Total Knee Arthroplasty Rehab Protocol

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The intent of this protocol is to provide the clinician with a guideline for the post-operative rehabilitation course of a patient that has undergone a total knee arthroplasty. It is by no means a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course based on their physical exam/findings, individual progress, and/or the presence of post-operative complications. If a clinician requires assistance in the progression of a post-operative patient they should consult with the referring surgeon.

GENERAL GUIDELINES:

• Focus on protection of surgical site.
• Individualized gradual progression of therapy to promote optimal level of functional independence
• Supervised physical therapy takes place for 3-6 months.

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING (ADLs)

• No bathing/showering of surgical site until after suture removal (about 2 weeks)
• Driving: Return within 12 weeks of surgery, average around 4 weeks
• Weight-bearing as tolerated immediately post-op if no complications
• Wean from walker/rollator/cane or return to prior level of function for ambulation as treatment progresses 
• Return to normal daily activities/work as directed by PT/MD based on demands and goals.

Rehabilitation Progression

PHASE I: Week 0 – 6:

Goals:

• Protection of surgical site
• Improving safety with mobilization and transfers
• Decrease pain and inflammation
• Restore knee range of motion
• Promote optimal quadriceps contraction
• Prevent muscle atrophy
• Muscle re-education and motor control of post-op leg
• Educate patient on weight bearing status
• Normalize gait, gradual ween off of assistive device 
• Gradual progression of exercises to improve strength
• Initiate home exercise program of aerobic and light resistance training

Precautions:

• Avoid prolonged sitting
• Monitor wound healing for signs and symptoms of infection
• Monitor for increased edema

Weight Bearing Status:

• Weight bearing as tolerated (WBAT) with walker or cane

Exercises:

• Gait training
• Ankle pumps
• Heel slides
• Straight leg raise
• Short arc quads
• Long arc quads
• Glute sets
• Weight shifts
• Mini-squats
• Forward, retro and lateral step downs
• Heel and toe raises
• Progressive hip abduction strength
• Core stabilization progression

Criteria to advance:

• No signs of infection
• Demonstrate adequate quad set and straight leg raise with no knee lag
• Tolerable pain if any with exercises

PHASE II: Weeks 6-9:

Goals:

• Protect surgical site
• Normal gait with no assistive device or prior assistive device
• Stair navigation with reciprocal gait with or without railing
• Improve dynamic and static balance 
• Continue progressive home exercise program
• Restore functional knee strength
• Promote optimal knee range of motion

Precautions:

• Avoid prolonged sitting

Weight Bearing Status:

• Weight bearing as tolerated (WBAT)

Exercises:

• Continue prior exercises as needed with increased range of motion and intensity
• Dynamic balance activities
• Advanced open and closed knee strengthening

Phase III:  Week 9 to 12):

Goals:

• Symmetrical knee ROM
• Able to tolerate 20 minute walk
• Up/down stairs without railing
• Knee strength at functional level
• Adequate range of motion for ADL’s, gait and recreational activities
• Able to resume normal lifestyle without limitations in pain or weakness
• Progress home exercise program

Exercises:

• Progression of prior phase
• Advanced static and dynamic balance activities
• Include individualized recreational/ADL/work specific exercises

Phase IV:  3 to 6 Months:

Goals:

• Resume normal lifestyle of work, ADL’s and recreation
• Individualized progression of exercises based on patient’s goals
• Patient independent with home exercise program for continued improvements of strength, balance and cardiovascular exercise
• Maintain cardiovascular stamina and knee strength
• Maintain balance to prevent falls

Exercises:

• Progression of previous phase
• Higher level recreation/ADL/work specific exercises