Total Knee Replacement (TKR)
Post-operative Physiotherapy/Hydrotherapy
Pre-operative guidelines
- Restore Full knee range of motion (0-135°)
- Strengthen the Quads, hamstrings and glutes to promote recovery.
- Gait re-education
- Educate Patient on post-op compliance to ensure the best functional outcome
- Home advice: Don’t sit on low seats
Ice and Heat to decrease pain
Avoid uneven surfaces
Wear good/supportive footwear
No Kneeling
No sitting cross-legged
Phase 1: (Post Op Days 1-7)
Frequency: 1-2 times per week
Duration: 6-12 weeks depending on physiotherapy findings
Goals:
- To complete a full assessment in clinic including goals i.e.: returning to work and hobbies to promote specificity of rehab.
- To ensure sufficient pain management.
- To ensure that patient is free from DVT or infection.
- Demonstrate safe and independent transfers from the bed to chair.
- Demonstrate safe and independent ambulation with assistive devise.
- To demonstrate safe use of stairs to mimic their home environment.
- To attain full extension (0°) and 90/100° flexion.
- To demonstrate a safe home exercise program.
- To orientate to pool and treadmill program and given information pack.
- To address secondary problems at the hip, lumbar spine and ankle to promote re-alignment of the musculoskeletal system.
*All Post Op programmes have been carefully formulated to facilitate and promote the normality of tissue to repair throughout the stages of healing:
- Inflammatory phase –Essential component of healing. Starts in first few hours post injury and peaks at 1-3 days, gradually resolving after 2 weeks.
- Proliferation phase –Production of scar (collagen) material. Rapid onset of 24-48 hours and peaks at around 2-3 weeks post injury. (The more vascular the tissue the shorter the time it takes to reach its peak). This phase continues for several months post trauma.
- Remodelling Phase- Results in an organised quality and functional scar which will behave in a similar way. Starts around 1-2 weeks and continues for several months.
Water component (1-2 weeks)
Underwater Treadmill
- Water level at 1000- 1200m to reduce weight bearing by 50%-75%
- Walking slowly encouraging a normal gait.Re-education phase, i.e. heel to toe
- To increase speed of belt to encourage larger stride lengths and full knee extension/ VMO activation.
- Walking slowly with knees high to encourage mobility in hips and knees.
Hydrotherapy Pool
- Walking forward and backwards
- Marching/clap unders
- Walking heel to buttocks
- Walking lunges in comfortable range
- Kickboard hip flexion/extension
- Step lunges
- Step ups
- Semi squats in pain-free range
- Knee flexion/extension with buoyancy aid to promote further range
- Cycling legs under water
- Hip abduction exercises
- Single leg balance with eyes open/closed
- Core stability exercises
Cryotherapy
- 15 mins cryotherapy to be done at the end of each session.
Land component
- Strengthening exercises for Quads/Hamstrings/Glutes/Core
- Stretching exercises for Quads/Hamstrings/Glutes/Core
- Patella mobility
- Scar massage
- Ice for reducing swelling
- Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.
Post-operative 2-6 weeks
GOALS
- Reduce pain and swelling
- Restore mobility to full knee extension (in 2-3 weeks) and to increase knee flexion to 120° by week 5.
- Restore patella mobility
- Fair/good recruitment of vastusmedialis oblique (VMO)
Water component (2-6 weeks)
Underwater Treadmill
- Reduce water level at 900-1000m to increase weight bearing
- To increase speed of belt to encourage increase stride length.
Hydrotherapy Pool
REPEAT OTHER EXERCISES FROM WEEK 1-2
- Sit to stand with weight
- Lunge with weight
- Single leg squat
- Step ups with weight
Cryotherapy
- 15 mins cryotherapy to be done at the end of each session.
Land Based
- Continue with mobilisations techniques
- Stationary bike
- Manual stretching
- Patella mobilisations… all glides
- Balance and Proprioception exercises.
- Encourage home exercises – Stair Quad stretch, Partial squats, Self-mobilisations for knee extension in sitting.
- Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.
Post-Op Weeks 6-10
Goals
- Minimal effusion
- Full active and passive ROM
- Good recruitment of Quads
- Normal reciprocal stair negotiation with/without rail
- Meet Self- management criteria at the end of this phase
Water Component
Underwater Treadmill
- Reduce water level at 600-900 to increase weight bearing depending on progress
- To increase speed of belt to encourage increase stride length
- To start jogging and incorporating interval training for CV fitness and plyometrics
Hydrotherapy Pool
REPEAT OTHER EXERCISES FROM WEEK 2-6
- Walking Lunges with weight or medicine ball with rotations
- Kickboarding exercises with hip flexion/extension
- Lateral Lunges with weight
- Increase height of step ups
- Increase depth of step downs
- Single leg squats
- Challenge balance
Land Based
- Continue strengthening program: Leg Press, Leg extensions, Leg Curls, Shoulder Bridge, Lateral step ups, Step Downs,
- Continue Balance/Proprioception exercises: Rocker board, Walking Lunges
- Cardiovascular exercises: Treadmill walking with an incline and increasing resistance on stationary bike.
- Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.
Discharge Criteria
- Symmetrical hip/ankle active range of movement
- Knee active range of movement 0° to 120°-130° depending on the surgeons expectations
- Minimal to no limitations in patella mobility
- Good recruitment in VMO
- No scar sensitivity
- Normal gait pattern
- 4/5 to 5/5 Quads and hamstrings strength
- A good understanding and performance of their home exercise program
- Failure to Progress
- Failure to Comply
See attachment for illustrations of exercises