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Knee Release
Monday June 9, 2008


Anil Bhave, MPT, division head for rehabilitation at Sinai Hospital in Baltimore, was routinely treating patients after total knee arthroplasty (TKA) surgeries when he started to observe a disturbing trend: A certain percentage of his patients were not happy with the outcome of their procedure, and some of these patients were not improving even after standard physical therapy.

Bhave teamed up with several physicians to study this anomaly. They examined 56 patients following TKA who were suffering from functional problems such as knee flexion contracture, quadriceps muscle weakness, knee flexion deficit, limb length difference, foot and ankle malalignment, and peroneal nerve entrapment. The researchers experimented with a variety of novel techniques to help these patients, and their results were published in November 2007 in Clinical Orthopaedics and Related Research. Their findings suggest that specialized physical therapy can significantly improve outcomes for certain TKA patients who do not respond to traditional therapy.

Tried and true PT

For the vast majority of patients with TKAs, traditional physical therapy strategies can help those who are suffering from some of the same problems explored in Bhave’s study, such as quadriceps muscle weakness, knee flexion deficit, and knee flexion contractures.

Kelly Bailey, BS, MSPT, coordinator of Physical and Occupational Therapy at Harris Methodist HEB Hospital in Southlake, Texas, usually sees patients status post TKA after they have already received PT in the hospital and with home health. One of the most common problems she sees are knee flexion contractures. These patients are usually comfortable sitting with their knees bent, so she encourages them to sit with the operated leg propped on a footstool to promote straightening. Many times these patients prefer to sleep with a pillow under the knee. “The elderly love that position, so we have to educate them that this is not an option,” Bailey says.

Another common problem she treats in patients after TKA is quadriceps weakness. For these patients, she typically prescribes exercises such as using a short step stool at home to practice step-ups both forward and laterally. These types of exercises lay the groundwork to help patients build the strength for activities such as stepping over the edge of a shower, getting in and out of chairs, getting in and out of the car, and climbing and descending a flight of stairs.

In some cases, patients have so much pain after surgery that muscle function is inhibited; these patients benefit from neuromuscular electrical stimulation (NMES) to activate the quadriceps and make functional exercises more successful.

Although an increased level of pain can significantly slow down the speed of recovery, a patient’s physical fitness and general health before the surgery is also a major factor in how quickly someone responds to physical therapy, says Amy Wilusz, PT, MS, DPT, MTC, CSCS, senior physical therapist at California Pacific Medical Center in San Francisco. Wilusz has worked with patients with a wide variety of backgrounds, and finds that those who are flexible and physically fit prior to surgery have a better chance of a rapid recovery.

One of Wilusz’s patients was a 62-year-old ex-ballet dancer who could bend her knee 130 degrees early in the rehabilitative process; others who are less flexible and healthy may start with as little as 65 degrees of flexion, and then progress is slower.

In some cases, PT can benefit patients who have lost functionality, flexibility, and strength due to complications such as postoperative infections. Often, a combination of patellar and knee joint mobilization, progressive stretching, and modalities for pain control and muscle activation help patients progress back to independence. Regardless of approach, most experts agree that mobilization of the knee as early as the first postoperative day is essential to rapid recovery.

Breaking the mold

While traditional PT can be effective for most patients after TKA, it may not improve the outcome in about 15 to 20 percent of cases. Problems after TKA are frequently linked to co-morbidities, radiographic loosening, or poor prosthetic alignment, but this does not explain continued problems in some cases, according to the team at Sinai Hospital.

Some of the patients in the Sinai study struggled to respond to traditional PT because they unknowingly had nerve problems prior to surgery, such as peroneal nerve entrapment or lumbar disc dysfunction. While many physicians treat this type of pain with traditional pain medication, the Sinai team tried a combination of Neurontin and Lyrica, says Bhave, who also is director of the Gait Lab at Sinai Hospital. This combination helped the patients more successfully participate in postoperative rehabilitation.

The team also tried nontraditional techniques in patients suffering from knee flexion deficits, such as applying a customized knee brace designed by Bhave for as long as three hours each day over a seven-week period. The brace’s hinges are aligned to the knee axis, and elastic bands in a figure-eight pattern are used to impart torque on the knee. The team also tried injecting the operated knee with a local anesthetic to enhance rehabilitation, stretching the patient after the injection to increase knee flexion.

For patients with quadriceps muscle weakness to the extent that they could not lift their legs against gravity, the team used NMES with exercise until patients could lift at least one-third of their body weight. In cases in which the patients were still struggling to improve flexion even after specialized therapeutic techniques were applied, the team used Botox injections in patients with hamstring or gastrocnemius muscle spasms.

The final outcomes of the 56 patients suggest that these specialized strategies were highly successful in helping difficult cases after TKA. Ninety-five percent of the participants had a Knee Society score of 80 points or higher at the final 24-month follow-up, and patient satisfaction was a mean of 9.1 out of 10 points.

For Bhave, the greatest reward is seeing patients return to their much-loved activities. One such case was a 62-year-old ballroom dance teacher who had severe postoperative knee stiffness such that she was unable to bend or straighten her knee. She traveled from Washington to Baltimore to seek help from Bhave. He injected her knee with an anesthetic before performing straightening exercises, and also prescribed his brace for four hours per day — two hours keeping it straight and two hours keeping it bent. After two sessions per week for eight weeks, the dancer improved so much that she could return to the dance floor. Now she leads a class for patients who want to dance after joint arthroplasty.

“My patients want to be able to walk as much as possible and be independent,” Bhave says. “I love to see the smile on their faces when they can get back to their
functional activities.”


• Ulrich, S. D., A. Bhave, D. R. Marker, T. M. Seyler, and M.A. Mont. 2007. Focused rehabilitation treatment of poorly functioning total knee arthroplasties. Clin Orthop Relat Res 464:138-45.

Heather Stringer is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to

Monday June 9, 2008
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