One of the most common surgical procedures many people go through as we age is a Total Knee Replacement. Although you don’t want to have surgery before you need it, at the right time it can make a big difference to your pain and function. The goals of this surgery are to alleviate joint pain and improve walking or climbing stairs and to help you return to recreational activities. Some people are even able to return to golf and tennis. Once you decide that this is the right procedure for you, how you approach your Total Knee Replacement physiotherapy and understanding the milestones along the way will help get you the best outcome from your surgery.
When is it time to choose total knee replacement surgery?
Most people go through a series of steps before finally deciding on knee replacement surgery for osteoarthritis.
- Step 1 – physiotherapy exercises, mobilization therapies, bracing and medication to control pain and inflammation
- Step 2 – Cortisone injection
- Step 3 – Injection of synthetic joint lubricants i.e. hyaluronic acid, synvisc.
- Step 4 – Total knee replacement (TKR)
After completing any one or all three of these steps a Total Knee Replacement may be indicated. Although experts agree that you do not want to go through this procedure before it is necessary, if the X-ray shows that the joint cartilage is worn away and you are having the following symptoms you may want to meet with an Advanced Practice physiotherapist and/or a surgeon to consider your options.
Symptoms Total Knee Replacement:
- Significant, ongoing joint pain and stiffness
- Difficulty with activities such as walking and climbing stairs
- Sleep disturbance due to pain
What to expect after Total Knee Replacement surgery
Once you have chosen surgery it is important to understand what to expect and what are the normal milestones in recovery. Having the best outcome from this major investment in health is facilitated by knowing what to expect and how to make good decisions. Committing to your therapy after your surgery can make a big difference in restoring function and maintaining physical independence.
Total Knee Components: The top metal piece fits onto the end of the thigh bone and the white plastic piece fits onto the top of the shin.
Routine post op Total Knee Replacement protocol:
Most people can expect to achieve good results by following a routine post-op Total Knee Replacement protocol. These standardized protocols typically begin the day after surgery.
Many hospitals will provide you with a standardized booklet which includes pictures and a description of the exercises to perform. It contains general information on wound care, bathing and swelling control. This is a valuable guide to compliment your recovery in the early stages. If you choose to work with a physiotherapist after your surgery it is helpful to bring this guide to your appointments as it assists in understanding the expectations of the surgeon for your post-op recovery progression.
Often these booklets recommend how many times per day you should do your exercises and how many repetitions. However in the initial stages your ability to exercise can be highly variable and it is important to tailor the intensity and frequency of exercise according to what you can handle. If you are finding the progression too demanding or painful it can be helpful to see a physiotherapist to determine the cause of these symptoms and to adjust the progression based on your individual recovery.
As you continue to progress these standardized protocols often cover what you need to do in the first few weeks but typically do not include more demanding or intense exercises necessary to promote balance and agility in the later stages of rehab. A more intense program is often needed to ensure you complete the full scope of therapy.
Physiotherapy treatment goals after Total Knee Replacement
Immediately after surgery the top physiotherapy priorities are regaining the range of movement in the knee, managing pain and reducing swelling. We also look to make sure you are safe when walking. Early exercise reduces the risk of joint stiffness by limiting the formation of scar tissue. It helps to ensure you return to physical activities. as quickly as possible. The goal is to return you to your everyday activities such as walking without an aid (cane) and climbing stairs confidently by the four to six month mark. For some, return to recreational activity is also a realistic goal including golf or tennis occurring sometime between six to nine months post op.
These goals are achieved by:
- control of pain and swelling through the use of medication, ice, rest and elevation
- early mobilization using an aid such as a walker or canes
- regaining joint flexibility with exercises that incorporate bending and straightening the knee
- strengthening the muscles around the thigh and hips through targeted exercises
- developing a plan for graduated functional activity which incorporates a return to walking and other recreational activities.
Post-op physiotherapy is an essential part of recovery after a total knee replacement. Once discharged from hospital, (day 3-4) continuing with a daily regime of exercise/activity and rest will hasten your recovery. This should be done at home as well as at an out patient clinic where the Physiotherapist can carefully monitor your progress.
Typically you can expect to get your knee flat on the bed and bend it beyond a right angle (90 degrees) by the 4th to 6th week. If you are slow to achieve this milestone a Physiotherapy assessment will help to determine if the treatment should be changed or modified from the standard protocol. It will also help to establish if you need to follow-up more closely with your surgeon. When indicated, the incorporation of carefully applied “hands-on” manual therapy techniques by your Physiotherapist may be just what you need to get back on track.
Around the 6th-8th week, as the tissues continue to heal, the pain and swelling lessen, and joint flexibility is restored, there is a shift in focus to more weight bearing exercises. These include step ups and single leg stands to strengthen not only the thigh but also the hip (“glutes”) and ankle muscles to improve your walking. These exercises also help to improve balance and endurance, essential for walking safely. It is my experience that this end stage in treatment is not always covered with sufficient intensity in the standard protocols and patients need more individual guidance to finish their rehab.
Once flexibility and strength have been restored and you are walking and functioning safely it is important to continue with your exercise program independently. If you wish to return to golf or tennis your program should be tailored to prepare you for these activities. Following up periodically with your physiotherapist every few months can help you maintain your focus on exercise and deal with any issues that may arise as you return to your normal lifestyle.
A patient’s experience:
A recent article in the Washington Post (*Topol, December 4 2016) described one patient’s rehab experience following a total knee replacement. It highlighted the need to tailor treatment when things don’t go according to plan. In this case the treatment followed a routine intensive exercise program post op and yet he didn’t improve. Problems with pain, swelling and stiffness not only continued, they progressively worsened.
The reason for the lack of progress was due to a rare complication of joint surgery, “Arthrofibrosis” (arthro=joint, fibrosis= fibrous) Here, abnormal scar tissue formed around the joint severely limiting movement. Eventually, because of the lack of progress, a different and less aggressive approach to therapy was taken and the movement and his pain improved. This change in approach helped to get his recovery back on track.
In reading this article I was struck by the lack of early recognition that the patient was not progressing normally. It caused me to reflect on what could be learned from this patient’s rehab experience and how these problems could be avoided.
- As a physiotherapist, I consider whether there are other complications which may be slowing progress. These complications may need a change of treatment from the routine exercises. Unless addressed, conditions such as “Arthrofibrosis” or other complications may delay your recovery.
- Although the standard approach will get results for many people, some need a more tailored approach. The addition of manual therapy (hands-on techniques) and a careful analysis of the cause of your pain can get you back on track. Trying to push through the pain is not always the best option.
If you are having the following symptoms post-op consider seeking more individualized physiotherapy:
- Excessive pain
- Excessive swelling
- Difficulty regaining joint flexibility and strength
- Difficulty progressing walking function
Achieving Best Outcomes
Over the last thirty years I have treated countless patients with arthritis of the knee, some of whom have avoided as well as benefitted from joint replacement surgery. My clients have achieved impressive functional recoveries due to advances in surgical technique, better post op pain control and a well tailored, structured rehab protocol of exercise and manual therapy suited to their individual needs. My approach to treating patients after a total knee replacement includes individually tailored exercises, manual therapy and lots of education to help you to return to activity as quickly as possible. Ongoing assessment of progress is essential in the early stages to recognize any abnormal stiffness and to change treatment accordingly.
In the Fall of 2017 I will be giving a free seminar at the clinic covering arthritis of the knee. It will focus on what you can do to prevent and reduce the risk of knee arthritis and promote function. For more information please go to http://orthophysio.com/seminars and check out the entire Orthopaedic Therapy Clinic Seminar series.