Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2014;95:1135-40

ORIGINAL ARTICLE

Guidelines for the Early Restoration of Active Knee

Flexion After Total Knee Arthroplasty: Implications
for Rehabilitation and Early Intervention
Jay R. Ebert, PhD, Claire Munsie, BERSc, Brendan Joss, PhD
From the School of Sport Science, Exercise and Health, University of Western Australia, Crawley, Perth, WA; and Hollywood Functional
Rehabilitation Clinic, Nedlands, Perth, WA, Australia.

Abstract
Objectives: To investigate the association between active knee flexion at initial (1e2wk) and final (7wk) outpatient visits after total knee
arthroplasty (TKA), and to develop a guide for the expected progression of knee flexion in the subacute postoperative phase.
Design: Prospective case series.
Setting: Rehabilitation clinic.
Participants: Consecutive sample of patients (NZ108) who underwent TKA between December 2007 and August 2012.
Intervention: TKA followed by a standardized, 5-week outpatient rehabilitation program (2 sessions per week) immediately after hospital
discharge.
Main Outcome Measure: Active knee flexion was recorded on the patients first outpatient visit (1e2wk) and then biweekly throughout the
patients 5-week outpatient rehabilitation program.
Results: Active knee flexion at initial (1e2wk) and final (7wk) outpatient visits were significantly correlated (rZ.86, P<.001). Mean active knee
flexion significantly improved (P<.001) across all patients from 90.4 at initial outpatient visit to 110 at final outpatient visit. At 7 weeks
postsurgery, a value of 100 was determined as the cut-off point for an acceptable active knee flexion, which corresponded with 80 of active
knee flexion at initial outpatient presentation at 1 to 2 weeks.
Conclusions: Active knee flexion at the initial outpatient visit exhibits a strong correlation with knee flexion at 7 weeks after TKA. These knee
flexion guidelines may allow for the provision of individualized rehabilitation, allow practitioners to provide patients with realistic goals of
progression throughout the subacute phase, and allow the early identification of patients at risk for poor long-term outcomes who may benefit from
further intensive care or other early intervention.
Archives of Physical Medicine and Rehabilitation 2014;95:1135-40
2014 by the American Congress of Rehabilitation Medicine

Articular cartilage injury to the knee is extremely common.1

Given the poor capacity of cartilage to repair, the inevitable,
long-term progression is to osteoarthritis (OA) of the knee.2 The
most common treatment for severe OA of the knee is total knee
arthroplasty (TKA).3 The number of patients with debilitating
OA of the knee is increasing; therefore, the number of TKAs is
also expected to increase with time.4-6 The primary goal of
TKA is to provide the best possible outcome for a patient.7
However, it has been reported that up to 15% of patients can
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.

have substantial dysfunction for a variety of reasons, including

persistent pain and limited knee range of motion (ROM).8
Indeed, restricted postoperative knee flexion remains one of
the most frequent postoperative complications and indicators
for patient dissatisfaction after TKA.9 Previous research has
indicated that at least 110 of knee flexion is required to achieve
satisfactory function for most patients and to complete most
activities of daily living.9-11 Therefore, in addition to the resolution of pain, studies have shown that the restoration of knee
flexion and function are important in determining the success of
a TKA.12-14
A range of factors have been reported that affect the progression and final postoperative knee flexion after TKA. These may

0003-9993/14/$36 - see front matter 2014 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2014.02.015

1136
include preoperative and postoperative hospital discharge knee
flexion, pain, physical activity level, age, body mass index, underlying disease and tibiofemoral varus/valgus angle, surgical
technique, implant design, the height of postoperative joint line,
patellar diameter, and postoperative physical therapy.7,8,15-23 Of
interest to this study, active knee flexion on hospital discharge has
exhibited an association with knee flexion at 12 months.24,25 This
would suggest that if patients can improve their flexion within the
early acute inpatient setting, this may translate to improved
longer-term outcomes.
There appears to be very little research on the association
between active knee flexion at hospital discharge and that
exhibited within the subacute phase. It is generally agreed that
postoperative improvements will climax at 12 months postsurgery.12 However, the expected progression toward this
endpoint, and whether this flexion endpoint is indeed reached
earlier than 12 months, is yet to be determined.12 Furthermore, we
know little about the expected progression of active knee flexion
throughout this subacute period.
Tracking the progress of knee flexion after TKA allows for
better identification of patients progressing poorly, which may
require alternative early intervention. In addition, ensuring that
weekly knee flexion goals are met may provide a means of
reinforcement and/or reassurance to the patient that they are (or
are not) undertaking the work required to increase the chance
of a good long-term outcome. This may invariably lead to
improved patient confidence and satisfaction in their rehabilitation progression and final outcome. Therefore, the aims of
this study were to investigate the association between active
knee flexion at the initial outpatient visit (1e2wk) and at 7
weeks postsurgery, to develop a guide for the expected progression of active knee flexion throughout the first 7 postoperative weeks after TKA, and to identify the degree of knee
flexion at time of the initial outpatient visit that would
invariably be associated with an unacceptable knee flexion at 7
weeks postsurgery.

Methods
We retrospectively evaluated the clinical data of 113 patients who
underwent TKA between December 2007 and August 2012. In all
patients, surgery had been followed by a standardized, 5-week
outpatient rehabilitation program at the Hollywood Functional
Rehabilitation Clinic. Patients were excluded from the current
analysis if they had been diagnosed with an active infection
(nZ0), had developed deep vein thrombosis (nZ0), or did not
have active knee flexion ROM data documented at the initial
outpatient visit immediately on hospital discharge and/or twice
weekly throughout the 5-week outpatient rehabilitation program
(nZ5). Therefore, 108 patients (57 men, 51 women) with a mean
age of 66.8 years (range, 38e86y) were evaluated. This retrospective analysis had ethical approval from the Hollywood
Functional Rehabilitation Clinic. All patients had signed a consent
form to allow their clinical data to be deidentified and used for
research programs.

List of abbreviations:
OA osteoarthritis
ROM range of motion
TKA total knee arthroplasty

J.R. Ebert et al
For this retrospective analysis, there was no standardization of
orthopedic surgeon, surgical approach, or type of prosthesis used.
In total, 6 surgeons referred the 113 patients to the Hollywood
Functional Rehabilitation Clinic for routine outpatient postoperative care. However, postoperative inpatient and outpatient
rehabilitation was standardized across all patients. Physical therapy was undertaken twice daily for the first 3 postoperative days in
hospital and then once daily from day 4 through until hospital
discharge. This consisted of teaching of proficient use of crutches
and safe ambulation; ambulatory and transfer activities
commencing on day 1 and as tolerated; deep breathing and
coughing exercises; active dorsi- and plantarflexion of the ankle to
encourage lower extremity circulation; and isometric contraction
of the quadriceps, hamstrings, and gluteal musculature to maintain
muscle tone and minimize muscle loss.
Knee-based exercises were undertaken in supine (activeassisted knee flexion using a bandage, straight-leg raises, and
terminal range knee extensions), seated (active-assisted knee
flexion using the contralateral limb and inner range quadriceps
contractions), and standing (hip and knee flexion, active
hamstring curls, lunges on a step, hamstring stretches) postures.
These exercises were undertaken 3 times per day and in sets of
10 repetitions. The assigned hospital physiotherapist was present to assist as required on 2 occasions per day for the first 3
postoperative days and then once daily from day 4 until hospital
discharge. Cryotherapy was used for 20 minutes at least 3 times
daily. Continuous passive motion was used twice daily for 1
hour and was initiated on day 1 postsurgery. The maximum
permitted continuous passive motion range was 90 of knee
flexion; however, the actual range attained comfortably for
patients was not documented and varied depending on what was
tolerated by each patient. After hospital discharge, patients
were referred to the Hollywood Functional Rehabilitation
Clinic for a standardized, outpatient rehabilitation program.
This was initiated in all patients at 1 to 2 weeks postsurgery.
Sessions were undertaken twice weekly (1e1.5h duration) and
consisted of progressive ROM and resistance exercise and
hydrotherapy.
Active knee flexion was initially measured on the patients
initial outpatient visit at 1 to 2 weeks (7e14d) postsurgery. It
was further measured on a biweekly basis throughout the
5-week rehabilitation program at 2 to 3 weeks (15e21d), 3 to 4
weeks (22e28d), 4 to 5 weeks (29e35d), 5 to 6 weeks (36e
42d), and 6 to 7 weeks (43e49d) postsurgery. The highest
recorded active knee flexion measure out of the 2 sessions each
week was used in this analysis. This was measured using a
standard long-arm goniometer, creating an angle made by 3
anatomic landmarks: greater trochanter of the femur at the hip,
lateral femoral condyle at the knee, and lateral malleolus at the
ankle. The patients initially lay supine with both legs extended.
They were then instructed to keep their heel on the bed/plinth at
all times and move their foot (ie, flex their knee) proximally
toward their bottom as far as possible. This process was undertaken 3 times, and the maximum values were recorded,
measured to the nearest degree. There are known limitations
with the accuracy of assessing knee flexion using handheld
goniometry. It has been reported that the reliability of goniometric measurements improves when the assessment is performed by the same individual using the same measurement tool
and in a standardized test position.26,27 Each patient in this study
was assigned to a specific physical therapist. Therefore,
although 6 therapists were involved in the assessment of knee
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Restoration of range of motion after total knee arthroplasty

flexion over the recruitment period, active knee flexion for each
patient was measured in its entirety by the same therapist.
Because the main focus of this analysis was within-person
change, we did not attempt to adjust for variability in goniometric measurement of knee flexion between testers. Furthermore, we did not investigate the ratio of patients treated by each
therapist within each of the stratified low-high knee flexion
groups as subsequently discussed.
For the statistical analyses, the strength of the linear association between active knee flexion at the initial (1e2wk) and final
(6e7wk) outpatient visits was first assessed using Pearson correlation coefficient.28 This association was also presented graphically using a scatterplot. Second, comparison of active knee
flexion between men and women throughout the postoperative
assessment timeline was determined using repeated-measures
analysis of variance. Third, the progression in active knee
flexion over the postoperative timeline was presented, stratifying
all 108 patients into 5 subgroups (>100 , 90 e99 , 80 e89 ,
70 e79 , <69 ) based on active knee flexion at initial outpatient
visit (1e2wk). Comparison between groups was also determined
using a repeated-measures analysis of variance design with post
hoc comparisons.
Finally, a cut-off for an acceptable (or unacceptable) knee
flexion range at the final outpatient visit (6e7wk) was determined
using current reported literature outlining the minimum amount of
knee flexion required to perform most activities of daily living and
the expected upper limit of knee flexion generally attained after
TKA. To achieve this study aim, previous research had indicated
that at least 110 of knee flexion was required after TKA to
achieve satisfactory function for most patients and to complete
most activities of daily living.9-11 Furthermore, patients generally
attain up to 120 as a knee flexion endpoint after TKA.9 Given that
patients in this analysis achieved a mean knee flexion range of
110 at 6 to 7 weeks postsurgery, this would allow for a further
10 increase toward a final expected endpoint range of 120 .
Therefore, anything <100 at 6 to 7 weeks postsurgery (ie, 110 e
10 ) would not permit the 110 required as a minimum functional
flexion endpoint. Using this acceptable cut-off value of 100 at 6
to 7 weeks, the minimum knee flexion value required at the initial
visit (1e2wk) was determined. Statistical analysis was performed
using SPSS version 19.0 softwarea where experimental significance was set at an alpha of .05. Power calculations indicated that
110 patients provided over 93% power to detect differences in the
initial versus final knee flexion measures as small as 5 based on
an estimated SD of baseline measures of 15 and a within-person
correlation of 0.5.

Table 1

1137

Results
Active knee flexion at the initial (1e2wk) and final (6e7wk)
outpatient visits were significantly correlated (rZ.86, P<.001).
There was no significant group (PZ.352) or interaction (PZ.676)
effect for active knee flexion postoperatively when comparing
men and women (table 1).
The mean active knee flexion across all patients significantly
improved (P<.0001) over the postoperative timeline from
90.4 12.4 at the initial outpatient visit (1e2wk) to 110 15 at
the final outpatient visit (6e7wk). After stratification of the entire
cohort into the 5 subgroups based on active knee flexion at the
initial outpatient visit, all individual groups also significantly
improved (P<.001) over the postoperative timeline. A significant
group (P<.001) and interaction (PZ.001) effect was exhibited
(see table 1 and fig 1). Post hoc tests demonstrated that although a
significant difference in active knee flexion between all stratified
groups was observed at the initial outpatient visit (1e2wk), as
expected because of the artificial group stratification, all groups
remained significantly different from each other at the final
outpatient visit (6e7wk) (see table 1 and fig 1). After stratification
of patients into the 5 subgroups, there was an improvement in
active knee flexion from the initial to final outpatient visit of 15.3
(>100 ), 20.3 (90 e99 ), 21.2 (80 e89 ), 22.9 (70 e79 ), and
26.8 (<69 ).
Using the acceptable cut-off value of 100 at 6 to 7 weeks as
previously discussed, the minimum active knee flexion value required at the initial visit (1e2wk) was 80 (fig 2). An active knee flexion
<80 at 1 to 2 weeks was present in 19 patients (17.6%). Of these
19 patients, the mean active knee flexion at the initial outpatient visit
was 64.1 , which improved to 87.7 at the final outpatient visit.

Discussion
The success of a TKA is often measured on the restoration of knee
ROM.12 Restricted postoperative knee flexion remains one of the
most frequent complications and indicators for patient dissatisfaction after TKA.9 The aim of this study was to investigate the
association between active knee flexion at hospital discharge
(initial outpatient visit) and at 6 to 7 weeks after TKA and develop
a guide for the expected progression of active knee flexion in the
subacute postoperative phase.
Active knee flexion significantly improved over the postoperative timeline to a final outpatient value of 110 . Previous
research suggests that patients after TKA generally acquire 95 to
120 at 12 months postsurgery.7,9,12,25,27,29 The greatest change in

Active knee flexion throughout the postoperative timeline until 6 to 7 weeks postsurgery

Knee Flexion (deg)

Age (range) (y)

Week 1e2

Week 2e3

Week 3e4

Week 4e5

Week 5e6

Week 6e7

All (NZ108)
>100 (nZ38)
90e99 (nZ24)
80e89 (nZ27)
70e79 (nZ9)
<69 (nZ10)
Men (nZ57)
Women (nZ51)

66.8
68.7
64.8
67.0
66.2
64.1
67.8
65.6

90.412.4
106.06.1
93.56.1
84.33.0
74.93.2
54.26.7
91.915.1
88.714.8

95.312.6
109.67.4
98.67.5
89.07.8
81.96.9
62.49.0
96.714.5
93.915.1

101.412.1
113.97.9
104.97.7
97.28.7
88.67.2
68.89.3
102.813.4
99.915.7

105.611.4
116.87.5
109.37.5
102.58.9
92.18.0
74.68.6
106.816.7
104.314.7

108.312.4
120.27.8
111.87.5
104.28.0
94.47.6
77.48.1
109.516.5
107.016.1

110.015.0
121.37.9
113.87.8
105.57.8
97.14.9
81.08.2
111.311.4
108.611.5

(38e86)
(48e86)
(46e74)
(48e80)
(43e75)
(38e74)
(38e86)
(48e84)

NOTE. Knee flexion progression is presented based on sex and following stratification of the entire group based on active knee flexion at the initial
outpatient visit (1e2wk). Values are mean  SD or as otherwise indicated.

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1138

J.R. Ebert et al

Fig 1 Active knee flexion for the entire group and following group stratification based on active knee flexion at the initial outpatient visit
(1e2wk) throughout the postoperative timeline until 6 to 7 weeks postsurgery. Means  SDs are shown. Abbreviation: deg, degree.

flexion occurs within the first 12 months with little improvement

thereafter.7 The results of this study suggest that the greatest
improvement in knee flexion occurs within the first 6 to 7 weeks
postoperatively and the actual progression in flexion from this
time to 12 months requires further investigation. Furthermore, sex
has been shown to influence both pain and function after TKA.30
This study demonstrates that active knee flexion, at least in the
postoperative subacute phase, is not affected by sex.
Although a significant interaction effect was exhibited on group
stratification of patients based on initial outpatient knee flexion, the
gradient of improvement appeared similar. It would be expected
that those patients with high knee flexion at discharge would most
likely experience smaller gains over time because of the ceiling
effect imposed by the maximum number of degrees the knee
prosthetics are designed to flex. However, despite the larger room
for improvement in patients with a lower discharge knee flexion
value, they did not appear to improve toward a final 6 to 7 week
outcome at a much faster gradient. It has been previously suggested
that low knee flexion groups will achieve greater changes from
baseline to final ROM compared with high flexion groups.31 This
was indeed the case in this study, though the comparative differences in knee flexion change from the initial to final outpatient visit,
between the low and high flexion groups, were not as great as expected. Patients who demonstrated >100 at the initial outpatient
visit improved by 15.3 over the 5-week outpatient rehabilitation
program. However, for the remaining groups (90 e99 , 80 e89 ,
70 e79 , <69 ), there was a mean improvement in active knee
flexion from the initial to final outpatient visit of 20.3 to 26.8 with
only a varied improvement of 6.5 . Furthermore, all groups still
remained significantly different from each other at 6 to 7 weeks
postsurgery as was the case at the initial outpatient visit. The similar
gains in absolute knee flexion for all patients in this study, irrespective of the amount at hospital discharge, were also reflected by
the strong positive correlation between active knee flexion on
hospital discharge and at their final outpatient visit at 6 to 7 weeks
postsurgery.
In order to undertake many normative activities of daily living, a
full active knee flexion is imperative. Activities, such as rising from

sitting (93 ), ascending stairs (105 ), descending stairs (107 ), and

picking an object up off the floor (117 ), require high levels of
active knee flexion.15 Devers et al9 demonstrated that greater
postoperative knee flexion was correlated with a higher level of
perceived patient satisfaction, whereas patients with <110 of knee
flexion were not satisfied with their TKA outcome. Furthermore,
they did not perceive their knee function or quality of life any better
than presurgery. This highlights the importance of early attainment
of active knee flexion even prior to hospital discharge for long-term
actual and perceived benefit. An association between preoperative
knee flexion and postoperative outcome has been previously
demonstrated.20,29,32 Therefore, further research is required to
demonstrate the benefit of optimal preoperative conditioning with a
focus on increasing passive and active knee flexion on early (and
late-stage) postoperative knee ROM.
There is no definitive active knee flexion value considered unacceptable after TKA (certainly at 6e7wk), and the progression of
knee flexion from 6 to 7 weeks postsurgery to a final flexion
endpoint at 12 months is unknown. A minimum knee flexion value
of 110 is required in order to complete most activities of daily
living.9-11 Therefore, we determined a minimum knee flexion
standard at 6 to 7 weeks based on the expected progression toward a
final endpoint value of 120 , taking into account what is required in
order to undertake most normative daily functional tasks (110 ).
First, we determined that anything <100 at 6 to 7 weeks postsurgery would not permit the 110 required as a minimum functional flexion endpoint at 12 months. Using the strong correlation
we observed in active knee flexion between the initial and final
outpatient visits, this equated to 80 at the initial outpatient visit. In
this study, 19 of the 108 patients fell below this cut-off. Second, a
significant difference was still observed between the stratified knee
flexion groups at 6 to 7 weeks postsurgery as was the case on initial
outpatient presentation. Based on the aforementioned knee flexion
requirements for normative daily tasks, these differences also
appear clinically relevant. For example, patients initially presenting
with <80 to 89 of knee flexion would still find it difficult to ascend
(105 ) and descend (107 ) stairs properly at 6 to 7 weeks postsurgery based on that previously reported for these common tasks.15

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Restoration of range of motion after total knee arthroplasty

1139

Fig 2 A strong linear correlation (rZ.86) was observed between active knee flexion at the initial (1e2wk) and final (6e7wk) outpatient visits.
The cut-off for an acceptable active knee flexion of 100 at 6 to 7 weeks was associated with a knee flexion of 80 at the initial outpatient visit
(1e2wk). Abbreviation: deg, degree.

Study limitations

Recommendations for future research

There are a number of clear limitations associated with this study.

First, a range of factors have been reported to affect the progression of knee flexion after TKA. These may include preoperative and postoperative hospital discharge knee flexion, pain,
activity level, age, body mass index, underlying disease and
tibiofemoral varus/valgus angle, surgical technique, implant
design, height of postoperative joint line, patellar diameter, and
postoperative physical therapy.7,8,15-23 Many of these variables
were not documented and, given the retrospective nature of this
analysis, cannot be obtained. Furthermore, patients were recruited
from 6 surgeons, and this does not allow for differences that may
present from varied surgical approaches and prostheses.33 Previous research investigating postoperative knee flexion after TKA
has used both single and multisurgeon designs.12,25,34 However,
the aim of this study was not to investigate the influence of these
coexisting variables to the progression of knee flexion. Rather, we
sought to investigate the association between discharge and final
outpatient knee flexion through the subacute phase of rehabilitation and expected progression in active knee flexion in the TKA
population as it presents. This may also be seen as a study benefit
by increasing the generalizability of study outcomes for what is
normally a very heterogeneous patient cohort.
Second, one variable that was controlled for was physical
therapy. This also presents as a limitation because not all patients
are educated on the importance of postoperative rehabilitation or
can afford postoperative supervised therapy. Although the general
trends observed across all stratified groups were similar, different
patients may respond in different ways to appropriate education,
advice, and physical care. Additional benefit has been previously
demonstrated from intensive rehabilitation immediately after
hospital discharge.35 However, the actual benefits of therapy in
this retrospective study are unknown because of a lack of a control
cohort. All patients in this trial underwent supervised therapy
twice per week for the duration of their 5-week outpatient rehabilitation, which also aimed to ensure the appropriate goniometric
knee measurements were taken. Third, this study focused solely
on the subacute phase after TKA, but it did not evaluate these
flexion outcomes at longer-term time points.

Given the aforementioned limitations of this study and current

literature, future research may look to use large prospective trials
that better account for the numerous variables known to influence
postoperative knee flexion. Although this would prove difficult
and large patient numbers would be required, it would allow for
the development of more definitive guidelines pertinent to patients
of varied age, sex, activity level, body mass index, coexistent
disease, and lower limb anatomy. It may also evaluate the true
benefit of both pre- and postoperative intensive rehabilitation.
Furthermore, ongoing research should assess the progression in
knee flexion from the completion of the patients outpatient
rehabilitation (6e7wk in this study) to a final knee flexion value at
12 months postsurgery. Based on our data, a mean knee flexion of
110 at 6 to 7 weeks across the entire group does not allow for a
large further increase after this period, until the reported
maximum knee flexion of 120 is reached.9 Further follow-up will
identify this progression and the real importance of the subacute
phase in the attainment of a good long-term active knee ROM.

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Conclusions
Knee ROM after TKA is an important clinical indicator of patient
progress. Given the predictive nature of initial and final outpatient
knee flexion in this study, early identification of problematic patients may be possible as early as the first few weeks after TKA.
Using the expected knee flexion progressions based on presentation at the initial outpatient visit (1e2wk) provided in this study,
the practitioner can assess the patients presentation in the very
early postoperative TKA period and determine their potential
ROM outcomes. This will allow therapists to best educate,
encourage, and reinforce the patient that their progress is (or is
not) progressing at an acceptable rate. It will also allow for the
provision of individualized rehabilitation based on this progress
and provide patients with realistic goals of progression throughout
the subacute phase of the patients rehabilitation. Finally, it permits the early identification of patients at risk of poor long-term
postoperative outcomes that may further benefit from intensive
care or other early intervention.

1140

Supplier
a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

Keywords
Arthroplasty, replacement, knee; Rehabilitation

Corresponding author
Jay R. Ebert, PhD, The School of Sport Science, Exercise and
Health (M408), The University of Western Australia, 35 Stirling
Highway, Crawley, WA 6009, Australia. E-mail address: jay.
ebert@uwa.edu.au.

Acknowledgments
We thank Anne Smith, PhD, for her assistance with statistical
advice and procedures.

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