Total Knee Rehabilitation Roadmap

5/25/2016

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.

total knee

35 Comments

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?

Christopher Gorczynski, MD link

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.

Richie

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.

Mike

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.

Bernard Cunningham

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:

https://www.youtube.com/watch?v=xQASZaKZRxs

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
With the stretching exercises to be able to go the full 120 ? and
Better still if I work real hard at it ,how many times a day do you
recommend?

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.

S.C

2/21/2021 03:03:01 am

Dr. Gorczynski,
Reading your rehabilitation article with interest thank you. I’ve been thinking about rehabilitation following tkr and I have a pre surgery question if I may ask?

What is your experience and/or considered opinion about female patients with very wasted quads undergoing tkr? What have you observed of the post operative and long term outcomes of these patients?

I’m 54 and weigh around 119 pounds.
At the moment I can drive my car, walk unaided (with a limp) 6,000 - 10,000 steps daily pain permitting, and use stairs at home.
Following surgery and rehabilitation I want to continue these things plus do more walking/ hiking. I certainly don’t want to be worse off or lose what I can do now.

2 years ago diagnosed with bone on bone right knee osteoarthritis consequence of lateral meniscectomy in 1980’s.

I appreciate your time.

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?
I didn’t want an osteomy or a partial knee replacement when all this began in 2016.
Appreciate your opinion.

2/25/2021 04:22:21 am

Dr Gorczynski,
I forgot to say not only are the quads atrophied they are weak. Is there a stage where surgeons say to patients that surgery isn’t suitable due to the muscle function? I was wondering what the patients present with for the surgeon to make this decision.
Thank you

2/25/2021 02:08:39 pm

@SC

"Bone on bone" arthritis means the articular cartilage has been completely worn away from the bone ends allowing them to scape against each other. This is end-stage osteoarthritis. The knock-kneed deformity is due to loss of this articular cartilage, not loss of meniscus tissue or a meniscal tear.

In spite of the deformity and bad looking imaging studies only you as the patient can decide that you are a candidate for surgery. After all- we as surgeons should be treating you, not your imaging studies.

You are a candidate for knee replacement surgery based on your imaging studies, but you personally need to decide if your pain level is high enough and quality of life is low enough to justify undergoing an operation. This is a personal decision.

As a surgeon, it does appear that knee replacement would be appropriate for you, and I would expect it to improve your quality of life, however, you remain quite functional and it appears your pain level is not severe. If you are able to tolerate your present situation well enough, maybe it is not yet time for surgery.

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!

Thank you for enlightening me about the bone ends articular cartilage that’s worn away causing knock knee. How long can this go on for without causing me complications or complications during surgery? I don’t suppose this scraping together of the bones is ever reason enough on its own to have TKR? Or does it go back to pain levels and quality of life too?

(If only this was a subject that wasn’t affecting me, I could find it possibly quite fascinating.... as it is, it seems to generate more questions and what if’s... )

Whether to consent to a major operation of a TKR or not is a major decision. So I appreciate your opinion, helps me to have a plan for what will probably be in the not too distant future.

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.

You are correct, knee replacement surgery is a major decision, and you are appropriately contemplating this.

Kathleen Lake

4/1/2021 11:00:54 pm

Dr. Gorczynski,
My clinical course was picture perfect through 3 mos post TKR 10/14/20 (had 0 deg extension and 120 deg at 6 wks, 125 deg ROM at 3 mos). After 3 mos my progress plateaued despite continuing my stretching & strengthening exercises. I had more difficulty at night straightening my knee after sleeping with it in a flexed position. Also when I walk up and down stairs I feel a click with each step and after sitting in the car or at my desk, my knee feels locked for the 1st few steps. When I try to ride my Peloton I feel the same click with each revolution. I cannot tell if my knee is clicking because of “bone on bone” sensation or if my patella is not moving effectively and that or something else is causing the clicking sensation. Otherwise, I am able to walk 2-3 miles/day w/o any difficulty or pain (overall 8000 - 9000 steps/day). Any insight or suggestions for me?

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.

Kathleen

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.

Pat F.

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.

Mark Teahan link

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.

Dr. Arun Partani link

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.

Jonathan Lesser

12/5/2021 05:40:58 pm

Dear Dr. Gorczynski -
I had TKR on November 3 and thankfully found your website a few days ago. I was doing some duration stretches per the PT, but just for 5 minutes at a time. I can hold the seated flexion stretch for 15 minutes now. I then try several others for as long as I can. I think I'm at around 110 degrees. Two questions:
1. I get on my stationary bike after the prolonged stretching. It feels good to do so, but is it OK? Does the exercise bike help break up adhesions? Should I do the exercise bike before prolonged stretching?
2. I am now 4 1/2 weeks post-surgery. My orthopedist told me that, because of my previous condition (limited range because of a botched surgery and staph infection 40 years ago - a long story) that I was unlikely to get much additional range beyond what I had, but if needed, he could try surgical bending. However, I am not scheduled to see him again until 7 weeks post op. Is that too late for the surgical bending?
Thank you for your website!!!

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.

I prefer to do manipulation around 6 weeks, but 7 weeks postop should be ok.

If you were already at 110 degrees by postop week 4, it is unlikely that you will require manipulation.

Cynthia

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.

You have definitely not "failed your TKR." You are only a couple months into recovery.

At this point, I recommend you take full responsibility for your rehab. Stretch for long durations, every day. Do not make the physical therapists try to catch you up at every session.

There are no special stretching moves that only good physical therapists know. The concept is easy, push your knee into full extension, however you can- and hold it there for a minimum of 30 minutes. Then push your knee into deep flexion-and hold it there for 30 minutes minimum. Repeat this sequence over and over as often as needed.

This all being said, if you still have significant restriction in range of motion as you documented above, I would definitely consider manipulation. But then approach the rehabilitation as I outlined above. Consider the PT your guide, but spend hours every day on your own making your knee move.

Best of luck to you!

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