Physical Therapy Guide to Total Knee Replacement (Arthroplasty)
The knee is the most commonly replaced joint in the body. The decision to have knee replacement surgery is one that you should make in consultation with your orthopedic surgeon and your physical therapist. Usually, total knee replacement surgery is performed when people have:
- Knee joint damage due to osteoarthritis, rheumatoid arthritis, other bone diseases, or fracture that has not responded to more conservative treatment options
- Knee pain or alignment problems in the leg that cause difficulty with walking or performing daily activities, which have not responded to more conservative treatment options
Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To locate a physical therapist in your area, visit Find a PT.
What Is Total Knee Replacement (TKR)?
A total knee replacement, also known as total knee arthroplasty, involves removing the arthritic parts of the bones at the knee joint (the tibia, sometimes called the shin bone; the femur, or thigh bone; and the patella, or kneecap) and replacing them with artificial parts. These parts consist of a metal cap at the end of the femur and a cemented piece of metal in the tibia with a plastic cap on it to allow the surfaces to move smoothly. When appropriate, the back part of the kneecap also may be replaced with a smooth plastic surface.
How Can a Physical Therapist Help?
The physical therapist is an integral part of the team of health care professionals who help people receiving a total knee replacement regain movement and function, and return to daily activities. Your physical therapist can help you prepare for and recover from surgery, and develop an individualized treatment program to get you moving again in the safest and most effective way possible.
The better physical shape you are in before knee replacement surgery, the better your results will be (especially in the short term). A recent study has shown that even 1 visit with a physical therapist prior to surgery can help reduce the need for short-term care after surgery, such as a short stay at a skilled nursing facility, or a home health physical therapy program.
Before surgery, your physical therapist may:
- Teach you exercises to improve the strength and flexibility of the knee joint and surrounding muscles.
- Demonstrate how you will walk with assistance after your operation, and prepare you for the use of an assistive device, such as a walker.
- Discuss precautions and home adaptations with you, such as removing loose accent rugs that could cause you to “catch” your leg on them when maneuvering with an assistive device, or strategically placing a chair so that you can sit instead of squatting to get something out of a low cabinet. It is always easier to make these modifications before you have surgery.
Longer-term adjustments that are recommended prior to surgery include:
- Stopping smoking. Seek assistance or advice from your physician on stopping smoking, as you schedule and plan for your surgery. Being tobacco-free will improve your healing process following surgery.
- Losing weight. Losing excess body weight may help you recover more quickly, and help improve your function and overall results following surgery.
Immediately Following Surgery
You may stay in the hospital for a few days following surgery, or you may even go home on the same day, depending on your condition. If you have other medical conditions, such as diabetes or heart disease, you might need to stay in the hospital or go to a skilled nursing facility for a few days before returning home. While you are in the hospital, a physical therapist will:
- Educate you on applying ice, elevating your leg, and using compression wraps or stockings to control swelling in the knee area and help the incision heal.
- Teach you breathing exercises to help you relax, and show you how to safely get in and out of bed and a chair.
- Show you how to walk with a walker or crutches, and get in and out of a car.
- Help you continue to do the flexibility and strengthening exercises that you learned before your surgery.
As You Begin to Recover
The goal of the first 2 weeks of recovery is to manage pain, decrease swelling, heal the incision, restore normal walking, and initiate exercise. Following those 2 weeks, your physical therapist will tailor your range-of-motion exercises, progressive muscle-strengthening exercises, body awareness and balance training, functional training, and activity-specific training to address your specific goals and get you back to the activities you love!
Range-of-motion exercises. Swelling and pain can make you move your knee less. Your physical therapist can teach you safe and effective exercises to restore movement (range of motion) to your knee, so that you can perform your daily activities.
Strengthening exercises. Weakness of the muscles of the thigh and lower leg could make you need to still use a cane when walking, even after you no longer need a walker or crutches. Your physical therapist can determine which strengthening exercises are right for you.
Body awareness and balance training. Specialized training exercises help your muscles "learn" to respond to changes in your world, such as uneven sidewalks or rocky ground. When you are able to put your full weight on your knee without pain, your physical therapist may add agility exercises (such as turning and changing direction when walking, or making quick stops and starts) and activities using a balance board that challenge your balance and knee control. Your program will be based on the physical therapist’s examination of your knee, on your goals, and on your activity level and general health.
Functional training. When you can walk freely without pain, your physical therapist may begin to add activities that you were doing before your knee pain started to limit you. These might include community-based actions, such as crossing a busy street or getting on and off an escalator. Your program will be based on the physical therapist's examination of your knee, on your goals, and on your activity level and general health.
The timeline for returning to leisure or sports activities varies from person-to-person; your physical therapist will be able to estimate your unique timeline based on your specific condition.
Activity-specific training. Depending on the requirements of your job or the type of sports you play, you might need additional rehabilitation that is tailored to your job activities (such as climbing a ladder) or sport activities (such as swinging a golf club) and the demands that they place on your knee. Your physical therapist can develop an individualized rehabilitation program for you that takes all of these demands into account.
Can This Injury or Condition Be Prevented?
If you have knee pain, you may be able to delay the need for surgery by working with a physical therapist to improve the strength and flexibility of the muscles that support and move the knee. This training could even help you avoid surgery altogether. Participating in an exercise program designed by a physical therapist can be one of your best protections against knee injury. And staying physically active in moderately intense physical activities and controlling your weight through proper diet might help reduce the risk of osteoarthritis of the knee getting worse.
What Kind of Physical Therapist Do I Need?
Although all physical therapists are prepared through education and experience to treat people who have a total knee replacement surgery, you may want to consider:
- A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems
- A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in orthopedic physical therapy, giving the physical therapist advanced knowledge, experience, and skills that may apply to your condition
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist:
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with knee replacements.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence about physical therapist treatment of total knee replacement. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract (summary) of the article or to free access of the entire article, so that you can read it or print out a copy to bring with you when you see your health care provider.
Harmelink KE, Zeegers AV, Hullegie W, et al. Are there prognostic factors for one-year outcome after total knee arthroplasty: a systematic review. J Arthroplasty. 2017 August 1 [Epub ahead of print]. Article Summary in PubMed.
Pua YH, Seah FJ, Poon CL, et al. Age- and sex-based recovery curves to track functional outcomes in older adults with total knee arthroplasty. Age Ageing. 2017 August 30 [Epub ahead of print]. Article Summary in PubMed.
Sobh AH, Siljander MP, Mells AJ, et al. Cost analysis, complications, and discharge disposition associated with simultaneous vs staged bilateral total knee arthroplasty. J Arthroplasty. 2017 September 13 [Epub ahead of print]. Article Summary in PubMed.
Bistolfi A, Zanovello J, Ferracini R, et al. Evaluation of the effectiveness of neuromuscular electrical stimulation after total knee arthroplasty: a meta-analysis. Am J Phys Med Rehabil. 2017 October 7 [Epub ahead of print]. Article Summary in PubMed.
Otero-López A, Beaton-Comulada D. Clinical considerations for the use lower extremity arthroplasty in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):795–810. Article Summary in PubMed.
Loyd BJ, Jennings JM, Judd DL, et al. Influence of hip abductor strength on functional outcomes before and after total knee arthroplasty: post hoc analysis of a randomized controlled trial. Phys Ther. 2017;97(9):896–903. Article Summary in PubMed.
Piva SR, Teixeira PE, Almeida GJ, et al. Contribution of hip abductor strength to physical function in patients with total knee arthroplasty. Phys Ther. 2011;91:225–233. Free Article.
Dowsey MM, Liew D, Choong PF. The economic burden of obesity in primary total knee arthroplasty. Arthritis Care Res (Hoboken). 2011;63(10):1375–1381. Article Summary on PubMed.
Piva SR, Gil AB, Almeida GJ, et al. A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther. 2010;90:880–894. Article Summary in PubMed.
Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Ortho Sports Phys Ther. 2010;40:559–567. Free Article.
Walls RJ, McHugh G, O’Gorman DJ, et al. Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty: a pilot study. BMC Musculoskelet Disord. 2010;11:119. Free Article.
Topp R, Swank AM, Quesada PM, et al. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. PM R. 2009;1:729–735. Article Summary on PubMed.
Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee [published correction appears in: N Engl J Med. 2009;361:2004]. N Engl J Med. 2008;359:1097–1107. Free Article.
Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335:812. Free Article.
Moffet H, Collet JP, Shapiro SH, et al. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2004;85:546–556. Free Article.
Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2000;132:173–181. Free Article.
*PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
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