Walking After A Total Knee Replacement: (When and How Much?)

As a physical therapist, having progressed hundreds of total knee replacement patients through the first 3 weeks after surgery, walking endurance is one primary focus of the patient’s rehabilitation program.

Out of all the exercises a human being can do, walking is the best overall exercise that will return the best benefits for the time and effort invested.

That includes everyone of all ages, including total knee replacement patients.

Research shows that total knee replacement patients have a significant increase in tolerance of the number of times they are willing to get up and walk short distances.
See Research Article…..

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.

How soon after Total Knee Replacement will I be able to walk?

A new total knee replacement recipient will be walking with a physical therapist in the hospital the day after the surgery.
The patient will be required to demonstrate the ability to walk with a walker before being discharged from the hospital.

Most hospital records I read, before seeing the Total Knee Replacement patient in their home to initiate home health physical therapy, reports the patient has usually ambulated with a physical therapist about 150 feet using a front wheeled walker.

Additionally, if the total knee recipient has stairs at home to negotiate, the therapist will train the patient on stair climbing and the patient will be required to demonstrate going up and down stairs safely.

Stairs cannot be safely negotiated with a walker, in my opinion.
I recommend having two walkers, one upstairs and one downstairs.
A good walker to consider is the Drive Medical 2-Button Folding Walker (Amazon link).

How far should I walk immediately after Total Knee Replacement?

A total knee replacement patient should be walking about 150 feet with a walker the day after the surgery.
By three weeks after surgery most patients are able to walk about ¼ mile without any ambulatory aid such as a walker or cane.

Most surgeons have a post-surgery binder of specific instructions that are issued to the total knee replacement recipient upon their discharge from the hospital.

In this binder of instructions is usually a section that discusses how much the surgeon wants the patient to walk during the two to four weeks of home therapy before the patient initiates outpatient physical therapy.

In those instructions, they almost always say “Walk 10 to 15 munites a day”.
Those instructions are unclear and too general for the average patient to understand.

First, the surgeon is telling the patient to “walk 10 to 15 minutes a day” as part of a home exercise rehabilitation program.
Walking to and from the bathroom is not considered part of an exercise program, it is considered activities of daily living. And all walking done as part of the activities of living does not count as time toward the rehabilitation exercise program.

Secondly, the recommended 10 to 15 minutes of walking is all at one time. It is not broken into smaller segments of time that are then added together to achieve 10 to 15 minutes of walking.

Thirdly, the surgeon is not taking into consideration the patient’s speed or stride length when recommending walking 10 to 15 minutes daily.

On rare occasions, at my first home health physical therapy visit, usually day 1 or 2 after surgery, the patient’s ability to walk is severely limited (less than 100 feet).
And the patient’s apprehension is highly elevated.

This limitation is almost always apprehension about falling, but occasionally the limitation in walking is some other orthopedic or medical problem.

There is a balance test I perform at the initial evaluation that gives me some information about the patient’s risk of falling, but also gives me some indication of the patient’s ambulation endurance tolerance.

TUG Test:

TUG test (Timed Up and Go). The test instructs the patient to rise from a seated position, walk 10 feet away from a chair in which they were seated, and then return to that same chair and sit down. If it takes the patient more than 14 seconds, the test scores rate the patient as High Fall Risk.

In the many years I have been performing this test with my home health physical therapy knee replacement patients, I would say less than 5% complete the TUG test in 14 seconds or less (and almost 100% of these patients are younger than 65 years of age).

Almost all my patients initially test at 30 to 90 seconds to complete this 20 foot round trip test.
That’s a HUGE difference in performance, even though the distance was the same.

That being said, if my most speedy patient walked for 10 minutes, they would have walked 858 feet.
If my slowest patient walked for 10 minutes, they would have walked 132 feet.

The point being that recording the amount of time a patient can ambulate continuously tells me very little about the patient’s functional ability but the distance a patient can ambulate tells me a lot about that patient’s functional ability.

How I Progress My Patients With Walking

I always request my patient to not take pain medications at least two hours before my arrival, otherwise, the pain medications mask the pain. I need unmasked pain responses from my patient during treatment to be sure the treatment is within the patient’s pain tolerance limits.

At the initial evaluation, I walk my patient, usually with a front wheeled walker, to the distance that they begin to feel like that is as far as they should go. I request they walk until their body gives them the first sign that they should consider stopping.

Since I am asking the patient to stop at the first signs of discomfort, I have to pick a walking route that will allow the patient to be seated as soon as any discomfort is felt. This means I can’t walk the patient in a straight line until discomfort (we would still have that same distance to return), so I pace out a 50-foot lap within the home that we walk until the patient needs to sit down.

Usually, that first session, the tolerated distance is somewhere between 150 feet and 500 feet.
I always stop the patient at 500 feet on the initial visit, even if they feel they can go further.
Many years of experience have taught me that allowing the patient to walk further than 500 feet on the first visit is safe for all my patients, but allowing them to go further on the first visit can cause some patients to experience increased pain after walking further.

For the patient’s home program, I request the patient to walk 50% the distance that the patient walked with me.
I ask them to do this 50% distance 2-3 times a day.

I do not want them to walk as far as they walked with me, only ½ that distance, but to repeat that distance 2-3 times daily.

At each physical therapy session, with me present, I will push the patient for additional distance.
Each time the patient’s home walking program will be adjusted to 50% of whatever distance they were able to walk with me that day.

Within 3-4 sessions I expect the patient to have reached at least the 1,000 feet mark (a ¼ mile is 1,320 feet).

By then I expect to hear my patient say something like:
“When I’m in the kitchen I don’t use the walker. I just touch the countertops as support”.

At this point, I am going to start walking with my patient using no assistive device at all.

Again we will establish a baseline of tolerance for walking without any assistive device and increase that distance at each of the next 3-4 visits with the expectation they will be able to walk about ¼ mile without any assistive device.

I do not transition my patients from a walker to a cane.
I do not like canes for ambulation.
I transition patients from walkers to no assistive device at all.

It has been my experience that transitioning to a cane causes patients to activate that old ambulation motor memory pattern of limping, canes just do that.

On rare occasions, a patient may need additional support when transitioning from a walker to nothing, but it is never because of the need to reduce weight-bearing on the new total knee. Weight-bearing should not be painful even from the start.

Almost always the issue of transitioning from walker to nothing is a confidence or balance issue.
The patient simply needs a third point of reference just for balance input. That is best achieved through the use of a walking stick.

Walkers and walking sticks allow the patient to walk without activating that old “limp” motor memory. A cane will activate that old motor memory limp.

What Are the Average Non-Surgical Walking Metrics For Adults Under 60?

Walking has become the rage of the human population over the last few years. Many opinions have been expressed about how far the average human being should walk. The consensus seems to be about 10,000 steps a day, and 3,000 should be at a brisk pace.

Studies show that the average man’s stride length is 2.5 feet per step while a woman’s stride length is 2.2 feet per step.

10,000 steps per day translate into:

Men:
4.73 miles per day.
Men walk, on average, about 3 miles per hour at a normal pace and about 4 miles per hour at a brisk pace.
7,000 normal-paced steps at 3 miles per hour is 3.31 mile (about 65 minutes)
3,000 brisk-paced steps at 4 miles per hour is 1.42 miles (about 21 minutes)

Women:
4.17 miles per day.
Interestingly, women also walk, on average, about 3 miles per hour at a normal pace and about 4 miles per hour at a brisk pace. They just take more steps to cover the same distance but the speed is pretty much the same as for men.
7,000 normal-paced steps at 3 miles per hour is 2.92 miles (about 58 minutes)
3,000 brisk-paced steps at 4 miles per hour is 1.25 miles (about 19 minutes)

EVERYTHING CHANGES PAST THE AGE OF 60 YEARS OLD!!!!!

Studies show the average number of steps a senior citizen should be achieving should be 5,500 steps but can go as low as 1,200 steps daily for patients with complications (such as a new total knee), however, the senior citizen should try to increase those 5,500 steps to as close to 10,000 steps as they can tolerate.
See study…..

Not only does stride length start to decrease, but the walking speed also declines about a ¼ mile per hour every decade after 60 years of age.

And after a Total Knee Replacement surgery, things come to a grinding halt for about 3 weeks!!!!!

The walking progression I have described above is what I see in 95% of my total knee replacement patients.

The exceptions are frequently patients that have other orthopedic or medical issues that prevent them from achieving the walking goals defined above.

Of all the total knee replacement patients I see, I can classify them into three groups:

  • Those that “stay in the lane” of the outlined walking and exercises they do as a home program.
  • Those that need some encouragement to do the level of walking and exercises they are requested to do as a home program.
  • Those that say “If 3 is good, 6 is better”. These patients I have to continually pull back into “the lane”

Those that I have to continually try to restrain their over-activity are the only patients that have problems meeting the goals (not only of walking but also range of motion and pain).

At least 50% of these over-achiever type A personalities will set themselves back 7-10 days because of the surgical site’s bad reaction to being over-exerted.

Stay in the lane and you too can walk out of this post-surgical debilitation in about 3 weeks.

Read my other articles about Total Knee Replacement

Happy Non-Limping Painless Walking.

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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