Recommended Physiotherapy Activities After Knee Replacement Surgery
Immediate knee mobilization and strength/neuromuscular training should be the foundation of any rehabilitation program after knee replacement surgery. 1
Early Postoperative Phase (First Week)
- Begin isometric quadriceps exercises in the first week to reactivate the quadriceps muscles, provided they cause no pain 1
- Implement immediate weight bearing with correct gait pattern (using crutches if necessary) with no pain, effusion or increase in temperature 1
- Apply cryotherapy in the first postoperative week to reduce pain 1
- Start immediate knee mobilization within the first week to increase joint range of motion, reduce knee pain and prevent complications like extension deficit 1
- Consider neuromuscular electrical stimulation (NMES) as an addition to isometric strength training for re-educating voluntary contraction of the quadriceps muscles 1
Weeks 2-4
- Begin closed kinetic chain (CKC) exercises from week 2 postoperative 1
- Progress from isometric exercises to concentric and eccentric exercises when the quadriceps is reactivated and the knee doesn't react with effusion or increased pain 1
- Continue supervised rehabilitation with a physiotherapist, though home-based rehabilitation may be suitable for highly motivated patients 1
- Incorporate pedaling-based exercises, which have shown superior outcomes in the early postoperative period compared to non-pedaling protocols 2
Weeks 4-8
- Start open kinetic chain (OKC) exercises from week 4 postoperative in a restricted range of motion (ROM) of 90–45° 1
- For bone-patellar tendon-bone (BPTB) grafts, extra resistance is allowed at this stage 1
- For hamstring (HS) grafts, avoid adding extra weight in the first 12 weeks to prevent graft elongation 1
- Gradually increase ROM in OKC exercises: to 90–30° in week 5, to 90–20° in week 6, to 90–10° in week 7, and to full ROM in week 8 1
Beyond 8 Weeks
- Add neuromuscular training to strength training to optimize self-reported outcomes and prevent reinjuries 1
- Continue rehabilitation for 9–12 months, depending on the final return-to-work or play goals 1
- Measure quadriceps and hamstring strength regularly to track progress 1
- Evaluate psychological changes during rehabilitation using objective instruments 1
Assessment and Return to Activities
- Perform an extensive test battery for quantity and quality of movement before returning to sports or demanding activities 1
- Include strength tests, hop tests, and quality of movement assessments 1
- Use a Limb Symmetry Index (LSI) of >90% as a cut-off point for general activities 1
- For pivoting/contact sports, aim for an LSI of 100% 1
Delivery Methods
- Both individual and group physiotherapy sessions can provide similar outcomes 3
- Home-based physiotherapy may be as effective as outpatient clinic-based therapy for motivated patients 1, 4
- Supervised rehabilitation should be continued for optimal outcomes, especially for complex cases 1
Special Considerations
- Avoid continuous passive motion as it is not recommended by most guidelines 1
- Postoperative functional bracing is generally not recommended 1
- Consider aquatic therapy as an alternative for strengthening exercises 5
- A pedaling-based protocol has shown superior outcomes compared to standard multi-exercise protocols in the immediate postoperative period 2
Common Pitfalls to Avoid
- Delaying mobilization can lead to stiffness and extension deficits 1
- Failing to address quadriceps strength deficits can significantly impact long-term functional outcomes 1
- Progressing too quickly with open kinetic chain exercises with hamstring grafts can lead to graft elongation 1
- Neglecting neuromuscular training alongside strength training increases risk of reinjury 1
- Discontinuing rehabilitation too early (before 9-12 months) may compromise optimal functional recovery 1