Structured Physiotherapy Protocol (Post-TKR, Age 70, Current Flexion 40°, Walking With Walker)

1) Baseline and Safety Check (Day 1 of plan)

• Pain (VAS), swelling, warmth, wound status
• ROM: flexion/extension (record daily/alternate days)
• Quadriceps activation (quad lag, straight leg raise ability)
• Gait quality with walker
• Red flags:
  • Calf pain/swelling, sudden breathlessness, chest pain
  • Fever, wound discharge, increasing redness
  • Sudden loss of movement or severe night pain
    If any red flag is present, urgent surgeon review.

2) Goals by Phase

Phase A: Week 0-2 from now

• Pain and edema control
• Improve knee flexion from 40° to about 60-70° (as tolerated)
• Achieve full extension (0°) or near full extension
• Independent bed mobility and transfers
• Safe walker gait indoors

Phase B: Week 3-6

• Flexion target: 80-95°
• Better quadriceps control and less extension lag
• Improve standing tolerance, step training
• Progress gait quality and endurance with walker or stick (if safe)

Phase C: Week 7-12

• Flexion target: 100-110° (functional goal based on need)
• Independent community ambulation (assistive device as required)
• Stair climbing with minimal support
• Functional strengthening and balance

3) Daily Treatment Structure (45-60 min, 1-2 sessions/day)

A. Pain and Swelling Management (10-15 min)

• Cryotherapy: 10-15 min after exercise
• Limb elevation above heart
• Ankle pumps: 30-40 reps hourly while awake
• Compression (if advised by surgeon)

B. ROM Restoration (15-20 min)

1. Heel slides (supine)
   • 3 sets x 10 reps, hold 5-10 sec at end range
2. Assisted knee flexion with strap/towel
   • 3 x 10, gentle sustained holds
3. Seated knee flexion (foot back under chair)
   • 10-15 reps, 5 sec holds
4. Terminal extension work
   • Towel under heel, knee extension stretch 3-5 min total
5. Patellar mobilization (if wound healed and approved)
   • Superior/inferior/medial/lateral glides, gentle

C. Strengthening (15-20 min)

1. Quad sets: 3 x 10 (5-8 sec hold)
2. Gluteal sets: 3 x 10
3. Straight leg raise (if no lag): 3 x 8-10
4. Short arc quads: 3 x 10
5. Heel raises (supported): 3 x 10
6. Sit-to-stand (high chair): 2-3 x 6-10
7. Mini squats (0-30°) when tolerated: 2 x 8-10

D. Gait and Functional Training (10-15 min)

• Walker gait drills:
  • Upright posture
  • Equal step length
  • Heel strike to toe-off pattern
• Distance progression:
  • Start with multiple short walks/day (3-5 min each)
  • Increase by 1-2 min every 2-3 days as tolerated
• Transfer training: bed-chair-toilet safety
• Stair training when ready:
  • Up: non-operated leg first
  • Down: operated leg first

4) Weekly Progression Targets

• End Week 1 of program: flexion 55-60°, better quad set, safe transfers
• End Week 2: flexion 65-70°, walking 8-10 min cumulative/day
• End Week 4: flexion 80-90°, improved sit-to-stand, less walker dependence
• End Week 6: flexion ~90-95°, start cane trial if balance/strength adequate
• End Week 8-12: flexion 100°+, functional gait/stairs with confidence

5) Criteria to Progress Assistive Device (Walker to Stick)

• Pain controlled
• No significant knee buckling
• Good single-leg stance support (with supervision)
• Near symmetrical step length
• Adequate quad control in terminal stance

6) Home Program (Essential)

• Heel slides
• Extension stretch
• Quad sets + SLR
• Supported marching/heel raises
• 2-4 short supervised walks/day

• Pain score
• Flexion angle (if possible)
• Walking duration
• Swelling response next day

7) Precautions in Elderly Post-TKR

• Avoid aggressive forced flexion
• Watch for orthostatic dizziness/fall risk
• Ensure hydration, protein intake, and medication timing before therapy
• Footwear: non-slip closed shoes
• Supervision during balance/stair sessions

Full Physiotherapy Plan After Total Knee Replacement

1) General rules for patient and family

1. Do exercises daily. Consistency is more important than intensity.
2. Mild pain/stretch is acceptable, but stop if sharp pain, locking, or giving way.
3. Use this pain rule:
   • During exercise: pain up to 4 to 5 out of 10 is acceptable
   • Next morning: pain/swelling should return to baseline
   • If worse for >24 hours, reduce repetitions next day
4. Ice knee for 10 to 15 min after exercise and after walks.
5. Keep leg elevated when resting, ankle above heart level if swelling.
6. Take prescribed medicines on time, especially before exercise sessions if advised.
7. Wear non-slip shoes, avoid loose rugs/wet floors.
8. Never walk without aid until therapist clears progression.

2) Milestone targets (functional roadmap)

• Week 1-2 (from today): flexion 60 to 70°, full or near-full extension, independent bed-chair transfers, indoor walker gait stable
• Week 3-4: flexion 80 to 90°, improved quadriceps control, longer indoor and corridor walking
• Week 5-6: flexion 95 to 100°, begin cane training if gait stable
• Week 7-8: better balance, stair confidence, outdoor supervised walking
• Week 9-12: independent household walking, community ambulation as tolerated

3) Detailed phased protocol till independent walking

Phase 1: Protection + ROM recovery (Week 0-2 from now)

Clinic / supervised (5 to 6 days/week)

• Patellar mobilization (if incision healed)
• Assisted heel slides and sustained flexion holds
• Knee extension stretching (heel propped)
• Quad activation drills (biofeedback/tapping if needed)
• Gait correction with walker: posture, step length, heel-toe pattern

Home exercise (2 sessions/day)

1. Ankle pumps: 30 reps every waking hour
2. Quad sets: 3 sets x 10 reps, hold 5 to 8 sec
3. Glute sets: 3 x 10
4. Heel slides (assisted with towel): 3 x 10, hold end range 5 sec
5. Knee extension stretch (heel on pillow, knee unsupported): 3 to 5 min
6. Straight leg raise (only if no extension lag): 3 x 8
7. Seated knee bends: 2 x 10
8. Walking with walker: 4 to 6 short walks/day, 3 to 5 min each

Phase 2: Strength + gait endurance (Week 3-6)

Supervised sessions (3 to 5 days/week)

• Progress ROM to 90° and beyond
• Closed-chain strengthening
• Sit-to-stand retraining
• Step-up training (low step)
• Balance with support

Home exercise (2 sessions/day)

1. Continue Phase 1 ROM work
2. Short arc quads: 3 x 10
3. Terminal knee extension with band: 3 x 10
4. Sit-to-stand from chair: 3 x 8 to 10
5. Supported mini-squat (0-30°): 2 x 10
6. Heel raises holding counter: 3 x 12
7. Standing hip abduction/extension: 2 x 10 each side
8. Marching in place holding support: 2 x 30 sec
9. Walking program: start 8 to 10 min total/day and progress to 20 to 30 min total/day

Walker to cane decision criteria

• No knee buckling
• Good quad control in stance
• Able to walk 10 to 15 min with good pattern
• Minimal swelling flare after walk
• Therapist confirms safety

Phase 3: Transition to independent ambulation (Week 7-12)

Supervised focus

• Normalize gait speed and symmetry
• Improve single-leg control and confidence
• Stair training and directional changes
• Community ambulation skills

Home exercise (1 to 2 sessions/day)

1. Stationary cycle (if available): 10 to 20 min low resistance
2. Step-ups (4 to 6 inch step): 3 x 10
3. Lateral step-ups: 2 x 10
4. Sit-to-stand lower chair height: 3 x 10
5. Mini-lunges (supported): 2 x 8
6. Tandem standing / semi-tandem balance: 3 x 30 sec
7. Single-leg stance with support: 5 reps x 10 sec
8. Walking progression:
   • Week 7-8: 15 to 20 min continuous (with cane if needed)
   • Week 9-10: 20 to 30 min, increase outdoor exposure
   • Week 11-12: household independent walking, community with minimal aid as needed

4) Daily schedule template for patient

• Morning: ROM + strength set (25 to 35 min)
• Midday: short walk + ice + elevation
• Evening: ROM + gait practice (20 to 30 min)
• Night: swelling check, ankle pumps, leg elevation 15 min

5) Instructions to give the patient (simple language)

• Bend and straighten your knee every day.
• Do not skip exercises for more than 1 day.
• Walk many short times instead of one long painful walk.
• Keep your knee straight while resting sometimes; do not always keep pillow under knee.
• Use walker/cane exactly as taught.
• Use ice after exercise and after longer walks.
• Call doctor if fever, wound discharge, calf swelling, chest pain, sudden breathing trouble, or sudden severe pain.

6) Stair and walking safety instructions

• Stairs:
  • Going up: good leg first
  • Going down: operated leg first
  • Use railing always initially
• Walking aid fit: Walker height should allow slight elbow bend (about 15 to 30°).
• Remove home fall risks: loose rugs, poor lighting, clutter, wet bathroom floor.

7) When to seek reassessment (physio/surgeon)

• Flexion still <70° after 2-3 weeks of consistent rehab
• Persistent extension lag
• Recurrent night pain/swelling not settling
• Increasing dependence on walking aid instead of progression