Download Total Knee replacement Protocol

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 vastus medialis 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