Total Knee Replacement Surgery: Care and Rehabilitation

Before you start: Walking correctly is an important part of the knee’s recovery. Start on the day of surgery, once you have no dizziness or nausea. Wear closed, non-slip shoes, and wear the knee immobiliser until you can lift your leg straight up without the knee bending. Stand upright inside the walker frame and share your weight between your hands and your feet.

How to do it:

1. Move the walker one short step forward and make sure all four of its legs are on the ground.
2. Step the operated leg forward with the knee straight so that the heel touches the ground first.
3. As you move forward, put the whole sole of the foot on the ground and take part of your weight through your hands on the walker.
4. Bring the non-operated leg forward, and start the next step by moving the walker forward.

Movement tips: Repeat the order “walker, operated leg, non-operated leg” slowly and at an even rhythm, without rushing. Do not drag your toes along the ground, and to turn, take several small steps rather than pivoting on the operated leg. Signs that you are doing it correctly: your trunk stays upright, both feet are inside the walker frame and the heel touches the ground first. Mild tiredness is normal; sit down between sessions and put your leg up.

Amount, repetitions and progression: In the first days, walk several short times during the day, a little more each day; the aim for the first few weeks is about 30 minutes of walking, 2 to 3 times a day. Once you can stand and walk with the walker for more than 10 minutes without putting your weight on it, it is time for the cane.

Stop immediately if: you feel dizzy, your knee gives way or you feel a sharp pain in the knee; sit down right where you are.

Common mistakes: Pushing the walker too far ahead, hanging on your arms, taking long steps, pivoting on the operated leg, and getting up from a chair by pulling on the walker.

Easier version: Shorten the route, and have someone walk beside you for the first few sessions.

Before you start: This movement helps blood circulation in the leg and is part of preventing blood clots. From the first hours after surgery, start lying on your back or half-sitting, with your calf and heel supported; loosen the bedsheet from around your ankle. No equipment is needed.

How to do it:

1. Keep your thigh and knee still so that only the ankle works.
2. Slowly pull your toes towards your face until you feel a gentle stretch behind the calf.
3. Point your toes away from you, as if you were pressing the accelerator pedal.
4. Repeat this back-and-forth movement at an even rhythm, without jerking.

Movement tips: You can move both ankles together. Do not push extra at the end of the movement, whether up or down, and do not hold your breath. The sign that you are doing it correctly is that your thigh and knee stay still and only the ankle and toes move. Mild calf tiredness is normal and goes after a few moments of rest.

Amount, repetitions and progression: Do it 2 to 3 times every waking hour, for 2 to 3 minutes each time. Keep doing this exercise at home until the swelling in your ankle and calf has gone completely; also do it during long periods of sitting and when travelling.

Stop immediately if: you develop new or increasing calf pain, tightness or swelling, especially in one leg, or shortness of breath; follow the warning-signs section.

Common mistakes: Fast, jerky movement, rotating the whole leg instead of moving the ankle, and holding your breath.

Easier version: Make the movement smaller; even a short ankle movement is better than staying still.

Before you start: A knee that does not straighten fully makes you limp and makes walking tiring. From the first day, lie on your back or sit on the bed, and place a folded towel under the heel only, so that the heel is off the bed and the back of the knee stays completely free.

How to do it:

1. Keep your toes pointing to the ceiling.
2. Tighten the front thigh muscle and try to bring the back of the knee down to the bed.
3. Keep the knee fully straight.
4. Relax the muscle and let the weight of your lower leg gently straighten the knee a little further; then repeat.

Movement tips: The support goes under the heel only, never under the knee. A mild stretch behind the knee is to be expected and should settle a few minutes after you finish. Do not press on the knee with your hand, and do not put a weight on it. The sign that you are doing it correctly is that the gap between the back of the knee and the bed gets smaller day by day.

Amount, repetitions and progression: Hold it straight for 5 to 10 seconds each time and repeat until your thigh is tired; the whole exercise takes about 3 minutes. Do this exercise every day; in the first weeks, full straightening of the knee comes first.

Stop immediately if: you get a sharp pain behind or inside the knee, or your leg tingles.

Common mistakes: Putting the towel under the knee, pressing the knee down with your hand or a weight, and turning the toes outwards.

Easier version: Use a thinner towel, and make each session shorter.

Before you start: The knee has to bend for sitting down, getting up and stairs, and this exercise gently brings that bending back. From the first day, lie on your back on the bed with both legs straight, or sit leaning back; with socks on, your heel slides more easily on the sheet.

How to do it:

1. Slide the heel of the operated leg along the bed towards your buttock so that the knee bends.
2. Pause at the deepest bend at which you still feel only a stretch.
3. Slowly slide the heel forward until the knee is fully straight again.
4. Repeat several times; the kneecap always stays pointing to the ceiling.

Movement tips: Keep the knee in line with your toes, and do not let it fall inwards or outwards. Breathe out as you bend, and do each back-and-forth movement slowly. A stretch at the front of the knee is to be expected and should settle quickly. The sign that you are doing it correctly is that the heel slides along a straight line and your pelvis does not lift off the bed.

Amount, repetitions and progression: Pause for 5 to 10 seconds at the deepest bend and repeat several times, until your leg is tired or the knee bends fully; the whole exercise takes about 2 minutes. Bend a little further each day; if pain or swelling is worse by the next morning, reduce the range and go back to the previous day’s amount.

Stop immediately if: you feel a sharp pain inside the knee instead of a stretch, or the discharge from the wound increases.

Common mistakes: Lifting the pelvis, letting the knee fall inwards, jerky movement and holding the position for a long time in pain.

Easier version: Make the range smaller, or use a towel looped around your ankle to pull your heel gently towards your buttock.

Before you start: The front thigh muscle must be able to hold the knee straight and firm when you walk. Start in the first few days, once you can tighten the front thigh muscle well. Lie on your back on the bed or sit leaning back; bend the non-operated leg and put its sole flat on the bed, and keep the operated leg straight with its toes pointing to the ceiling.

How to do it:

1. Tighten the front thigh muscle of the operated leg so that the knee is fully straight.
2. Lift the leg a few centimetres with the knee straight, no higher than the level of the thigh of the bent leg.
3. Hold the leg up.
4. Lower the leg slowly and relax the muscle.

Movement tips: The knee stays straight throughout the movement; if it bends a little as you lift, the muscle is not ready yet and you need to practise tightening the muscle more. Breathe out as you lift, and lower the leg slowly. Your lower back stays on the bed. Tiredness at the front of the thigh is normal, but joint pain or increased swelling is not.

Amount, repetitions and progression: Hold the leg up for 5 to 10 seconds each time and repeat until your thigh is tired; the whole exercise takes about 3 minutes. Continue this exercise until your thigh strength has fully returned.

Stop immediately if: the knee bends as you lift, your lower back arches or you get a sharp pain inside the knee.

Common mistakes: Lifting the leg before tightening the muscle, letting the knee bend, swinging the leg and holding your breath.

Easier version: For now, only tighten the front thigh muscle, or do not lift the leg as high.

Before you start: Getting up from a chair is one of the things you do most often in a day. Use the safe way of getting up (pushing on the chair’s armrests, never pulling on the walker) every time you stand up from the first day; start repeating it as a group of consecutive repetitions from the third week, once standing with the walker is safe. Choose a sturdy, fairly high chair without wheels and with two armrests, and place the walker in front of you; sit on the edge of the chair with the soles of both feet on the floor and the operated leg slightly further forward.

How to do it:

1. Lean your trunk slightly forward from the hips until your head is above your toes.
2. Push down on the armrests of the chair with your hands and stand up on both legs.
3. Stand fully upright, and then put your hands on the walker.
4. To sit down, step back until you feel the edge of the chair against the back of your legs, take hold of the armrests and sit down slowly.

Movement tips: Both legs should take your weight, and the operated knee should not fall inwards. Breathe out as you stand up, and sit down slowly and with control rather than dropping onto the chair. Never pull on the walker to get up; the walker is for standing, not for pulling yourself up. Thigh tiredness is normal.

Amount, repetitions and progression: Start with one short group of repetitions; the aim is 3 groups each time you exercise, with 15 to 25 repetitions in each group. Do this exercise 5 to 7 days a week. Once the movement is smooth and controlled and both legs are working equally, rely less on your hands and use a lower chair.

Stop immediately if: your knee gives way, you feel dizzy or you get a sharp pain in the knee; sit down.

Common mistakes: Pulling on the walker, dropping onto the chair, tucking your feet under the chair and getting up with the non-operated leg only.

Easier version: Use a higher chair, or put a firm cushion on the chair.

Before you start: When you walk and use stairs, the calf muscles push the body forward with each step. Start once you can stand with light support and put your weight evenly on both legs. Stand at a kitchen counter or a fixed handrail, not at a light chair; keep your feet shoulder-width apart and your knees straight, but do not push them backwards.

How to do it:

1. Put both hands on the support and spread your weight over both feet.
2. Slowly lift both heels off the floor by the same amount.
3. Stay up on your toes.
4. Lower your heels slowly to the floor.

Movement tips: Keep your body upright without swaying forwards and backwards; your weight should be equal on both feet. Breathe out as you rise, and come down slowly. The sign that you are doing it correctly is that both heels rise together and by the same amount. Calf tiredness is normal.

Amount, repetitions and progression: Each time you exercise, do 3 groups, repeating the movement 10 times in each group, staying on your toes for 5 seconds each time. Once you are stronger, do the same exercise on one leg at a time, taking turns with each leg.

Stop immediately if: you lose your balance, your body sways, or a calf cramp does not go away after a few moments of rest.

Common mistakes: Leaning on a light chair, putting your weight on the non-operated leg only, and dropping down suddenly.

Easier version: Do not lift your heels as high, and hold on firmly to the support with both hands.

Before you start: This exercise increases knee bending through the work of the muscles themselves. Start from the third week, once standing with light support is safe. Stand facing a kitchen counter or a fixed handrail and hold on with both hands; keep your weight on the non-operated leg.

How to do it:

1. Keep the thigh of the operated leg straight and beside the other thigh.
2. Slowly bring your heel up towards your buttock so that the knee bends as far as possible.
3. Pause at the deepest bend.
4. Lower the leg slowly until the sole of the foot is back on the floor.

Movement tips: The thigh does not move forward and the pelvis stays level; only the lower leg moves up and down. Breathe calmly and move without swinging the leg. The sign that you are doing it correctly is that the two knees stay side by side and your trunk is upright. A stretch at the front of the knee and tiredness at the back of the thigh are normal.

Amount, repetitions and progression: Each time you exercise, do 3 groups, repeating the movement 10 times in each group, staying at the deepest bend for 5 seconds each time.

Stop immediately if: you lose your balance or feel a sharp pain in the knee.

Common mistakes: Moving the thigh forward, hitching up one side of the pelvis, swinging the leg and leaning on a light chair.

Easier version: Bend the knee less and hold it for a shorter time.

Before you start: When knee bending is progressing slowly on its own, gentle help from your hands moves it forward. From the third week, lie on your back on the bed, loop a long folded towel around the ankle of the operated leg and hold its two ends in your hands.

How to do it:

1. Slide your heel along the bed towards your buttock so that the knee bends.
2. Pull gently on the towel to bend the knee a little further.
3. Pause in this position.
4. Loosen the towel and straighten the leg slowly.

Movement tips: Pull on the towel gently and steadily, not in jerks. The kneecap stays pointing to the ceiling, and the knee does not fall inwards or outwards. Breathe calmly. A stretch at the front of the knee is to be expected and should settle a few minutes after the exercise.

Amount, repetitions and progression: Stay at the deepest bend for 5 to 10 seconds and repeat several times, until your leg is tired; the whole exercise takes about 2 minutes. If the stretch has not settled a few minutes after the exercise, pull less on the towel next time.

Stop immediately if: you feel a sharp pain inside the knee instead of a stretch.

Common mistakes: Pulling the towel suddenly, lifting the pelvis and holding the position for a long time in pain.

Easier version: Pull less on the towel, or do only the heel slides.

Before you start: Going up stairs is both a strength exercise and something you need for life at home. From the first days you use the stairs with the handrail and one cane, with someone beside you, leaving the walker at the bottom or top of the stairs; from the third week, stairs also become part of your daily exercise. Hold the handrail with one hand and the cane with the other, whichever side the handrail is on; the steps should be no higher than the usual height, that is, about 18 centimetres.

How to do it:

1. Stand close to the first step and hold the handrail firmly.
2. Put the non-operated leg on the step above.
3. Push up with the non-operated leg, with help from the handrail, and place the operated leg beside it.
4. Bring the cane up onto the same step as well, and start the next step in the same way.

Movement tips: The rule is: “up with the non-operated leg”. Go up one step at a time, and put both feet on the same step. Keep your trunk upright and do not rush. The sign that you are doing it correctly is that you are always supported by the handrail and the cane, and the operated leg comes up after the non-operated leg.

Amount, repetitions and progression: At the start, 2 to 3 steps are enough, and until the knee’s strength has come back, have someone beside you. Add a few more steps each day. Once you walk without the cane and without a limp, put the other foot on the next step each time, as you did before surgery, and keep holding the handrail.

Stop immediately if: your knee gives way, you lose your balance, you feel dizzy or you get a sharp pain in the knee; hold the handrail firmly, sit down on the step you are on and do not carry on.

Common mistakes: Going up with the operated leg first, letting go of the handrail, taking two steps at once and rushing.

Easier version: Go up and down one step only, with someone standing beside you.

Before you start: Going down stairs is harder for the operated knee than going up. From the first days you come down stairs with the handrail and one cane, with someone beside you, leaving the walker at the bottom or top of the stairs; from the third week, coming down stairs also becomes part of your daily exercise. Stand at the edge of the step, and hold the handrail with one hand and the cane with the other, whichever side the handrail is on.

How to do it:

1. Put the cane in the middle of the step below.
2. Slowly lower the operated leg onto that same step.
3. With help from the handrail and the cane, place the non-operated leg beside it.
4. Start the next step in the same way.

Movement tips: The rule is: “down with the operated leg”. Go down one step at a time, and put both feet on the same step. Control your weight with the handrail and the cane, and do not lean forward. The sign that you are doing it correctly is that the operated leg comes down slowly and with control, and the knee does not fall inwards.

Amount, repetitions and progression: At the start, 2 to 3 steps are enough, and until the knee’s strength has come back, have someone beside you. Add a few more steps each day. Once you walk without the cane and without a limp, put the other foot on the next step down each time, as you did before surgery, and keep holding the handrail.

Stop immediately if: your knee gives way, you lose your balance, you feel dizzy or you get a sharp pain in the knee; hold the handrail firmly, sit down on the step you are on and do not carry on.

Common mistakes: Going down with the non-operated leg first, letting go of the handrail, leaning forward and rushing.

Easier version: Go up and down one step only, with someone standing beside you.