Total Knee Replacement (TKR) Rehabilitation Protocol – Clinician Summary
(Fast-track / Robotic-assisted pathways)
Rehabilitation Philosophy
This protocol is criteria-based, function-driven, and biologically informed, designed to optimise recovery following total knee replacement while minimising stiffness, swelling-related inhibition, and maladaptive movement patterns.
Timelines are guides only, progression is dictated by swelling response, strength, movement quality, and functional control, not time alone.
Key Surgical Considerations
Robotic-assisted TKR enables:
Improved implant alignment
More predictable soft-tissue balance
Earlier confidence with functional loading when criteria are met
However, implant accuracy does not replace the need for progressive strengthening and neuromuscular rehabilitation.
Core Rehabilitation Priorities
Early restoration and maintenance of full knee extension
Quadriceps activation and strength as the primary driver of function
Swelling-controlled load progression
Gait quality and movement symmetry
Walking for mobility and confidence, not as a substitute for strengthening
Clinical Governance & Escalation
Persistent effusion, loss of extension, increasing pain, gait regression, or failure to progress functionally warrants targeted load modification and review with the treating surgeon (Dr Lynskey).
Key Principles
Rehabilitation must be individualised based on:
Surgical complexity (primary vs revision)
Pre-operative deformity and stiffness
Baseline quadriceps function
Patient goals and functional demands
Early priorities:
Knee extension
Quadriceps activation
Functional task retraining
Avoid:
Over-reliance on walking volume
Aggressive or forced flexion in the presence of swelling
Movement quality and swelling response govern progression.
Time alone must not be used to justify advancement
Preoperative Phase (Prehabilitation)
Goals
Maximise knee extension
Optimise quadriceps activation
Maintain functional lower-limb strength
Prepare patient for fast-track recovery expectations
Clinical Notes
At least one pre-operative physiotherapy session is recommended
Address:
Fixed flexion deformity
Quadriceps inhibition
Gait aid use and home setup
Education focus:
Early mobilisation expectations
Strength-led rehabilitation philosophy
Expected pain and swelling trajectory
Phase 1 – Early Mobility & Activation (0–2 Weeks)
(Fast-track / robotic TKR aligned)
Goals
Achieve and maintain full knee extension
Reduce swelling and pain
Establish early quadriceps activation
Achieve safe functional mobility (not endurance walking)
Rehabilitation Focus
Immediate active ROM (extension prioritised)
Quadriceps sets and straight leg raises
Heel props and extension stretching
Ankle pumps
NMES to quadriceps if inhibition present
Sit-to-stand practice
Progressive weight bearing as tolerated with gait aid, maintained until quadriceps function and knee control are sufficient to prevent giving-way or compensatory gait patterns
Cryotherapy and elevation
Clinical Emphasis
Short, frequent movement bouts
Avoid prolonged bed rest
Prioritise strength and control over step count
Avoid
Prolonged immobilisation
Routine CPM use
Forced or aggressive flexion
Phase 2 – Early Strength & Gait Normalisation (2–6 Weeks)
Goals
Restore functional ROM
Improve quadriceps strength and endurance
Normalise gait pattern
Build confidence in daily tasks
Rehabilitation Focus
Progressive closed kinetic chain exercises:
Sit-to-stand
Mini-squats
Step-ups and step-downs
Stationary cycling (ROM and conditioning adjunct)
Progressive knee flexion work (bed and seated)
Balance and proprioceptive training
Stair training (rail-assisted initially)
Walking
Encouraged for mobility and confidence
Not used as the primary conditioning stimulus
Monitor Closely
Swelling response to load
Post-exercise pain flare
Gait asymmetry
Phase 3 – Strength & Capacity (6–12 Weeks)
Goals
Build meaningful lower-limb strength
Restore symmetrical movement patterns
Improve functional capacity for ADLs
Rehabilitation Focus
Progressive resistance training:
Squats
Lunges
Step-down control
Hip and core strengthening
Cycling and treadmill walking as conditioning adjuncts
Dynamic balance tasks
Clinical Emphasis
Strength drives function
Endurance walking alone is insufficient
Phase 4 – Advanced Function (3–6+ Months)
Goals
Maximise independence and confidence
Improve tolerance for uneven terrain and prolonged activity
Return to preferred lifestyle and recreational activities
Rehabilitation Focus
Higher-load functional strengthening
Directional control and balance training
Endurance conditioning matched to patient goals
Low-impact recreational conditioning
Return To Activity (Criteria-Based)
Driving
Must demonstrate safe emergency braking, and no opioid / sedating medication usage
Typical guidance:
Right TKR: ~4–6 weeks
Left TKR: ~2–3 weeks (automatic vehicle)
Return to Recreation – Minimum Criteria
Minimal or no effusion
Functional ROM (typically ≥110–120° flexion)
Independent, non-antalgic gait
Confident stair negotiation
Adequate quadriceps strength for repeated sit-to-stand
Encouraged
Walking (recreational)
Cycling
Swimming
Golf
Gym-based low-impact strengthening
Discouraged
Running
Jumping sports
High-impact pivoting activities
Surgical Notes VBJS
Extension and quadriceps strength matter more than distance walked
Swelling is the key limiter — load should not exceed recovery capacity
Robotic-assisted TKR often allows earlier confidence in loading when criteria are met
Modify rehabilitation for:
Revision TKR
Significant pre-operative deformity
Poor baseline quadriceps function
Concerns regarding loss of extension, persistent effusion, or functional stagnation should prompt review with Dr Lynskey
Key Clinical Message
Staying mobile prevents stiffness, but strength training is what restores knee function.
Walking supports recovery, progressive strengthening determines outcomes.
