to my knee before surgery and my presurgery numbers were 115 flexion and 10 degrees from straight. My surgeon seems happy with my numbers and hinted that I should not expect much more. I would like to achieve 0-125. I’ve been holding the longer stretches as you suggested but concerned that it is not enough and that I’m running out of time. I would be open for any suggestions and insight.
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6/26/2020 06:49:40 am
I think your approach is appropriate. If you dedicate several hours each day to stretching over the next couple of weeks, there is an excellent chance you will meet your goals. Without this level of time and dedication, however, I think you may fall short since range of motion tends to become increasingly difficult to obtain as you get farther from surgery. Best of luck!
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Renée Owens
12/5/2020 11:04:19 am
Thank you for sharing this information. I am 11 days out. I had a rough few days this week, and I'm terrified of the manipulation by my PT. I know it's necessary but I don't know how to make myself relax during it so that I'm not inadvertently fighting against her. Any suggestions? I feel like I'm behind and I'm trying real hard. I'm trying to do my exercises at home and i get on my recumbent bike to help push my flex and extension. How often should I be doing this? And for how long? I'm worried about the balance between not enough and too much? Finally, should I only ice or ice and heat? Ice before exercises, after or both? When would you use heat? I put heat on my hip and upper thigh today. My hip on my right side hurts from the straight sitting/ lying down position. My thigh only hurts occasionally from the exercises 12/7/2020 09:11:29 pm
Early after surgery I recommend using ice. Perhaps consider buying an ice machine to allow safe, long duration cryotherapy.
Kevin
9/11/2020 02:01:11 pm
Hi could someone give me advice please i am.a 46 year old man just found out most my cartilage worn away , however is very large with fluid, dur to lockdown im waiting to be fully assesed what can i do in the mean time i do have aspergers recent diangnosed because i was opiate dependent im now nearly 2 year clean from codiene no other drugs im finding it so hard to find someway of easing pain
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9/13/2020 10:58:35 am
Until you see your orthopedic surgeon, I would recommend using ice, avoiding high impact activities, and (if you can tolerate it) over the counter anti-inflammatory medications.
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Lori
9/25/2020 05:51:03 pm
Why are knee replacements clearly better in mom-opioid dependent patients? 9/25/2020 11:52:20 pm
Surgery, in general, turns out better in patients that are not opioid dependent. Multiple studies have demonstrated this. We do not know for sure why this is. But, I do have a theory. People rapidly become tolerant to opiate medications. This means that a particular dose of the drug becomes less effective over time. In addition to other medications, we also prescribe some opiate pain medication after surgery. When a patient is already tolerant to pain medication before surgery, the dose required after surgery must be significantly higher. Even then, opioid-dependent patients often have difficulty dealing with the unpleasant sensations experienced during rehabilitation. Unfortunately, poor ability to rehabilitate in the early post-operative period is likely to result in a stiffer, more uncomfortable knee.
Thank you for an excellent blog. I gound this information so helpful as I am 2 weeks post TKR. My knee is tight and swollen but as a retired
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Stacey
12/7/2020 01:07:53 am
First, thank you for this blog. It’s super helpful! I am 6 days out of TKR (scope for meniscus tear 3 months ago). My physical therapist is scaring me to death by telling me I am behind in my PT only being at 68 ROM. She told me this on day 3. Is this true? I stretch several hours a day and I am honestly not in the best shape...not the worst either but gave a few pounds to lose. Do I need to be concerned or is she just aggressive in her approach?
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12/7/2020 09:03:14 pm
Having surgery is stressful. I try my best to avoid increasing the anxiety level unnecessarily. The reality is that there is a limited time period during which a patient can regain range of motion. Good motion is necessary for a good result. Your surgeon and physical therapists all want you to get a great result, but they all know that rehabilitation is ultimately the patients responsibility. I think they are trying to motivate you to work as hard as you can. It is much easier to get motion back early rather than trying to "catch-up" later on. Stretching does not get easier as time goes by.
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ckennedy36
12/11/2020 03:21:34 pm
I am 6 weeks out From TKR(left knee) and have flexion of 110 on my own and w/PT assistance they can get me to 117. I just came across this post this week and started holding my stretches longer than the suggested 3-5 seconds (from PT) and feeling the results/relieft already. Can you clarify that your recommendation is to work up to 10 minute holds on a stretch with a goal of getting to 30 minute hold? Right now I can hold a stretch for about 3-4 minutes. Thank you!
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12/14/2020 10:36:18 pm
Correct. The longer you hold the better. I consider 10 minutes at the endpoint the minimum at this stage, with longer stretches even better. Unfortunately it becomes increasingly difficult to make progress with regard to range of motion the farther you get from surgery. This is because the scar tissue becomes more organized and stiffer with time.
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gary pinder
12/17/2020 02:18:55 pm
On my 8th week and my knee is still getting stiff and swollen. The swollen goose down from time to time. As far as bending i can bend it as far my other knee.
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Doug Smith
1/3/2021 10:22:41 pm
My left knee replacement 3 years ago was perfect in every way. I had my right knee replaced 4 months ago. Two days after my right knee total replacement, my knee buckled a bit while trying to stand without the walker. That is when I realized something was amiss. My knee felt like the implant would fall over a bit as I tilted my knee inward/medially. During my last PT visit, my PT doc noted that there was an unusual amount of laxity in my MCL. It's been 4 months and nothing has changed, even with all the PT exercises I do, which includes a lot of quad work. My knee clicks, clunks and catches a lot when I walk, frequently resulting in a snag that makes me squeal in pain. It's loose and feels unstable. It seems improbable that I will be able to rehab my way out of this. I wish I could get a 2nd opinion now and get this revised, but when I tried to make an appointment for a 2nd opinion I was told to call back a year after surgery. Isn't it possible to evaluate a knee replacement sooner than that to tell if revision warranted to fix the imbalance in ligaments?
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1/4/2021 09:22:30 pm
I think a second opinion is appropriate. There is no reason to wait for a year. A knee replacement does not make your knee immune to injury. Most primary knee replacements require balance between the medial and lateral structures in the knee. It sounds like you may have sustained a partial tear of the MCL. At minimum this should be braced for a 6-8 week period to protect it while it heals. In the event it does not heal, and remains unacceptably lax, revision to a more constrained implant may be necessary. If your original surgeon refuses to evaluate your knee for this complaint, I would seek a second opinion.
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Douglas Howard Smith
1/22/2021 03:30:48 pm
Thank you for your response. I am grateful for this wonderful service you provide. I have a 2nd opinion appointment scheduled for March 1st. I had a prolotherapy doc look at the MCL with ultrasound. All is good there. My patella tendon will hurt, pretty much all over, after a short brisk walk or just 10 minutes of slow walking on my incline treadmill. It doesn't hurt when I ride my spinner, do leg extensions, squats or wall sits. I did not have any issues with the patella tendon before surgery. Will a slightly unstable knee, such as I am experiencing, aggravate a patella tendon? 1/26/2021 11:48:00 pm
While it is possible to irritate your patellar tendon for a variety of reasons, the most common reason I see is secondary to hip weakness. Specifically hip flexor, abductor, and external rotator weakness. Check out my anterior knee pain article:
Addie Levesque
1/16/2021 02:14:27 pm
I had TKR on nov. 10th. 2 months later and I was doing pretty good. 116 rom, I think my pt said _ 2 for leg straightening.
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1/16/2021 09:44:52 pm
It is hard to believe you caused much damage doing what you described 2 months after knee replacement surgery. Perhaps it was the cumulative effects of all the activity you did that day. Did your knee swell up?
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Ruth Gill
2/22/2021 05:40:15 pm
I am very pleased to have found your website. I am 4 weeks post op and my knee is quite straight but also stiff. I don’t tolerate pain well but so can see I will need to do a lot more stretching!
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Tracey
3/6/2021 05:58:46 am
Hi, reading all your previous replys has been informative. I'm a 53 year woman who had a left tkr 3 and 1/2 weeks ago. My extension is very good but I just can't get my flexion to go any further than a our 80. I fell year and 1/2 ago and had spiral # to my left tibia and also # tibia plateau. I was in external fixation for 6 months and had to wear a fixed brace for 3 months.My rom preoperative was flexion 50 and extension was always ok, ended up with valgus deformity. My consultant managed to get my knee flexion to 120 while in surgery. But I just cant get it to bend when in lying position any further. I'm I expecting too much to soon. My surgeon also said I might never get past 90 flexion because of the trauma. Any advice would be helpfull
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3/12/2021 02:20:53 pm
In addition to the stretching recommendations I make on this website, I would ask your surgeon for a static stretching brace. Something like a J.A.S. flexion brace. This should help you maintain the stretch for long enough to at least get you beyond 90-95 degrees or so.
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4/9/2021 07:10:56 pm
A friend is about to have a TKR, and is seeking my advice since I had my TKR in late November 2020. Thanks to your articles and correspondence with you I feel I have a much better grasp on the need for stretching. But would you please confirm that stretching should be started ASAP after the operation. I seem to recall your saying that a couple of days after the operation, the knee should be able to achieve 90 degree flexion simply by letting the leg hang vertically from the seated position. This seems to be a great starting point, rather than waiting one or two weeks. I cannot locate the article where you wrote this.
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