Total knee replacement rehab protocol

• All times are to be considered approximate, with actual progression based upon clinical presentation.
• Patients are weight bearing as tolerated with the use of crutches, a walker or a cane to assist walking until they are able to demonstrate good walking mechanics, then full weight bearing.
• Early emphasis is on achieving full extension equal to the opposite leg as soon as able.
• No passive or active flexion range of motion greater than 90 degrees until stitches are removed.
• Regular manual treatment should be conducted to the patella and all incisions so they remain mobile.
• Early exercises should focus on recruitment proper quadriceps set.
• No resisted leg extension machines (isotonic or isokinetic) at any point in the rehab process.

Week 1

• M.D./nurse visit after hospital discharge to change dressing and review home exercise program.
• Icing, elevation, and aggressive edema control (i.e. circumferential massage, compressive wraps).

Manual

• Soft tissue treatments and gentle mobilization to the posterior musculature, patella, and incisions to avoid flexion or patella contracture.

Exercises

• Initiate quadriceps/ gluteal sets, gait training, balance/ proprioception exercises.
• Straight leg raise exercises with proper quad set (standing and seated).
• Passive and active range of motion exercises.
• Well leg cycling and upper body conditioning.

Goals

• Decrease pain and edema.
• Range of motion <90 degrees (until stitches removed).

Weeks 2 - 4

• Nurse visit at 14 days for stitch removal and check-up.

Manual

• Continue with soft tissue treatments and gentle mobilization to the posterior musculature, patella, and incisions to avoid flexion or patella contracture.

Exercises

• Continue with home program, progress flexion range of motion, gait training, soft tissue treatments, and balance/proprioception exercises.
• Incorporate functional exercises as able (i.e. seated/standing marching, , hamstring carpet drags, hip/gluteal exercises, and core stabilization exercises).
• Aerobic exercise as tolerated (i.e. bilateral stationary cycling as able, upper body ergometer)

Goals

• Decreased pain and edema.
• Range of motion < 10 degrees extension to 100 degrees.

Weeks 4 - 6

• M.D. visit at 4 weeks.

Manual

• Soft tissue treatments and gentle mobilization to the posterior musculature, patella, and incisions to avoid flexion or patella contracture.

Exercises

• Increase the intensity of functional exercises (i.e. progress to walking outside, introducing weight machines as able).
• Continue balance/proprioception exercises (i.e. heel-to-toe walking, assisted single leg balance).
• Pool work outs once incisions completely closed.

Goals

• Gait without a limp.
• Range of motion < 5 degrees extension to 110 degrees.

Week 6 - 8

Manual

• Continue soft tissue treatments, joint mobilizations, patellar glides to increase range of motion.

Exercises

• Add lateral training exercises (i.e. lateral steps, lateral step-ups, step overs) as able.
• Incorporate single leg exercises as able (eccentric focus early on).

Goals

• Patients should be walking without a limp.
• Range of motion should be 0 to 115 degrees.

Weeks 8 - 12

Manual

• Continue soft tissue treatments, joint mobilizations, patellar glides to increase range of motion.

Exercises

• Begin to incorporate activity specific training (i.e. household chores, gardening, sporting activities).
• Low impact activities until week 12.
• No twisting, pivoting until after week 12.
• Patients should be weaned into a home/gym program with emphasis on their particular activity/sport.

Goals

• Range of motion with-in functional limits.
• Return to all functional activities.