My Pre and Post Rehab Program for Total Knee Replacement
Are you facing knee replacement surgery and want to know what to expect? Read my previous blog post “Knee Replacement Surgery: When Life Catches Up To You” for an insider’s view leading up to and after total knee replacement surgery. Curious about rehab? Here’s what I did to get ready for surgery, immediately afterward and in the months that followed my knee replacement.
* Disclaimer: this is not intended as medical advice. You should consult with your doctor or medical provider before adopting any exercise and/or rehab program and to recommend an exercise and/or rehab program that is appropriate for you. All surgeons have their own pre-operative and post-operative protocols which may differ from the one that I followed. The following information is intended only as an example of what you might expect if you are facing total knee replacement surgery.
Pre-hab Is Key
I knew from previous knee surgeries that the stronger I was going into surgery, the easier the rehab process would be post-surgery. During the weeks/months leading up to surgery I made sure I did something every day to improve core strength. Most days this was a Pilates mat workout but it could be whatever exercise modality you prefer which gives you a full-body workout. I recommend full-body because of course you want to work your abdominals (including obliques) but you also need to work your glutes (for stability), back (for core strength and to protect you from low-back strain as you recover) and shoulders (you’ll need shoulder strength to help you transfer from seated to standing and vice versa as well as safely ambulate with crutches or a walker). Be sure to include a combination of exercises for strength, stamina, stability and balance which will be important as you recover from surgery. I also recommend practicing with your crutches or walker before your surgery so that you are comfortable using them after surgery.
In addition to my regular core work, I included a “leg day” at least 2-3 times a week. For this I sought professional help from a physical therapist and strength coach in order to design a program that was suitable for me. With two painful knees (the one I was having replaced and one which was still recovering from ACL surgery), my exercises did not include anything requiring knee flexion beyond 90 degrees and specifically avoided things like squats and lunges. My pre-hab routine included exercises I did regularly and others that my strength coach would add to challenge me and keep things fun. My pre-hab program looked like this:
Routine Exercises:
1) Straight Leg Raises, 3x12 with light ankle weight
2) Hamstring Curls, 3x12 (options include: seated with resistance band, supine with feet on stability ball and rolling ball in/out, seated using weight machine w/ light weight).
3) Wall Ball Squeeze, 3x10 (pressing a small, squishy ball behind thigh as you extend knee in order to contract quad muscle)
4) Side Leg Lifts, 3x12 (lay on side with top leg internally rotated, lift/lower leg).
5) Bridges, 3x12 (semi-supine, press hips up, squeeze glutes, lower and repeat).
6) Heel and Toe Raises, 3x12 (using wall to balance, feet hip distance apart, lift toes towards shins standing on heels/lower, lift/lower heels standing on balls of feet).
7) Crab Walk, 3x20 side steps (with resistance band around feet, assume squat/athletic stance, side step against resistance of band keeping knee alignment).
8) Short Arc Quads, 3x12 (supine, using a foam roller behind and above knee so knee is bent with heel resting on floor, extend knee to lift heel off floor and contract quad).
Options to mix things up:
1) Large resistance loop band - pulling forward against the resistance to work quad strength, walking backwards against resistance to work hamstrings and glutes.
2) Stool on wheels - seated on a stool with wheels, alternating one heel then the other into floor to pull myself down a carpeted hallway which provided resistance in order to work my hamstrings.
3) Pilates Chair - primarily leg-focused exercises using the resistance of the spring loaded pedal including seated footwork, standing single leg pumps, shoulder bridge with feet on the pedal.
4) Pilates Reformer - using footbar for leg strengthening exercises such as footwork, side-lying single leg press, using straps for both symmetrical and asymmetrical leg strengthening exercises.
5) Stability Ball exercises for core strength, stability and leg strength including bridges, leg presses against a wall, plank/prone on ball for glute and hamstring work, using against the wall for wall squats.
6) Glute bands - using resistance bands above knees for shoulder bridges, clam shells, side planks to strengthen glutes.
Post-surgery Rehab (day 1-3* based on discharge/in-home PT)
PT for a TKR starts within hours of your surgery. The goal for the first few weeks is to regain range of motion which means 90 degrees of flexion and full extension (0 degrees). The strengthening exercises you do are really more about getting your muscles to start firing again after surgery and retaining your muscle tone. The real strengthening work comes later on once you’ve started outpatient therapy.
The post-op PT protocol I followed included (5-10 reps each, every hour I was awake):
1) Deep breathing using incentive spirometer (to keep lungs clear while in hospital).
2) Glute contractions - tighten/squeeze buttocks and hold for 5 seconds, then relax.
3) Quad contractions - flex foot and tighten quad muscle while trying to straighten knee and push the back of my knee down into the bed/floor, holding for 5 seconds and then relaxing.
4) Heel slides - working knee flexion by pulling my heel towards my bottom (they provided a sling for this to assist).
5) Ankle pumps - flex and point foot to keep blood/fluid moving.
They also get you up walking with crutches and putting weight into affected leg (partial weight-bearing based on pain tolerance).
In-home Rehab (week 1-3)
Within a day or two of coming home, you should have your first visit from an in-home Physical Therapist. You will likely have in-home PT twice a week for the first 3-4 weeks before being released to outpatient physical therapy. My therapist followed the protocol prescribed by my surgeon which included exercises as well as walking with crutches. The in-home PT program I followed included prone, seated and standing exercises which I did several times each day (recommended 10 reps each, 3 times/day):
Laying on back in bed or on floor:
1) Glute Contractions - tighten/squeeze buttocks and hold for 5 seconds, then relax.
2) Quad Contractions - flex foot and tighten quad muscle while trying to straighten knee and push the back of my knee down into the bed/floor, holding for 5 seconds and then relaxing.
3) Heel Slides - working knee flexion by pulling my heel towards my bottom (they provided a sling for this to assist).
4) Ankle Pumps - flex and point foot to keep blood/fluid moving.
5) Short Arc Quad - using a rolled towel under knee so that knee is bent when heel is resting on bed/floor, lift lower leg and try to straighten knee. Hold 5 seconds then lower heel.
6) Straight Leg Raise - bend unaffected knee so that foot is flat on the bed/floor, straighten affected leg and lift it up (6-12 inches), then lower it down slowly.
7) Passive Extension - place a rolled towel under the heel of affected leg and allow gravity to passively stretch the back of your knee in order to improve extension. Try to rest in this position for 20 minutes.
Seated exercises (in sturdy chair):
1) Hip Flexion - sitting in a chair, place hands under thigh of affected leg and gently lift leg up/lower down. As strength improves, do this without using hands for assistance.
2) Knee Extension - sitting in a chair with knee bent and foot on floor, lift leg and extend the affected knee. Hold for 5 seconds then slowly bend knee lower foot back to floor.
3) Knee Flexion - sitting in a chair, bent affected knee and try to get your foot underneath chair. Gently rock upper body forward over knee with leg in bent position and hold for 5 seconds. Use other leg to gently push affected foot back and increase flexion of affected knee.
Standing exercises (use counter, stable chair or other solid surface for support):
1) Heel Raises - Lift and lower heels, standing on the balls of your feet
2) Hip Flexion - lift affected leg up (forward, towards your chest), bending the knee and bringing it up as high as you can. Hold for 5 seconds then lower.
3) Knee Flexion - bend you affected knee behind you (heel towards bottom) as far as you can. Hold for 5 seconds and then slowly lower.
4) Lateral Leg Lifts - lifting straight leg to the side and slowly lowering (hip abduction and adduction)
5) Knee Lunges on a Step (aka, Stair Stretch) - place the foot of your affected leg on a step 1-3 steps higher than the floor, lean forward and bring your weight over your affected knee trying to gently increase knee flexion. Hold for 5 seconds and then relax.
Walking:
I was instructed to use two crutches (some may opt for a walker to start out) with every step and gradually increase the time/distance I walked over several weeks. My instructions for walking were as follows:
- start by walking daily for 5-10 minutes at a time, 3-4 times per day on even surfaces.
- gradually increase so that by week 6 I was walking 20-30 minutes, 1-2 times per day.
- weight bearing as tolerated on my operated leg until I felt comfortable enough to progress to a single crutch or cane. I practiced on/off throughout the day with a single crutch until I was able to gradually extend the time I was using only one crutch. It took me about ten days to adjust to a single crutch full-time.
Stairs:
I have stairs to deal with in my home so I got lots of practice, which is its own form of exercise! The rules for stairs is the crutches follow you up and lead you down. Be sure crutches are under your arms and firmly placed on the stairs. Going up: step with un-operated leg first, operated leg, then crutches. Going down: crutches first, then your operated leg followed by your un-operated leg.
Outpatient Rehab (weeks 4-16)
Starting outpatient PT included treatment (scar manipulation, stretching and end-range flexion/extension with assistance). This was followed by a warm-up on a stationary bike, practice walking up and down a hallway and drills such as walking backwards to help improve my gait, followed by strengthening exercises. My routine exercises were:
1) Quad sets, 3 sets of 10 with 5 second hold.
2) Straight Leg Raises, 3 sets of 10, both legs (gradually adding light ankle weights).
3) Side-lying Lateral Leg Lifts, 3 sets of 10, both sides (gradually adding light ankle weights).
4) Glute Bridges, 3 sets of 10
5) Clam Shells - side-lying with knees bent, keep heels together and lift top knee up/lower down, 3 sets of 10, both sides.
6) Standing Heel Raises, 3 sets of 10
7) Standing Single Leg Hip Hinge, 3 sets of 10, both legs - standing on one leg, hinge at waist, lowering chest ideally to parallel with floor as other leg lifts and reaches behind you, also parallel to floor ideally. Slowly lower leg as your upper body returns to vertical. Gradually added a 10-pound dumb bell weight, holding one end with both hands.
8) Straight Leg Kick Backs using a resistance band attached to stationary object and other end looped around ankle. Stand on one leg and press other leg straight behind. 3 sets of 10 reps, both legs.
After several weeks, as my range of motion increased and my pain and swelling decreased, I added the following exercises:
1) Wall Squats - these can be done with your back against the wall or using a large stability ball between your back and the wall. Ideally you squat as low as you can tolerate pain-wise and hold the squat for 20-60 seconds. I repeated this 5-8 times.
2) Short Arc Quad Sets - using a foam roller behind my thigh, just above my knee, knee bent with heel resting on table/floor where you are seated. Lift the leg and straighten, extending the knee and contracting the quad. Hold for 5 seconds and slowly lower. Repeat 3 sets of 10 reps. I gradually added light ankle weights.
3) Hamstring Curls - seated using a stationary weight machine which has weighted plates attached to a pulley system which is then attached to your ankle with a loop so that you pull your heel back under your seat to lift the weight and then slowly extend your leg to lower the weight. I also did this seated with a resistance band attached to a stationary object and looped around my ankle.
4) Raised Slant Board - standing on a raised, slanted foot stool so your toes are lower than your heels, stepping off the board with one foot (heel landing first) and then stepping back with same foot so that you are working the leg that stays on the slant board. This increases quad strength and improves gait and ability to go one-over going down stairs.
5) Straight Leg Deadlifts with dumbbells, barbell or hex bar - hinging forward with flat back and not squatting, 3 sets of 10 reps.
Pilates for Rehab:
I started with a few Pilates mat exercises from my hospital bed and continued this practice once I was home. The exercises included: Hundred (with legs down), Half Roll Back and/or Roll Ups, Spine Stretch Forward and Saw. These can all be done with little/no strain on your operated leg so they are my go-to after any knee surgery.
After about 4-5 weeks as my pain and swelling improved, I added my Pilates Chair and the leg exercise “Footwork” (in parallel foot position on one spring). I found the chair to be a great way to work on flexion and preferred it to doing stair stretches or trying to manually pull my heel to my bottom.
I did the following Pilates exercises (using Pilates apparatus as noted) on a daily basis from week 5 until I was released to full activity at 3 months post-surgery:
1) 8 -10 reps each position on the Pilates Foot Corrector
2) 8-10 heel raises/tendon stretch on the Pilates 2x4
3) 8-10 reps each position of Footwork on my Pilates Wunda Chair (using a light spring setting which I gradually increased over time).
This routine helped to improve my strength and confidence and made walking easier. As a result, I was able to increase my daily walks from 1/2 mile at a time to a mile or more. By week 8 I was walking 2 miles at one time and repeated that twice a day so that I was walking between 4-5 miles a day by week 10.
After 3 months/Release to Full Activity:
Once I was released to return to full activity I continued a regular program of leg strengthening with some of the exercises outlined above. I also increased my daily Pilates mat work until I was able to do all of the mat exercises within 6 months of my surgery. I added regular Reformer workouts (2-3 times per week), making modifications to spring tension as necessary and taking care not to force any exercises until I felt strong enough to handle them. I’ve continued a daily walking and/or spin cycle routine and also swim when warm weather allows. I’ve found movement truly is the best medicine so I try to do something every day to keep the joint mobile and strengthen the muscles that support me.
