Total Knee Rehabilitation Roadmap
How much motion should you have at any given point after surgery? Of course, you should speak to your surgeon about the specifics of your case. However I'd like to provide some general guidance on this subject.
During knee replacement surgery, the knee will be reconstructed using a metal and plastic prosthesis, and the ligaments balanced. At the conclusion of the operation, the knee will be able to fully extend (straighten) and fully flex (bend back). After surgery, although initially pain will prevent full range of motion, scar tissue has not had a chance to form. Most patients are able to move from full extension (0 degrees) to 90 degrees (foot flat on floor while sitting in normal chair) within 24-48 hours.
It is not uncommon for patients to lose a bit of motion around 7-10 days from surgery. This is a result of increased pain and swelling due to the inflammatory cascade. This inflammation peaks around 10 days from surgery. It is ok to go a bit easy on yourself during this time. Use plenty of ice and anti-inflammatory medication if it is allowed by your surgeon. But keep stretching. Do not allow yourself to lose full extension. This is crucial.
By the first postoperative visit around 2 weeks from surgery I would like to see a minimum of 0-90 degrees of motion.
By 6 weeks from surgery I would like to see 0-120 degrees minimum.
Patients may gain an additional 5-10 degrees of deep flexion over the course of the first year following surgery if they've gotten to 120 degrees by 6 weeks.
If these parameters are not met, other options are available. I begin asking patients to follow-up with me every other week or more to track their progress, to answer questions, and provide motivation and support. I understand that this process isn't always easy and is never fun. If inadequate range of motion isn't achieved by 6 weeks, I then recommend manipulation under anesthesia to break up scar tissue that has been allowed to form. This buys us some time and generally gets things back on track.
Karen M. Ohlsen
8/17/2016 12:16:29 pm
I have been doing some rehab with weights. I don' t have any pain but I would like to know if I can hurt my new knee and how much weight is too much?
8/18/2016 11:43:27 am
Gentle progressive resistance exercises are perfectly fine after total knee replacement. There is one important exception - I would definitely avoid the leg extension machine. This overloads the patellofemoral joint (knee-cap) and tends to pull the tibia forward. Although this exercise can strengthen the quadriceps, it is not optimal for knee function. I would focus more on strengthening the core, hip flexors, and abductors. Adding gentle squats would be fine as well. Please see the blog posting on anterior knee pain to see me demonstrating some simple exercises that will focus on hip strength.
12/20/2020 04:55:25 pm
Dr. Gorczynski, when you say you would like to see a minimum of 0-90 degrees of motion by two weeks from surgery, does that mean 90 degrees after being at rest for a while, or 90 degrees after warming up and stretching for several minutes?
12/22/2020 11:16:42 pm
I would like to see an easy 0-90 degree arc in my office at 2 weeks without a lot of warm up/stretching. If you are not quite there, no problem...just increase your duration and frequency of stretching so you start seeing progress.
12/20/2020 07:33:42 pm
I had TKR 10 months ago and although I can do all that I did prior to surgery, including playing golf, I still have some pain when I reach my flexion limit. I also still get some swelling after any activity. Is this normal?
12/22/2020 11:19:48 pm
It may be normal. This is partly dependent on what your range of motion is. In general, golf does not require very much knee range of motion, so I would not expect you to be maxing out your knee range of motion with that activity. If you mean it hurts a bit when you force flexion (and you have at least 120 degrees of flexion), I would expect this discomfort to gradually subside with time and as you stop pushing for more motion.
12/22/2020 03:49:25 pm
i have just had a replacement knee surgery on 3rd Nov.2020. With local NHS physio i was initially able to walk with a Zimmer frame. I continued with the exercises but know find that the more i excersis and try and straighten the knee joint the stiffer it becomes. The swelling has remained same size even after resting. I would appreciate your thoughts. Regards Bernard
12/22/2020 11:27:27 pm
Slow, long duration stretching is the key to rehabilitating your knee replacement. Ice can help. Swelling may occur, but this will resolve with time. the longer you hold the stretches for, the better. This video will be helpful to you:
Mrs Eddie Roseman
2/10/2021 09:53:30 am
So I had a knee replacement December 8th, 2020 we are now Feb.10th I’m I too late
2/13/2021 04:42:09 pm
It is never too late, but it will definitely require more time. Without knowing your current range of motion, I can't provide any more specific information. The longer you stretch, the better.
2/21/2021 03:03:01 am
2/24/2021 07:18:38 pm
I think you have reasonable expectations for after knee replacement surgery. I would not be too concerned about atrophied quadriceps preoperatively. I have not seen much ability to improve this via exercises or formal therapy before knee replacement surgery. To a certain extent this atrophy makes surgery a little easier for the surgeon (less muscle to work against), and this results in a bit less inflammation for the patient after surgery. I encourage you to work on regaining range of motion as soon as possible after surgery. The walking/hiking will happen naturally, but the range of motion requires hard work by you.
2/25/2021 03:00:14 am
Thank you for your reply, appreciate your time. May I also ask. Am I at the stage for total knee replacement? MRI in 2019 showed for first time Bone on Bone. I have some knock knee due to lateral meniscus is gone, the other compartments were ok I was told. I can walk at my own pace for 4 - 6 KM daily I sometimes have to stop to rest once or several times due to sharp lateral pain then I resume. I don’t usually have night time pain or pain at rest. I’ve had 4 steroid injections to the knee and the last one was 2019, I really don’t want further steroids to this knee. In view of my MRI findings, my daily living functionality and my quads... what’s your view of total knee replacement and when would it be timely as opposed to leaving it too long?
2/25/2021 04:22:21 am
2/25/2021 02:08:39 pm
2/25/2021 02:11:07 pm
Quad weakness due to disuse atrophy, or pain inhibition is not a contra-indication to total knee replacement. Neurologic quadricep weakness (paralyzed muscles) or chronic quadricep tendon rupture resulting in weakness would be. It sounds like you would be OK for knee replacement surgery based on your description.
2/25/2021 03:58:54 pm
Dr Gorczynski, thank you for your reply. You have been very generous with your time which I appreciate!
3/12/2021 02:48:07 pm
The decision for knee replacement should come down to pain level. Significant deformity or incomplete range of motion should also be considered. For example, a knee with poor motion or with angular deformity might be considered for surgery at a lower reported pain level than a knee without deformity.
4/1/2021 11:00:54 pm
4/13/2021 07:35:54 pm
With a knee replacement you certainly should NOT be feeling bone-on-bone. Your entire knee has been replaced. All bearing surfaces are metal/plastic. You might be feeling the patella floating a bit on synovial fluid (if your knee remains a bit inflamed). It is also possible that you are feeling some soft tissue crepitus due to synovial tissues/scar tissue gliding across your joint. There is also the possibility of less than perfect soft tissue balance such that you feel the artificial joint surfaces separating and then making contact again with certain activities. In the absence of significant pain, and with the good range of motion and high activity level you report, I would not worry about this too much. Your knee should continue to improve for many months yet to come. If symptoms worsen- have your surgeon check you out in the office.
6/22/2021 09:01:47 am
In follow-up to my previous email dated 4/1/21, I was diagnosed with patellar clunk syndrome on 4/14/21 (6 mos post-op) and told to return at 12 mos. I have been doing a 2nd round of PT x 3 mos (SAOS LE Protocol + Graston therapy). My LE strength has improved but I feel little change with my knee function. I still have initial difficulty and discomfort straightening my knee any time it's flexed and feel/hear the clunk right around 35-45 degrees of flexion. Also have difficulty/pain walking up (more so)/down stairs and no longer am able to use my Peloton without feeling discomfort with each revolution. Based on my reading, arthroscopy is the treatment of choice. Is it necessary to wait a full 6 mos before having arthroscopy? Any other suggestions during the interim? Thank you
6/23/2021 08:45:26 pm
Personally, I would not make you wait 6 months with a patellar clunk as irritating as yours sounds. Patellar clunk happens because some scar tissue forms at the distal end of your patellar tendon and it engages into the box or notch of a posterior stabilized total knee femoral component when you flex your knee. This generally does not resolve without surgery. Arthroscopic debridement of this tissue is generally very effective.
10/28/2021 09:05:08 am
Greetings! Just wanted to let you know my patellar clunk syndrome has resolved following arthroscopy 6 weeks ago however I still have IT Band tightness, which I now realize I've had for the past 12 months post TKR. This issue is interfering with my ability to walk upstairs comfortably (less so going down) and I also have discomfort straightening my leg after keeping it in a bent position (e.g. sleeping at night, riding in a car, etc.). I get short-term relief after the Graston Technique is performed by my physical therapist. Any recommendations for rehab for this condition and is it managed similarly to IT Band Syndrome? Various techniques are suggested online for IT Band Syndrome (e.g., foam roller, power percussion massage, etc.). I also understand that certain types of exercise can further aggravate this condition. I would appreciate your thoughts. Thank you
11/3/2021 09:24:07 pm
@Kathleen- Glad to hear the patellar clunk has resolved. I think direct ITB stretching is best. That can be done in addition to soft tissue mobilization techniques, but I really think directly focusing on slow steady stretches should pay dividends for you long-term. The best ITB stretch requires a hands-on physical therapist and you would be positioned on your side, with the tight side up, then the therapist would extend your hip, maintain neutral rotation, flex your knee, and then gently push your knee down toward your other knee (adduction). A tight ITB will resist this stretch, but should gradually yield with slow, steady treatment.
4/10/2021 01:21:02 pm
I am 53 yr old female and just had TKR on 4/6/2021, I have good extension and am able to get around with a walker. But it is very painful and difficult to bend my knee at all, I would guess I am at 20 degrees. I only had PT at the hospital so far and was given a leaflet of exercises to do. In your article you write “Most patients are able to move from full extension (0 degrees) to 90 degrees (foot flat on floor while sitting in normal chair) within 24-48 hours.” I was not able to do this, should I be worried?
4/13/2021 08:16:14 pm
I would not be worried, I recommend keeping anxiety low, working consistently on slow, prolonged stretching exercises to you can "catch-up." There is plenty of time. I have posted lots information to support your rehab process. Check out the videos. Consistency and long duration of stretching is crucial.
8/28/2021 07:28:21 am
Thanks, I appreciate your time spent on this. For me the 1st week my quads wouldn't fire. After 2 weeks I only had 75 degrees. I've really been working hard and at 5 weeks I've achieved a supported 120 degrees. One week to go I'm looking for 130 degrees and found your video. Longer stretches makes sense, but I can only bear that pain level for 5 mins. How much pain is acceptable in a stretch ? Do I go to the point where I feel a stretch or push beyond to maximum pain ? I get mixed messages from my PTs. Thanks again.
9/1/2021 03:45:40 am
Because pain is subjective, I can't tell you how much is too much. It sounds like you are making excellent progress. At a certain point, increasing your pain level could result in your muscles tightening up in response. This is definitely counterproductive and will not help you achieve your goals. Probably, anything prior to this level would be acceptable. Also consider pushing slightly less for longer periods of time.
CARMEN FAY PRICE
10/30/2021 02:33:55 pm
Thanks for the excellent information you're providing to patients! My question relates to anterior tibialis soreness after a TKA on 10/04. My range of motion is 130/0. I'm walking without a cane. But, my anterior tibialis is sore and tight to the point, where I can't ambulate without discomfort. I've been stretching and massaging and using heat. PT says this is normal and will resolve. Riding my bike trainer without difficulty about 15 minutes 3 x a day. Other than some stiffness the joint itself feels good Thought?
11/3/2021 09:15:17 pm
Excellent job regaining motion! While this is not the most common complaint early after total knee replacement, just about any pattern of soreness is possible in the first few weeks, depending on your own unique anatomy and post-op bleeding/inflammation. That being said, it should be expected to gradually resolve as you get further along in rehab. If the pain is not improving, or is worsening, then I would suggest you see your surgeon for an examination and get a fresh set of x-rays.
11/2/2021 03:23:12 am
Yes Good, One, this is proper geneuine information regarding total knee replacement , I am also a orthopedic doctor , and i think this information helps many individuals regarding knee or knee replacement surgery.
12/5/2021 05:40:58 pm
Dear Dr. Gorczynski -
12/16/2021 03:51:19 pm
The bike is fine to do. It will not break up adhesions better than prolonged stretching. It could be used judiciously either before or after stretching. It is no substitute for stretching.
1/7/2022 10:21:10 pm
I had a Right TKR 11/18/21. I switched PT at week 4 because I knew I was behind in my ROM and extension. I progressed well with the new PT from 64-88 but I’m still far behind. I had my 6 week appointment and was only at 75-88 range. My surgeon suggests a manipulation but wants me to do another 2 weeks of PT MWF schedule. Can I realistically improve enough in 2 weeks and not need the manipulation? If not, I would rather do it sooner vs later. I feel like I failed my TKR. I should’ve switched PT sooner but I didn’t know until I saw another PT and he was surprised that my PT wasn’t doing certain exercises with my rehab. That’s when I switched but I guess it was too late. Will the manipulation be as painful as the initial TKR?
1/22/2022 01:38:25 pm
I don't think this is the fault of your PT choice. The patients that have the best outcomes generally are stretching on their own, everyday. The PT session is not where gains are made, but where process is documented, and encouragement given. When patients struggle, there is a tendency to blame others. While this is natural, I believe it is counterproductive.
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Orthopedic Surgeon focused on the entire patient, not just a single joint.