TOTAL KNEE REPLACEMENT (T.K.R.

PHYSIOTHERAPY PROTOCOL

PRE-OPERATIVE
Patients should be evaluated prior to surgery, including:
• Assessment of joint range of motion, muscle strength, mobility and
general function
• Respiratory assessment and treatment if necessary
• Explanation of post-operative physiotherapy management,
including respiratory and circulatory exercises
• Teaching patient independence with bed mobility and transfers
• Pre-operative activity and exercise programme to include
quadriceps strengthening – there is evidence that this improves
function post-operatively (McHugh et al, 2008)
• Neuromuscular stimulation (NMT) if appropriate - there is
evidence that this improve quadriceps function pre-operatively
(Walls et al, 2008)
• Education - pre-operative education can reduce anxiety and
improve post-operative outcomes, especially with respect to pain,
functioning and length of hospital stay (McDonald et al, 2007). In
Cappagh this is achieved through attendance at a multi-disciplinary
pre-assessment clinic.

POST-OPERATIVE
• Check operation notes and post-operative physiotherapy and
mobility instructions.

Day 1
• Assess respiratory status and treat if necessary
• Encourage circulatory exercises
• Correct position in bed – knee extended in Robert Jones bandage to
minimise swelling (no pillows under knee). +/- heel raise.
• Review bed transfers mobility

Physiotherapy
January 2009
 • Isometric exercises for quadriceps, hamstrings, gluteals +/- straight
leg raises
• CPM, if appropriate (remove bandages to apply) – there is some
evidence that CPM combined with physiotherapy can produce
small short-term increases in knee flexion, but no evidence that it
influences pain, knee extension, long-term knee flexion,
complications or length of stay (Milne et al, 2003, Grella, 2008)
• Stand and mobilise with frame, if BP well controlled and power
and sensation adequate on non-operated side

Day 2
• Mobilise with frame, encouraging knee flexion in swing phase.
• Continue exercise programme (as day 1), add knee flexion (sliding)
in sitting
• CPM if appropriate
• Ice therapy

Day 3 onwards
• Exercise programme to increase range and strength of affected
knee and maintain range and strength of both lower limbs (open
and closed chain)
• Ice and elevation to control swelling
• Gait: assess and progress – crutches, 1 or 2 sticks as appropriate
• Balance work
• Transfers: assess and progress to restore independence
• Step or stair practice
• Home exercise programme
• Attend Occupational Therapy Education Group when
independently mobile
• Liase with other disciplines and family as necessary
• Refer for convalescence or community services as necessary
• CPM +/- NMT can be helpful with individual patients

Discharge Criteria
• Independent with appropriate walking aid
• Independent with transfers
• Independent on steps/stairs if appropriate
• Effective with home exercise programme
• Able to control swelling with ice
• 0-90° active ROM or expected to achieve this independently

Physiotherapy
January 2009
Criteria for further out-patient follow up with TKR patients
• Poor bend (less than 80º) and not improving and/or
• Poor quads strength (more than 15º lag) and not improving and/or
• Poor gait and/or
• Unusual circumstances e.g. drop foot, poor pain control, severe
swelling, poor comprehension, poor compliance with exercises
If possible, review in Cappagh. If not possible, refer to local outpatient
physiotherapy service.

Expected outcomes at 6 weeks

• Mobilising unaided around house and for increasing distances
outdoors
• Decreasing pain and swelling, though not fully resolved.
• 0º to 110º degrees range of motion.
• Reasonable quadriceps and hamstring strength (4-5/5)
• Beginning to climb stairs normally.
• Able to perform light household activities, such as cooking, light
polishing, sweeping floor.
• Able to swim if desired.
• Able to use ergometer and/or normal bike, if desired.

6-8 weeks onwards

• Review by their surgeon
• Wean off walking aids
• Advised to gradually return to normal activities such as driving,
recreational walking, swimming, sexual activity. All activities
should be within comfortable limits. Patients are invited to contact
their physiotherapist if they have concerns or for advice regarding
their progress.

Expected outcomes at 6 months

1) Mobilising unaided for unlimited distances.
2) No pain or swelling.
3) 0º to 120º degrees range of motion.
4) Good lower limb strength (5/5).
5) Able to manage stairs and slopes easily
6) Able to kneel and do all normal household activities such as
hoovering, washing.

TKR surgery can give dramatic relief from pain and significant
improvement in function BUT it is not a normal knee

Physiotherapy
January 2009
Return to Activities
RED ALERT: Running, jogging, contact sports (soccer, rugby, GAA),
jumping sports and high impact aerobics are considered dangerous
activities that are not allowed after TKR.
ORANGE ALERT: Vigorous walking or hiking, skiing, tennis, repetitive
aerobic step climbing and repetitive lifts of greater than 50lbs are
considered dangerous activities that should be avoided
GREEN: Driving, recreational walking and light hiking, swimming,
recreational cycling, golf and ballroom dancing are all activities that
should be encouraged and introduced gradually after 6-8 weeks.
Klein et al (2007)

References
Grella RJ (2008) Continuous passive motion following total knee
arthroplasty: a useful adjunct to early mobilisation? Physical Therapy
Reviews 2008 aug; 13(4): 269-79
Klein GR, Levine BR, Hozack WJ, Strauss EJ, D’Antonio JA, Macauley
W, Di Cesare PE (2007) Return to athletic activity after total hip
arthroplasty. The Journal of Arthroplasty, 22(2), 2007 pp 171-175
McDonald S, Hetrick S, Green S (2004) Pre-operative education for hip
or knee replacement. Australasian Cochrane Centre, Monash University,
Australia
McHugh G (2008) Pre-operative exercise for patients undergoing total
knee replacement. Department of Orthopaedic Surgery, Cappagh
National Orthopaedic Hospital
Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G,
Tugwell P (2008) Continuous passive motion following total knee
arthroplasty. Cochrane Database of Systemic Reviews 2008 Issue 2
Walls RJ, McHugh G, Moyna NM, O’Byrne JM (2008) Pre-operative
quadriceps femoris neuromuscular electrical stimulation in patients
undergoing total knee arthroplasty. Department of Orthopaedic Surgery,
Cappagh National Orthopaedic Hospital

Physiotherapy
January 2009