Total Knee & Hip Replacement | Age In Place School

As a physical therapist having seen total knee replacement patients for decades including bedside immediately after surgery, in the patients home after surgery, and finally in my own orthopedic outpatient physical therapy office for the patient’s final phase of rehabilitation, one thing clearly stands out to me. Of all the exercises necessary for a total knee replacement’s complete rehabilitation to the patient’s highest ability, the only exercise that is consistently there from day one of knee rehabilitation to the day the patient reaches their final goals is walking! Studies have shown a walking program after a total knee replacement surgery is very beneficial.See research article here….. One would think that “walking” would be a natural activity and patients would not need any instructions, but they would be wrong. There is much to learn about walking after a total knee replacement. That's my job, that's part of what I do as a home health physical therapist.See About me page….. Can you walk too much after knee replacement surgery? A total knee replacement patient can walk too much, especially early in the rehabilitation plan of care.The determining factors are pain lasting more than 5 minutes after stopping walking and any staining on the bandage.Both factors are early signs of doing too much. Following a progressive walking program, and using the following information to assure normal gait patterns, should allow the total knee replacement recipient to return to unlimited walking based on the patient’s overall conditioning instead of the total knee being the limiting factor. Pain lasting more than 5 minutes after stopping the activity: Prolonged pain after walking is certainly an indicator the patient has walked too far. This same principle applies to ALL activities the patient may engage in with their normal activities of living. This would include such things as standing at the kitchen sink doing dishes, cleaning, even standing at the sink brushing their teeth or shaving. The point is, let residual pain be the guide.If it hurts a little while doing the activity, but the pain goes away within 5 minutes of sitting down and putting the knee at rest, then that activity is probably alright for the patient to do. The same applies to the patient’s rehabilitation program designed by their physical therapist.And since walking is part of the physical therapy plan of care, it seems important to point out the 5-minute residual pain rule applies to physical therapy exercises as well. Staining on the bandage: Any staining on the bandage is an indicator the patient is too active. I see patients in their home a couple days after the total knee surgery. Patients still have their surgical incision covered with a Mepilex/Optifoam bandage, a thin absorbent stick-free pad with an adhesive layer that seals the pad and surgical site from moderate water exposure, such as in a shower. On the Mepilex/Optifoam bandage, the first sign of staining (blood spot) can be just a small spot even smaller than a pencil eraser If the spot is not large enough to warrant a bandage change, draw a circle around the outer edge of the stain spot and watch it over time to see if it is getting bigger. When I see the first sign of bandage stains I immediately take a picture of the stained bandage and text it to the physician. The physician makes the decision if the bandage needs to be changed or not, and if yes, they dispatch a nurse to change the bandage. About 10-15% of referring doctors prefer the older technique of dry sterile pads taped in place over the surgical site. A dry sterile gauze pad bandage seems to be a bit more absorbent and minor staining frequently does not show up on the surface of the bandage as quickly as on a Mepilex/Optifoam bandage. Because of the thickness of the gauze padding, it is not unusual for the bleeding to be non-visible until a more significant bleed happens. I personally prefer the Mepilex/Optifoam bandage. Length of time bandage stays on the surgical site: Different doctors have different protocols for surgical wound cleaning and bandaging. How the surgical site was closed can make a difference in how long a total knee replacement surgery bandage is left in place. I receive some referrals from an orthopedic surgeon that has the lowest documented infection rate in the entire United States Of America. He closes the surgical site with biological glue and steristrips and then applies a Mepilex/Optifoam bandage over the top to make it water-resistant. The bandage is then removed on day 7. Counting the day of the surgery as day one. Other referring doctors don’t remove the bandage until the follow-up visit with the surgeon. Follow-up visits for patients I see are generally 3-4 weeks post-surgery. How far should a total knee replacement patient walk? A new total knee patient should establish an initial base-line of endurance with a walker, progress to 1,320 feet as tolerated, abandon the walker, re-establish a base-line without any device, and progress to 1,320 feet as tolerated.This protocol should take about 3 weeks. This is how I progress my patient’s walking tolerance: I do not transition my patients from walker to a cane, I progress them from a walker to nothing! Canes As a betting man, I would bet that every total knee replacement patient I see had a limp before surgery. A cane will cause the patient to walk with that same limp pattern and a cane will reinforce the old bad motor memory of walking with a limp. My patients don’t have pain on weight-bearing on the new knee, so the use of a walker is mostly about balance and confidence levels. If my patient feels uncomfortable transitioning from a walker to nothing, I will recommend they use a walking stick instead of a cane (there is always a walking stick in my car). It's that third point of reference feedback from the walking stick the patient is looking for, not the ability to decrease weight-bearing. Why does walking with a total knee need physical therapy instructions? Improper gait patterns after total knee replacement can alter the patient’s outcomes and cause suboptimal results.Additionally, some walking abnormalities after TKR can wear the knee replacements out more quickly. Physical therapists are highly trained in gait patterns, starting with understanding what the wide range of normal looks like, and moving on into more complex subtle changes that cause deviation from normal patterns to modified patterns. These modified changes in gait can cause damage over time.Hence they are called abnormal gait patterns. Patients are not usually aware of their abnormal gait patterns because they cannot see themselves as they walk, and they perceive themselves to be walking normally. In the outpatient physical therapy setting, there will be large sheets of mirrors for the patient to be able to visualize themselves as they correct abnormal movement. In the home setting that tool is not available, so I frequently will use my smartphone to videotape my patient walking, then review the video with my patient. This usually helps the patient re-adjust their preception of correct posture and gait techniques and, consequently, helps them adjust their gait pattern towards normal. What gait abnormalities are common after total knee replacement? Wide-based gait pattern.Step-to gait pattern.Decreased knee flexion in the swing phase of gait.Discontinuous step pattern.Poor heel-strike.Decreased weight-bearing in the stance phase of gait.Poor push-off at foot lift. Wide-Based Gait Pattern: Wide-Based gait is considered an abnormality of gait. Using the Tinetti Test of fall risk, the gold standard test in the industry, a wide-based gait pattern is considered any gait pattern that causes the ankles to swing by each more than a couple of inches apart from each other as they pass. Wide-based gait patterns are caused by two things: Old motor memory.Lack of proprioception feedback from the surgical knee. Motor Memory: I work hard to break my patient's old motor memory gait patterns, that is why I try never to use a cane as a transitional tool to a normal gait pattern without a device. A walker corrects almost all old motor memory patterns and re-trains the gait pattern to an acceptable pattern within the normal range. Occasionally the old motor memory is very persistent and additional techniques, as well as additional verbal and tactile cues, are necessary to get rid of these old habits of gait. Proprioception: Proprioception is the body's feedback system that tells the brain where every joint in the body is in space. That's how a person can tell they have their hand in a claw position behind their back without being able to see the joints of the hand. The brain is more interested in where that joint is in space, even more than the amount of pain that joint is feeling.It does not want you to fall down! That’s why when a person hits their finger with a hammer, shaking the hand vigorously helps reduce the pain. The proprioceptors simply override the pain receptors so the brain concentrates less on the pain signals it is receiving. Primary proprioceptors are located in the cartilage within the joints. Secondary proprioceptors are located in muscles, ligaments, tendons. The total knee replacement patient has no cartilage in the new total knee, it has been replaced with man-made materials, therefore the brain is not receiving joint position information from that knee as quickly as it was when the proprioceptors were still in the cartridge. What this means for the patient is that they could be far enough off-balance before the brain recognizes they are off-balance to be able to save themselves from falling. This is what the patient instinctively knows, and this is why the patient is walking with a wide-base of support. It's just more stable. With training, in a couple of weeks the secondary proprioceptors in the muscles and ligaments around the total knee will become just as fast as the old primary proprioceptors that were in the knee cartilage, and the wide-based gait will return to the patient’s optimal pattern. Step-to gait pattern: Step-to gait is considered an abnormality of gait. Most patients I see on the first home visit after total knee replacement are pushing the walker forward, stepping into the walker with the operated leg, placing weight on their hands on the walker, then bringing the non-operated leg into the walker to the same level as the operated leg. They do not step-through the operated leg, they step-to the operated leg so the toes are at the same level on the floor. I immediately start correcting this step-to pattern and replacing it with a step-through pattern by having the patient push the walker forward, step into the walker with the operated leg BUT ONLY ½ WAY, then the non-operated leg is brought forward past the operated leg so that the step lengths are equal. This step-to abnormal gait pattern is usually the result of apprehension about weight bearing on the operated knee, not knee pain. Once the apprehension is overcome most of my patients tell me the normal gait pattern is more comfortable and secure than the step-to gait pattern. Decreased knee flexion in swing-phase of gait: Decreased knee flexion in swing-phase in the gait pattern is considered an abnormality of gait. A total knee replacement patient must bend their knee in the swing-phase of gait so that they can clear their toes from the floor as the leg moves forward. If the toe does not clear the floor in swing-phase, it becomes a huge fall risk from catching the toe on a rug or door jam that trips the patient. The patient without enough knee flexion to clear the toes from the floor in swing-phase will adopt the abnormal gait pattern of circumduction. Circumduction means the patient will swing the operated out to the side in swing-phase to gain the height needed to clear the toes from the floor. Instead of bringing the leg straight forward and bending the knee, the patient pushes the leg out to the side a little and swings the leg through without bending the knee (or at least not bending it much). This circumduction is frequently unrecognized by the untrained eye but the caretaker can usually tell me “something just doesn’t look right”. I will correct this abnormal gait pattern early by having the patient “prance like a horse” while they are walking with the walker.When they prance like a horse, they unconsciously bend the knee enough to clear the floor without even thinking about bending the knee. Discontinuous step pattern: Discontinuous steps are considered an abnormality of gait. Discontinuity of steps simply means there is a hesitation between step sets (two steps). The patient will step forward with one leg, usually the operated leg, then steps-through with the other leg in a normal pattern, but at this point, there is a hesitation about bringing the first foot forward again. This usually only happens when a patient is using a walker. I correct this abnormality even before the patient starts walking without the walker by encouraging the patient to keep the walker continuously moving forward instead of moving it forward, stopping the walker, stepping into the walker, then advancing the walker again. The reason most of my patients adopt this gait pattern has to do with their apprehension about putting full weight on the new total knee. Once they realize the knee will take a lot more weight than they thought, they become a lot more confident in their ability to trust the knee. Poor heel-strike: Poor or no heel strike is considered an abnormality of gait I do not often see the gait abnormality of a poor heel strike or no heel strike (patient places the entire foot on the ground at the point of floor contact) in patients that have had a total knee replacement. This gait pattern is more commonly seen in neurological conditions such as a stroke. Decreased weight-bearing in stance-phase of gait: Decreased weight-bearing in stance-phase is considered an abnormality of gait. Total knee replacement surgical components are fully capable of full weight-bearing once the patient wakes up after the surgery. However, most of my patients do not feel confident with full weight-bearing after surgery because of apprehension and balance, not because weight-bearing causes pain. Often I will include weight shifting onto the total knee replacement leg while standing at the kitchen counter as an exercise for my more apprehensive patients. My patients, over about 7-10 days have gained enough confidence and balance to start walking without any device at all. Well, at least for short distances. By the end of 3 weeks, I expect my patients to be walking ¼ mile without any device.Maybe 2 out of a 100 can’t quite get there. Poor push-off at foot lift: Poor push off is considered an abnormality of gait. Poor push-off is usually the result of the patient not being able to bend the knee enough to clear the floor, so what I see is the patient having a little “twist” in the front of the foot in push-off preparing it for the circumduction that is to follow. I typically do not see poor push-off in total knee replacement patients with adequate knee flexion to clear the toes from the floor. Happy Pain-Free Walking See My Related Total Knee Articles For Additional Information: Best Exercises To PREPARE For Total Knee SurgeryPrecautions After Total Knee Surgery: (Immediate and life-long)TENS After Total Knee Surgery: (A PT’s Settings & Pad Placement)Showering After a Total Knee Replacement: An OT’s RecommendationsA PT’s Total Knee Pain Expectations; (Day 1 through Day 30)Total Knee Replacement Manipulation: (When & Why To Consider)Total Knee Replacement Outcomes After Home Physical TherapyPain Control After Total Knee Surgery: (A Complete Guide)Sleep Through Night After Total Knee Surgery: (Dos And Don’ts)Walking After A Total Knee Replacement: (When and How Much?)Knee Pain After Total Knee Surgery: A Physical Therapist’s ViewIce After Total Knee Replacement: A PT’s Complete Guide Paying It Forward