Protection and early recovery
This protocol is for an uncomplicated primary total knee arthroplasty. Pacific Bone & Joint commonly uses a muscle-sparing subvastus exposure and rapid-recovery pathway. Cemented versus cementless fixation does not by itself change this therapy pathway unless the operative order says otherwise.
| Item | Default plan |
|---|---|
| Weight bearing | Weight bearing as tolerated with walker or crutches. Wean the device when gait is safe and there is no meaningful limp or knee buckling. |
| Brace | No routine brace. |
| Motion | No routine flexion ceiling. Prioritize full extension early and increase flexion as tolerated without forceful, prolonged pain. |
| Therapy start | Mobilize the day of surgery. Begin home or outpatient therapy as soon as practical after discharge. |
Early goals - first 2 weeks
- Control swelling and pain while increasing short, frequent bouts of walking.
- Restore full passive knee extension and progress flexion toward 90 degrees or more as tolerated.
- Establish a strong quadriceps contraction and straight-leg raise without an extensor lag.
- Achieve safe bed mobility, transfers, household walking and required stairs.
Protect the new knee
- Do not rest with a pillow directly under the knee. A heel prop or support under the ankle/calf may be used to work on extension.
- Do not force flexion through sharp pain or create a large next-day increase in swelling. Range-of-motion work should be frequent, not traumatic.
- Avoid twisting or pivoting on the planted operative leg until gait and balance are recovered.
- Monitor the incision. Do not submerge the wound until it is fully closed and cleared by the surgical team.
Therapy and home exercise progression
Days 0-14
- Ankle pumps, heel-prop extension, quadriceps sets, gluteal sets, heel slides and seated knee flexion.
- Straight-leg raise once the quadriceps can hold the knee straight; short-arc and long-arc quadriceps work as tolerated.
- Sit-to-stand, supported mini-squat, weight shifts, heel raises and basic balance when safe.
- Gait training with a symmetrical heel-to-toe pattern. Practice stairs needed for the home.
- Patellar mobility and gentle soft-tissue work may be used when the incision and soft tissues permit.
Weeks 2-6
- Progress toward 0-110 degrees or greater active range of motion. Full extension remains the priority if both cannot be achieved at once.
- Stationary bicycle: begin with rocking or partial revolutions and progress to full revolutions, then light resistance.
- Progress sit-to-stand, mini-squats, step-ups, controlled step-downs, bridges, calf raises, hip strengthening and balance training.
- Add resistance gradually. Increase walking distance before adding speed or hills.
- Wean cane or walker only when the patient can walk without a limp, buckling or unsafe balance strategy.
Weeks 6-12
- Progress quadriceps, hamstring, calf and hip strength with functional closed-chain work and appropriate machines.
- Advance step-down control, reciprocal stair training, single-leg balance and endurance on bicycle, elliptical or level walking.
- Pool exercise may begin after the incision is completely healed.
- Avoid repetitive jumping, running and high-impact training unless specifically cleared.
Progression and return to activity
Useful milestones
| Checkpoint | Target before advancing |
|---|---|
| About 2 weeks | Wound progressing normally; full or near-full extension; flexion generally 90 degrees or more; safe household gait; quadriceps control improving. |
| About 6 weeks | 0 degrees extension; flexion generally 110 degrees or more; independent community gait or minimal device use; controlled sit-to-stand and step-up. |
| About 12 weeks | Minimal reactive swelling; reciprocal stairs improving; good single-leg control; independent home program and aerobic exercise. |
When progress is slower
- Notify the surgical team for a persistent extension deficit, flexion that remains below about 90 degrees at 4-6 weeks, or a clear motion plateau despite appropriate therapy.
- Back off exercise volume when swelling, warmth, pain or limping is clearly worse the next morning. Restore a quiet knee before progressing load again.
- Kneeling can be trained after the incision is fully healed and the surgeon has cleared pressure on the knee. Use the separate PBJ kneeling-conditioning protocol, commonly beginning around 12 weeks.
Long-term activity
Low-impact recreation such as walking, cycling, swimming, golf and hiking can be progressed as strength, balance and endurance recover. Repetitive high-impact running and jumping are not routine goals after total knee replacement; discuss individual goals with the surgeon.
Call the surgical team
Call (808) 439-6201 for increasing wound drainage or redness, fever, a sudden loss of motion or strength, new calf swelling, a fall with new pain, or progressive rather than improving pain. Chest pain or shortness of breath requires emergency evaluation.
Clinical references: Morton PN. Knee Replacement Rehabilitation Protocol, 2020. Mass General Brigham, Rehabilitation Protocol for Total Knee Arthroplasty, 2025. AAHKS, At-Home Exercises Following Hip or Knee Replacement Surgery, 2025. Wainwright et al. Acta Orthop. 2020;91:3-19 (ERAS hip and knee replacement recommendations).
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Medically reviewed by Paul N. Morton, MD, FAAOS, FAAHKS. Last reviewed October 2026. For questions about an operative restriction, call (808) 439-6201.