Patient after TKR able to sit up and walk but not able for SLR knee flexion 90 degree leg not fully extended create physiotherapy protocol
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"total knee arthroplasty" AND "rehabilitation protocol" AND "quadriceps"
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"total knee arthroplasty" AND "physiotherapy" AND "range of motion"
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PMID: 40635148
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post TKR physiotherapy protocol quadriceps strengthening SLR knee extension flexion 90 degrees
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https://www.brighamandwomens.org/assets/bwh/patients-and-fam…
I now have excellent source material from Brigham and Women's Hospital and MGH protocols, plus the 2025 systematic review. Here is the complete, evidence-based physiotherapy protocol:
Post-TKR Physiotherapy Protocol
Patient Profile: Can sit up and walk - Unable to perform SLR, knee flexion <90°, knee not fully extended
Clinical Assessment First
Before starting, rule out:
- Extensor mechanism disruption (quadriceps/patellar tendon rupture) - inability to SLR with a palpable defect is a red flag requiring surgical review
- Arthrofibrosis - early aggressive mobilization is critical to prevent scarring
- DVT - monitor for calf pain, swelling, Homan's sign
- Wound healing status - no ROM work over open/infected incision
The patient's presentation (walks but no SLR, flexion <90°, extension lag) is consistent with quadriceps inhibition + early stiffness - a very common post-TKR picture at 1-4 weeks. The protocol below targets both problems simultaneously.
PHASE I - Immediate / Acute (Days 0-7 post-op)
If the patient is still in this phase or presenting late
Goals
- Reduce pain and swelling
- Initiate quad activation
- Achieve safe ambulation with assistive device
Interventions
Oedema & Pain Control
- Cryotherapy 15-20 min after every session
- Limb elevation above heart level at rest
- Compression bandaging (if surgeon-approved)
- Pre-medicate 30-60 min before PT session (coordinate with team)
- Manual lymphatic drainage (reduces early-stage oedema and pain per 2023 RCT evidence)
Quad Activation (most critical at this stage)
| Exercise | Technique | Dosage |
|---|---|---|
| Isometric quad sets | Lie supine, press back of knee into bed, hold 5-10 sec | 10 reps/hour |
| Ankle pumps | Dorsiflexion/plantarflexion in bed | 10-20 reps/hour (DVT prevention) |
| Gluteal sets | Squeeze buttocks, hold 5 sec | 10-15 reps, 3x/day |
| Heel slides (AAROM) | Supine - slide heel toward buttocks as far as comfortable | 10-15 reps, 3x/day |
Positioning (non-negotiable)
- Nothing under the knee - keep it flat to prevent flexion contracture
- Towel roll under heel to elevate and allow gravity-assisted extension when resting
PHASE II - Core Rehab Phase (Weeks 1-4)
This is the patient's current phase - primary intervention zone
Goals
- Achieve SLR without lag
- Restore full extension (0° or < -10° extension lag)
- Achieve knee flexion ≥90°
- Independent ambulation with assistive device
- Reduce pain to ≤3/10 with activity
Key Problem: SLR Failure
SLR inability = quadriceps inhibition (pain-mediated, swelling-mediated, or neuromotor). Progression:
Step 1 - Quad activation re-education
- Isometric quads with biofeedback (EMG biofeedback if available)
- NMES (Neuromuscular Electrical Stimulation) - if poor quad contraction: 2500 Hz, 75 bursts/sec, pulse width 400 microseconds, intensity to motor contraction, 10 sec on/50 sec off - evidence-backed per MGH protocol
- Short Arc Quads (SAQ): Roll a towel (15 cm diameter) under the knee, tighten quads and straighten fully, hold 5 sec - 2-3 sets x 15-20 reps, 2-3x/day
Step 2 - SLR progression
- Supine: isometric quad set first, then attempt SLR hip flexion (do not allow knee to bend)
- If lag >15° initially - use SAQ to build strength, then return to SLR attempts
- Progress to SLR in 4 planes: flexion, abduction, adduction, extension (prone)
- Target: 10 consecutive SLRs without lag before progressing
Key Problem: Extension Lag
| Exercise | Technique | Dosage |
|---|---|---|
| Heel-propped extension (gravity-assisted) | Lie supine, prop heel on rolled towel, let gravity extend knee passively | 10-15 min, 2-3x/day |
| Terminal knee extension (TKE) | Standing with resistance band behind knee, straighten from 20-30° - small arc | 3x15 reps |
| Heel-propped with weight | Add 1-2 kg sand bag over distal thigh for low-load prolonged stretch | 10-15 min sessions |
| Long Arc Quads (LAQ) | Seated on edge of table, extend knee fully from 90° | 3x10-15 reps |
Key Problem: Flexion <90°
| Exercise | Technique | Dosage |
|---|---|---|
| Heel slides (supine) | Slide heel progressively further each session | 3x15 reps |
| Seated gravity-assisted flexion | Sit on high chair, let gravity flex knee beyond 90° | Hold 30-60 sec, 5 reps |
| AAROM wall slides (supine) | Feet flat on wall, slide foot down to flex knee | 3x10-15 reps |
| Stationary bicycle (once able) | Begin with seat high, partial revolutions; progress to full revolutions | 10-15 min, no resistance |
| Low-load prolonged flexion stretch | Seated with strap around ankle, gently pull heel toward chair | 5-10 min sustained stretch |
Manual Therapy (by physiotherapist)
- Patellar mobilization (Grade III-IV) - superior/inferior/medial/lateral glides to prevent fat pad adhesion and maintain extensor mechanism mobility
- Tibiofemoral joint mobilization (Grade I-II for pain, Grade III-IV for ROM)
- Soft tissue massage: quadriceps, hamstring, ITB, calf
Strengthening (alongside ROM work)
| Exercise | Sets x Reps |
|---|---|
| Sitting quad activation at varying angles | 3x10 |
| Supine bridging (bilateral) | 3x10-15 |
| Sidelying hip abduction | 3x10-15 |
| Sit to stand (chair height adjusted) | 3x10 |
| Standing mini-squat at counter (30-45° only) | 3x10 |
| Standing hamstring curls | 3x10-15 |
Gait Training
- Continue walking with assistive device (walker → crutches → cane)
- Target: wean off assistive device by end of Week 2 if quadriceps control allows
- Gait cues: even step length, heel-strike, full knee extension at terminal stance
- No circumduction pattern (sign of quad weakness)
Criteria to Progress to Phase III
- SLR performed without lag
- Knee extension ≤ -10° (near full extension)
- Knee flexion >90°
- Ambulation with least restrictive device
- Pain controlled at 0-3/10 with ADLs
PHASE III - Progressive Strengthening (Weeks 4-8)
Goals
- Knee flexion >110°
- Normalize gait pattern
- Improve quad, hip, and core strength
- Achieve community-level ambulation
Exercises
- Front and lateral step-ups and step-downs
- ¼ lunge (front lunge, limited range)
- Wall slides (back against wall, slide to 45° squat)
- Stationary bicycle with light resistance
- Balance and proprioception: weight shifting, side-stepping, single-leg stance progression
- Pool/hydrotherapy if available (reduces load while maintaining ROM work)
- Continue NMES for quads if still showing poor activation
PHASE IV - Return to Function (Weeks 8-12+)
Goals
- ROM: full extension to ≥120° flexion
- Independent ADLs, stairs, community walking
- No assistive device
Exercises
- Step-ups with added height progression
- Leg press (light resistance, 0-60° range)
- Half squats with body weight
- Treadmill walking, progress incline
- Single-leg balance progression
- Home exercise program for long-term adherence (>6 months sustained exercise is key for maintained strength)
Session Frequency
| Phase | Frequency |
|---|---|
| Phase I (Week 1) | Daily inpatient or 5x/week |
| Phase II (Weeks 1-4) | 3-5x/week |
| Phase III (Weeks 4-8) | 2-3x/week |
| Phase IV (Weeks 8-12) | 1-2x/week + independent HEP |
Red Flags - Stop and Refer
- Sudden inability to extend after previously achieving extension → suspect mechanical block or hardware issue
- Fever + wound discharge + increased pain → infection
- Calf swelling, redness, warmth → DVT
- Increasing ROM loss after Week 6 → arthrofibrosis (may need manipulation under anaesthesia before 12 weeks)
Evidence Base
The protocol above is consistent with the 2025 systematic review by Aftab et al. (Musculoskeletal Care, 2025) which found that early physiotherapy with isotonic strengthening programs and early mobilization significantly improved ROM, pain, and quality of life post-TKA across 19 RCTs. Institutional protocols from Brigham and Women's Hospital and Massachusetts General Hospital formed the structural framework.
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