Best Exercises For Knee Replacement (TKR) Rehabilitation
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Many people view their Knee Replacement surgery as the solution to their problems with pain and function.
Unfortunately, unless you live a very sedentary lifestyle (and even then...) the surgery is likely not enough on its own.
As is the case with an injury, you will have to undergo periods of relative rest and healing after a surgery, but rest alone will not build function. Alongside good recovery, it is essential to also undergo excellent rehabilitation to get your knee feeling as good as new.
I've seen many people who have undergone a knee replacement and struggled with regaining their full range of motion and strength, as well as getting their pain under control. In many (the majority) of these cases, finding the right rehabilitation and having the right strategies to progress were the key to finally improving.
Before we go through the exercises (skip the next section if you want to get straight to seeing the exercises), let's briefly cover a "standard rehabilitation" scenario, why this might not be the best exercise for your entire rehabilitation plan, and why getting some more meaningful assistance is beneficial.
The Problem with Standard Rehab Alone
Your first thought if you have just had a knee replacement might be "I've got my exercises under control, they gave me a handout at the hospital with pictures and I already do them 3 times per day".
This is better than no exercise at all, and you should definitely start with the advice given to you by the treating team at the hospital. However, these exercises are only meant for the post-operative period, don't always take into account your specific recovery after discharge, and because they are given to you at a single point in time the recommendations remain relatively the same.
This would be like training for a marathon (42km) by only ever running 5km in training, never more, and then wondering why you struggle to finish on race day. At some point, you have to do more and/or different things to keep improving and build back up to where you need to be.
Bottom line: although a noble place to start we have to go beyond knee bend and extend in a chair, sit to stand, and balancing on one leg to get you back to being at your best !
The Keys to Getting the Best From Your Rehabilitation Exercises
Now that we know you'll need to up the ante after your initial post-operative period, let's see what will help you do the best exercise possible for your knee replacement.
Move through full range, but don't force it early!
Regaining range of motion is difficult in the early stages, and it can hurt to move your knee that has been freshly operated on. It's also something that I see done particularly poorly, in my opinion.
Regaining range of motion is the first thing your surgeon will look for at your follow up appointment, typically they will want you to have your knee fully straight and bending to about 90 degrees. In this case, most people will be encouraged to push their knee into the stiffness to "open up" the joint and reduce muscle tension.
Here's the issue with that: muscle tension and the joint itself (which is brand new and pristine) aren't the main limiting factors in the early stage, swelling is ! One of the best ways to get your knee hot, angry, and more swollen is to push it too hard too early. Instead: use assisted range of motion exercises or un-resisted movements through range early and "take advantage" of the range you have available, and prioritise swelling management (via compression and elevation).
NOTE: this DOES NOT MEAN put your foot up and leave it entirely, you must still walk on it, you must still exercise it, multiple times per day. Just don't feel like it needs to be "cranked" to get the range back.
THEN, once the knee has quietened down (after the initial healing and inflammation in the first few weeks to first month) you can assess muscle tension/joint stiffness and start to work the knee harder. Once you have a quiet and happy knee that isn't swelling, then you can use overpressure/stretching/higher resistance exercises to push the joint movement.
To Summarise:
- Early stages: knee extensions over a towel, quad squeezes with foot elevated/knee hanging, heel slides
- Once the knee settles: using your other leg to bend the knee under a chair, using a strap or towel, full range squats
Train the Whole Leg
Even though it is your knee that has been replaced, its function is supported by your entire leg.
Your ankle and calves created the foundation under your knee, your glutes and other hip muscles control the angle of your upper leg (which affects the knee) and these joints/muscles are not sufficiently trained just by doing knee exercises like leg extensions.
To get the best out of your exercises after knee replacement you must include exercises like calf raises, hip bridges, hamstring curls, and other similar movements that involve parts of the leg that aren't the knee. Don't neglect the small muscles either, think about side leg raises, resisted hip flexor exercises and even trunk exercises as being an important part of your rehabilitation.
Progress to 1 Leg
Speaking of the whole leg, make sure it's being used in the first place!
Sticking with two legged variations of calf raises, squats, and bridges gives your operated knee a chance to "hide" while the other leg and muscles pick up the slack. You don't have to drop in like you're dancing the Hopak, but you can gradually progress to using one leg.
As an example with an old favourite, the sit to stand:
- Start with a sit to stand to a high chair while the knee is stiff
- Gradually work down to a lower chair, or squatting as low as you can manage
- Then put one foot slightly in front of the other, and on your heel, so that the leg that remains flat is doing the bulk of the work. THEN do the squat/sit to stand
- If you get really good, the next step is to stand and sit from a chair ENTIRELY on one leg
There are other variations on this for bridges, and calf raises, and even other versions of the sit to stand, but the principle of working towards one leg is relevant for all of them.
Go the Next Step:
Add Resistance (and increase it over time!)
Once you have mastered your own bodyweight, or even slightly prior, add some resistance.
All resistance is beautiful. Don't discriminate against bands, cuff weights, machines or any other safe form of resistance.
Load it up, and keep building it up. Start low and go slow with the progressions if you need to, but you absolutely should, when the time is right, start to load on some resistance.
What about a "difficult" knee,
where these types of exercise are just too painful or aren't working?
Hydro.
Hydro, Hydro, Hydro.
For people who are feeling stuck, or don't respond well to on-land exercises like the ones I've outlined above: get yourself in the water. By reducing the weightbearing demands and being able to relax into a (hopefully warm) pool you'll be surprised how quickly things can change.
The only caveat: you MUST wait until after your wound reviews and get permission from the nurse, surgeon, GP or physio. We DO NOT want your new knee becoming infected because something in the pool water made its way under your dressing and into the surgical wound. You will usually be able to start hydro around the 4-6 week mark, which is plenty of time to try some of the earlier variations discussed above in the meantime.
The Better Recovery Journey with Exercise
Recovering from knee replacement surgery can feel overwhelming, especially when progress seems slow or exercises feel uncomfortable. However, regaining strength, range of motion, and confidence in your knee starts with tailored exercises that evolve as you heal.
The process
Begins with identifying your unique needs through a comprehensive assessment, alongside gentler movements to manage swelling and range
Progresses to strengthening the entire leg, and eventually includes resistance and single-leg exercises to build stability and power.
And gradually becomes life as normal again, as you regain control and trust in your knee.
Expect moments of frustration and challenge, but also gradual improvement. With dedication and the right strategies, you can transform from feeling uncertain and limited, to confident and capable of returning to an active, pain-free lifestyle.