In our last blog post, we talked about the first two weeks after your total knee replacement (TKR). That post included three areas you should address. Those were your environment, pain and exercise. We will now progress our discussion to what you should expect in weeks 3 and 4 after your TKR. These will include exercise and doing activities in and outside the home.
Your Exercise Routine
Hopefully, you have been compliant with the exercise program your physical therapist prescribed. By doing the initial exercises several times a day, you will notice a decrease in pain, an increase in range of motion (ROM) and improved ability to walk. Even if the exercises have not changed I hope that the number of repetitions and resistance has increased. I previously wrote about how I expect patients to progress their home exercise program (HEP). I hope that led to a discussion with your physical therapist.
Around week 3, I would expect your exercises are changing. You should be doing a combination of closed-chain and open-chain exercises. Closed-chain exercises are when your foot is in contact with the ground. An open-chain exercise is when the foot is not in contact with the ground.
A few examples of the closed-chain exercises:
- Sit to stand is doing what the exercise says. Sit in a chair or on the edge of the bed and stand up and sit down.
- Step ups and step downs can be started on a stair of decreased height. This exercise will help you do your stairs every other step. Right now, you are probably doing one step at a time.
- A third closed-chain exercise is single leg balance. When you start with this, you will be holding onto a counter or your walker. This exercise is important because, every time we walk, we are balancing on one leg.
Open-chain exercise are the ones you have been doing and were discussed in my previous blog. You have been doing straight leg raises, short arc quads (SAQs) and quadriceps sets, to name a few. You will continue to do these, but, I expect the repetitions and resistance to increase. There are two main ways to increase the resistance. One would be adding an ankle weight to the exercise. The other would be to use Thera-band or a similar product. I have not found research to back this up, but I would like to see the strength in your surgical leg to be 60% of the other leg by four weeks. Your physical therapist can help you determine what is 60% strength.
Increasing Activity Level Inside and Outside Your Home
One of the most common questions we receive around three weeks post-operation is, “When can I drive?” This is a question your physician will need to answer. However, there are a few factors that can help physicians make the decision. The first is if you are continuing to take your pain medication. As long as you need your pain medication, you should not be driving. The next factor depends on which leg you had surgery on. If you had surgery on your left leg, your physician may clear you to drive sooner. If surgery was on the right leg, you will need to show good strength, ROM and reaction time to be allowed to drive. Your physical therapist can address these areas in the progress note they will be sending to your physician.
If your TKR is progressing with no setbacks, you will be able to start getting out more. The problem with this is that your walker gets in the way. The walker also makes it difficult to get in and out of the car. By performing your HEP and working hard in physical therapy, I expect your physical therapist will be trying to progress you to a cane or nothing by this point. The keys to progressing to a cane or nothing are good strength and control. (Remember the single leg balance exercise we spoke of.)
As patients get more mobile and do more, they often come in and state, “You killed me the last treatment! I was sore, swollen and had a difficult time walking the next day.” What I find happens is totally different. I ask the patient how they felt after the last treatment and they respond, “Good. I had more motion and my pain was down. I was also happy because I progressed off that stupid walker.” My next question is, “What did you do after therapy?” The response is usually, “I felt so good we went out grocery shopping. Then I thought, while we are out, let’s go to dinner and, afterward, we will stop by and see the grandchildren.” As a physical therapist, I am glad when my patients start getting more active. But, there is no need to make up for two weeks of being in the house by doing every activity in one day. That is the reason for your soreness. I often tell my patients, “You do not run a marathon your first day of training. You build up to it.” This is the same with your activities after a TKR.
Remember, this is your rehab. You should be writing your questions down. Understand that this is your appointment and your are in charge. The therapist’s job is to help you attain your goals. Talk to them about your concerns, goals and how to maximize your exercises and time. The goal of having this surgery was to take care of the pain and return you back to the activities you enjoy. If you do not take responsibility for your rehab, who will?
The above information provides general ideas that I hope will allow you, your physician and your physical therapist to develop a custom treatment plan.
Eric O’Brien PT, MS, OCS