Precautions After Total Knee Surgery: (Immediate and life-long)

When I first started seeing total knee replacement patients as a physical therapist many years ago, the total knee recipient would have been in the hospital for up to 2 weeks and placed in a knee immobilizer for 6 weeks.

Today the total knee replacement patients I see are all discharged within 2 days of the surgery, and now I’m seeing some total knee replacements done on an outpatient basis and discharged to home on the same day as the surgery.

And none of my patients are ever in any kind of knee immobilizer and are encouraged to move the knee through the tolerated range of motion as soon as the patient is awake after the surgery.

Tip 1: Apply Cold Therapy Before Going To Bed.

All of my total knee surgery patients are using either Ice Packs or Cold Therapy Machines (Amazon affiliate links) multiple times daily to help control pain levels. Applying cold therapy for 40 minutes just before going to bed will reduce your pain while sleeping
See my article: Ice After Total Knee Replacement: A PT’s Complete Guide.

A lot has changed (for the better) over my many years of physical therapy practice.
As a result of this quick mobilization, a lot of total knee replacement patients believe there are no precautions after a total knee replacement surgery.

This is true when comparing knee replacement to hip replacement precautions (dislocation precautions) but it is not true for general precautions.

Most total knee precautions are only for the first 3-4 weeks after surgery, but there are a couple of life-long precautions recommended.

What are the precautions after total knee replacement surgery?

  • Precautions to avoid blood clots.
  • Precautions to avoid infection.
  • Precautions to avoid pneumonia.
  • Precautions to avoid falling.
  • Precautions to avoid overuse.
  • Precautions after full recovery.

Precautions to avoid blood clots

Blood clot formation in the legs after total knee replacement surgery is a serious threat to the patient.

A dislodged blood clot only has three options:

  • Lodge in the heart and cause a heart attack.
  • Lodge in the brain and cause a stroke.
  • Lodge in the lung causing a pulmonary embolism.

That’s why the surgeon takes a three-fold approach to prevent blood clots:

  • The surgeon places the total knee patient on blood thinners.
  • The surgeon places the patient in compression hose.
  • The surgeon asks the physical therapist to teach the patient ankle pumps.

Blood Thinners

I have seen over the years a shift in the protocols for using blood thinners after total knee surgery.

Initially, all the total knee patients I saw were using an injectable blood thinner that the patient would need to self-inject into their stomach daily for about 2 weeks.
Many patients throughout the country still are prescribed injectables for blood thinning.

This injectable precaution has its own precaution: most injectable blood thinners are affected by vitamin K, found dietarily in green leafy vegetables. Generally, the patient is told not to eat dark green leafy vegetables (like spinach).

And once or twice a week the patient will have blood drawn to determine if the injectable blood thinner needs to be increased or decreased.

Because the injectable is being regulated based on lab results, the patient can in fact eat dark green leafy vegetables. But they need to eat them either daily or not eat them at all.

It is only when the dark green leafy vegetables are eaten intermittently that the doctor has difficulty adjusting the blood thinner to the proper dose.

Over the years I have seen the surgeons move to more recently developed blood thinners that are in pill form rather than an injectable. And vitamin K does not interfere with oral medication’s ability to thin the blood so there are no dietary restrictions.

Most recently I am seeing some surgeons prescribing only aspirin to thin the blood.

The bottom line is that blood thinners are still the first line of defense (precaution) against forming blood clots in the legs after total knee surgery.

TED Hose

Ted hose are those white compression hose that are so difficult to put on.

TED hose come in knee-high and thigh-high lengths. I prefer the thigh-high TED hose even though that brings the compression stocking over the surgical site. The surgical site is already protected with bandaging and I have not experienced difficulty with thigh-high TED hose on the total knee patients I see.

The knee-high TED hose tends to roll down at the top (just below the knee) forming a tourniquet-like area at the top of the hose. I just don’t like that, it seems counterproductive to the purpose of the TED hose.

These TED hose are very difficult to put on but this task can be made much easier wearing latex gloves, the gloves improve the ability to grasp the slick hose material better.

Cross legs at ankles
TED Compression Hose

Ankle Pumps

Ankle pumps are also part of the blood clot formation prevention protocol.
Ankle pumps are meant to pump out some of the swelling in the lower leg thereby reducing the internal leg pressure and decreasing the risk of clot formation in the cardiovascular system of the leg.

Swelling comes from fluids outside the cells and blood vessels, collected by the lymphatic circulating system, then transferred back to the cardiovascular circulating system.

The lymphatic system moves fluids by skeletal muscle contraction, such as the big calf muscles.
The cardiovascular system moves fluids by a beating heart.

Unfortunately, I see far too many of my total knee patients in the first three weeks after surgery doing far too few of these exercises, in my opinion.

Commonly patients tell me that when they were in the hospital, they remember someone telling them to do the ankle pumps ten times, a couple times a day.

That’s way too little in my opinion!
We are trying to prevent blood clots from forming because we are not walking enough.

I instruct my patient to do 1 minute of ankle pumps every 90 minutes all day long.

Ankle pumps done correctly are just moving the foot straight up and down, all the way to the end of range of motion, and feeling a good muscle contraction at the end of range.

If my patients are following my instructions, I expect them to tell me they have a little muscle soreness in the front of the shin.

Flying and Blood Clots:
Out of the relatively few blood clots I have seen in my total knee replacement patients, I would guess that 50% of them were the result of the patient taking a long plane trip.

For myself, I would avoid any flying for about 3 months after the surgery.
Even then I would wear the TED compression hose and get my surgeon’s advice on using aspirin to thin my blood before the flight.

Precautions to avoid infection

A research paper in the National Institute of Health states the most devastating complication after a total knee replacement is an infection.

Choosing a surgeon and a hospital with the lowest rate of infection is the patient’s best defense against infection.
See surgeon and hospital infection rates here…..

Once the total knee patient comes home there are precautions that must be taken to decrease the risk of infection:

  • Bandage precautions.
  • Soaking the knee.
  • Skin appearance.
  • Temperature.
  • Dental work.


The bandages must stay clean and dry.

Any staining on the bandage needs to be brought to the surgeon’s or home health nurse or physical therapist’s attention.

For the total knee patients I see in home health, if the bandage is stained, wet, or no longer sealed, I will take a picture and text it to the case manager who then contacts the surgeon to make the decision to have the bandage changed or not.

Most of the total knee patients I see have a water-resistant Mepilex/Optifoam bandage that can come into contact with water (such as a shower) and patted dry.

If the bandaging is questionable, patients are allowed to shower if they wrap their knee with Saran Wrap.
See my article Showering After A Total Knee…..

Saran Wrap TKR picture
Saran-wrapped and ready to shower.

Start below the surgical scar and move upward to above the surgical site. This technique allows the overlap to be pointing downward so it won’t catch any runoff water.

Applying tape around the top of the Saran Wrap will prevent shower water from entering.

Soaking The Knee

Soaking the knee as taking a bath is best avoided until all signs of scabbing are gone and the entire surgical scar is completely sealed with newly epithelialized tissue.

Any scab, even if it is tiny, concerns me as being a possible wick into the depths of the new knee.

Skin Appearance

If an infection is happening, the skin around the surgical site (extending outside the bandage boundaries) will take on a shiny red appearance and will feel slick to the touch.
Commonly, the hair on that skin will be absent.


The shiny red skin will have a slight increase in temperature (above the previously already warm knee). The best way to check this temperature is by using the back of the hand, it is more sensitive to temperature changes than the palm side of the fingers.

General body temperature is sometimes slower to elevate but body temperature 101 degrees Fahrenheit or greater is an indication of infection.

Dental Work

It is advisable to get all the anticipated dental work (including teeth cleaning) done BEFORE the total knee replacement surgery.

Blood-borne germs love to hide and infect the total knee replacement where the metal component meets the bone. It takes about three months for the body to seal this metal-bone interface to decrease the risk of infection.

Usually, no dental work is permitted for three months after a total knee replacement, and even then the dentist may insist on a prophylactic one-time dose of antibiotics given just before the dental procedure.
This includes teeth cleaning.

Precautions to avoid pneumonia

After having been anesthetized during the total knee surgery, along with the pain medications that are being taken, a patient’s breathing pattern is being depressed.

The patient will be breathing much more shallowly for a few days, and with the additional charge of lying down a lot more after the surgery, the lower part of the lungs are not being properly ventilated.

This poor ventilating of the lower part of the lungs sets the patient up for a case of pneumonia.

Using a spirometer 4 -5 times a day can prevent the onset of pneumonia.

But only do about 5 breaths on the spirometer at a time. More breaths than 5 can cause some dizziness and the patient’s balance is already not good.

Precautions to avoid falling

Almost all the total knee replacement patients I see a day or two after surgery are at a high risk of falling as demonstrated using the Timed-Up-And-Go and Tinetti’s standardized tests.

Using a walker is the best first line of defense against falling.

Wearing good non-slip footwear is the second-best line of defense against falling.

Most of my total knee replacement patients move from a high fall risk to low fall risk within 3 weeks without any focused balance training.

Precautions to avoid overuse

There are three kinds of total knee replacement patients that I see:

  • Those that stay in “the lane” and do exactly the rehabilitation program I have outlined for them.
  • Those that are a little apprehensive and I need to push them a little to get them in “the lane”.
  • Those that think that if I said 3, 6 would be better. These are the type “A” personalities and 50% of them will set themselves back 7 – 10 days in their rehabilitation process.

The signs of over-use after a total knee replacement are:

  • Staining on the bandage.
  • Pain that does not go away within 5 minutes of stopping the pain-producing activity (including their physical therapy home program).
190817 TKR medium stain on bandage

Precautions after full recovery

Most total knee patients I see are able to return to their full normal activities of life in 3 – 4 weeks.

Most are able to return to sports in about 4 months after the total knee surgery.

I have had total knee patients return to:

  • Golf.
  • Tennis.
  • Horseback riding.
  • Skiing.
  • And many other sports.

For example, Golf:
At about 3 – 4 weeks I tell the patient they can go to the golf course and practice putting and short distance chipping. Restrict the time to about 15 minutes maximum and increase time as tolerated. There should be no residual pain.

At about 6 – 8 weeks they should be able to go to the driving range to hit balls.
Start with the 5 iron with the ball on a tee and attempt to hit the ball about ½ the distance of their normal 5 iron distance.

Start with just one small bucket and increase the number of balls hit gradually, always respecting the no residual pain longer than 5 minutes rule.

Increase the swing gradually until they can drive the golf ball about as far as they could dive it before surgery.

Once the patient can do a full swing with the 5 iron with no residual pain, they are ready to start running up and down their irons.

Once irons are no longer a problem they can start working with their woods, starting with the shortest wood and working their way up to the driver.

By this time the patient is usually about 4 months post-op and should be able to play golf without restriction, even if their pivot knee is the operated knee.

This same progression principle would apply to almost all sports.

The only activity that should be avoided are activities that require multiple high-impact heel strike activities like jogging.

Final Thoughts:

  • Blood clot formation prevention is critical in the first 3-4 weeks. After that the patient should be walking enough to discontinue those early interventions. However, any long-term static positioning like flying in an airplane, the patient is well advised to wear the compression hose even after full recovery.
  • The first line of defense against infection is starting by choosing a hospital and surgeon with a low infection rate track record.
  • Avoid potential for pneumonia by clearing out the bottom of the lungs regularly in the first 3-4 weeks after surgery.
  • Avoid fall risks with the use of assistive devices as needed.
  • Listen to the new knee, when it’s’ telling you to take a break, take a break.
  • Avoid high impact heel-strike activities and the new knee should last about 30 years.

Read my other articles about Total Knee Replacement

Wishing you an uneventful return to full activity

Paying It Forward

Perhaps you are approaching or already retired and wondering how you could earn extra money in retirement.
One option would be to do as I am doing.
Read my article How To Generate Retirement Income: Cash In On Your Knowledge.

Dr. Robert Donaldson

Dr. Donaldson is dually licensed; physical therapy in 1975 and doctor of chiropractic in 1995. He held credentials of Orthopedic Clinical Specialist in physical therapy for 20 years, QME in California, and taught at USC. He owns and operates an orthopedic physical therapy practice. See "About Me" page.

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