Rehabilitation after Knee Replacement

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada 2018).
• Sociodemographic information: age, sex, gender identity, language, living arrangement, occupation, caregiving responsibilities, health literacy, supports and communication or access needs.

Primary concerns

• Surgery and current plan: reason for surgery; operated side; total or partial replacement; primary or revision procedure; surgery date; surgeon and follow-up; operative and discharge information; weight-bearing status; movement or wound precautions; venous thromboembolism plan; and any complication, emergency visit or readmission.
• Current symptoms and course: knee, calf, thigh, hip or back pain; stiffness; swelling; bruising; wound change; fever or chills; shortness of breath or chest symptoms; fatigue; dizziness; numbness or weakness; sleep; and whether symptoms, mobility and daily activities are improving, unchanged or worsening.
• Baseline and current functioning: mobility and gait aid before surgery; current bed mobility, transfers, walking, stairs, self-care, household and community activities; falls; work or caregiving; driving; recreation; social participation; and assistance needed.
• Body systems review: cardiovascular and respiratory; neurological, cognitive and vestibular; musculoskeletal, including the other knee, hips, ankles and spine; skin and wound; vascular; genitourinary and gastrointestinal; nutritional; endocrine and metabolic; sleep; and mood symptoms that may affect safety, healing or rehabilitation.
• Health, lifestyle and history: osteoarthritis and other pain conditions; previous joint replacement or surgery; venous thromboembolism or bleeding; diabetes; cardiovascular, respiratory, kidney, liver, neurological, inflammatory and bone-health conditions; infection history; recent hospitalization; physical activity; nutrition and hydration; sleep; tobacco; alcohol or substance use; and falls history.
• Medications and postoperative care: analgesics, anticoagulants, antibiotics and other current medicines or supplements; adherence and adverse effects; wound and dressing instructions; compression or other devices; and who to contact with questions.
• Home, equipment and supports: discharge destination, stairs, bathroom and sleeping setup, gait aid and other equipment, transportation, access to food and medicines, caregiver availability, home services and ability to summon help.
• Social determinants of health: housing, income, food security, discrimination, social support, caregiver strain, transportation, digital access and availability or affordability of rehabilitation, equipment and follow-up (Public Health Agency of Canada 2026).
• Previous care and responses: preoperative preparation, inpatient or community rehabilitation, education, exercise, gait aids, pain and swelling care and other approaches tried; what helped, did not help, caused harm or was difficult to continue.
• Patient perspective: understanding of the operation and recovery plan, priorities, preferences, cultural context, acceptable risk, confidence, concerns, expectations and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use measures that are meaningful to the patient, safe for the postoperative phase and practical to repeat. Record the test setup, gait aid, assistance and weight-bearing status so repeated results are comparable.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF.
• Knee-specific symptoms and functioning: the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) can be used after total knee replacement when it fits the clinical question and setting.
• Mobility performance: a safe, repeatable task such as the Timed Up and Go or 30-Second Sit-to-Stand Test, selected according to mobility and the clinical question.
• Symptoms and impairments: a consistent pain rating, swelling measure, knee flexion and extension, quadriceps activation or strength, and use of analgesia when these findings will guide care.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the surgical plan, postoperative phase, presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, draping, pace, assistance and caregiver involvement, and confirm ongoing consent before examining the knee, wound or other sensitive areas.
• Surgical plan and stability: confirm the procedure, date, weight-bearing status, precautions, wound instructions and medical clearance before loading or moving the knee. Defer or modify testing when these are unknown or the person is medically unstable.
• General observation and wound: alertness, distress, breathing, pallor, hydration, posture, spontaneous movement, swelling, bruising, dressing or incision condition, drainage, skin integrity and signs of pressure injury.
• Vital signs and medical screening when indicated: heart rate and rhythm, blood pressure, oxygen saturation, temperature, orthostatic response, pain behaviour and signs of acute illness, bleeding or medication adverse effects.
• Neurovascular examination: distal pulses, colour, temperature, capillary refill, swelling, sensation and motor findings when new pain, weakness, numbness, vascular symptoms or a surgical complication is plausible.
• Pain and swelling: location, intensity and response to movement or loading; effusion and limb swelling using a repeatable method; warmth, tenderness and tissue sensitivity; and change after activity.
• Knee movement: active and passive flexion and extension as needed, noting movement quality, pain, restriction, end feel and extension lag. Interpret change against the person’s baseline, surgical plan and trend rather than a universal milestone.
• Strength and motor control: quadriceps activation and strength, straight-leg raise or extension lag when appropriate, and safe testing of hip, hamstring, calf and other lower-limb muscles that may affect mobility.
• Gait and mobility: bed mobility, sit-to-stand, transfers, gait initiation, step pattern, knee control in stance, turning, walking distance, stairs, weight-bearing tolerance, assistance and safe use of the prescribed gait aid.
• Functional assessment: patient-prioritized self-care, household, vehicle, work, caregiving, community and recreational tasks, and the interaction among the person, equipment, environment and available support.
• Balance and falls assessment: standing balance, turning, reaching and other tasks matched to safety and goals, especially when falls, fear, dizziness or unsteadiness are present.
• Adjacent regions: examine the other knee, hips, ankles, feet or spine when symptoms or impairments there may affect walking, loading or recovery.
• Imaging: review available postoperative imaging and the surgical report when relevant. New imaging is not routine for expected recovery; arrange medical or surgical assessment when new trauma, deformity, inability to bear weight, worsening focal pain or another suspected complication is likely to change care.
• Repeat and adapt: repeat focused findings to review progress, check the fit of the working presentation and decide whether rehabilitation, medical assessment or surgical follow-up needs to change.

Working clinical presentations

These presentations can overlap or change. Use them to organize assessment and care, not as fixed stages or substitutes for the surgical diagnosis and plan.

• Uncomplicated early recovery after primary total knee arthroplasty: expected postoperative pain, swelling, reduced knee movement, quadriceps inhibition and need for a gait aid, with a stable wound and gradual progress in mobility and daily activities (Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Ongoing strength and mobility recovery: pain and swelling are settling, while knee movement, quadriceps and lower-limb strength, walking, stairs, endurance or confidence remain below the person’s goals.
• Self-directed recovery with planned review: the person is medically stable, understands the plan, can mobilize safely, has suitable support and is progressing with a home or community program (NICE 2020).
• Supervised or interdisciplinary rehabilitation needs: daily activities, cognition, mobility, falls risk, wound or symptom monitoring, exercise progression, equipment, home setup or access needs call for individual, group, virtual, home or outpatient support (NICE 2020; Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Knee stiffness or arthrofibrosis risk: flexion or extension remains markedly restricted or is losing ground, with pain, swelling, guarding or tissue restriction limiting daily activities and progression. Confirm the surgical follow-up plan and use Red Flags when the course is unexpected.
• Persistent pain, swelling or loss of progress: symptoms remain high, worsen or no longer match the expected course, or mobility and participation decline after earlier improvement. Revisit complications, implant-related concerns, adjacent regions, pain contributors and medical or surgical review.
• Presentation outside routine primary knee replacement rehabilitation: revision or complex surgery, fracture, infection, neurological or vascular disorder, or another medical condition requires the relevant procedure-specific, medical or shared-care pathway.

Base care on the surgical plan, presentation, safety, goals, context and response. Develop the plan with the patient and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Recovery plan and safety: clear information can cover the procedure, expected variability in pain, swelling, stiffness and fatigue, wound and medicine instructions, exercises, gait aid use, daily activities, who to contact and the warning signs in Red Flags (NICE 2020; Rehabilitative Care Alliance 2026).
• Daily routines and participation: pacing, sleep, nutrition, hydration, medication routines, transport, home setup, work or caregiving changes and a practical home plan can support participation. Address barriers without assuming that difficulty following a plan reflects poor motivation.

Protection and optimal loading

• Early mobility and loading: when medically stable, mobility and rehabilitation can begin on the day of surgery or within 24 hours. Loading follows the surgeon’s weight-bearing plan, wound status, symptoms, motor control and safe use of the prescribed gait aid (NICE 2020; Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Activity response: progress walking, standing and daily tasks in manageable amounts. A temporary rise in soreness or swelling may call for a smaller dose or more recovery time; new marked pain, swelling, wound change or loss of mobility follows Red Flags.
• Falls and equipment: select and fit gait aids, rails, seating, bathroom or dressing equipment when they improve safety or independence, and review them as mobility changes.

Physical activity and exercise

• Knee movement: active, active-assisted and passive range-of-motion exercises can target flexion and extension. Dose reflects irritability, swelling, wound healing, movement quality and response rather than a universal target date (Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Progressive strengthening: quadriceps and lower-limb strengthening can progress from activation and supported tasks to resistance and weight-bearing exercise. Progression reflects technique, symptoms, swelling, recovery after exercise and goals (Bove et al. 2026).
• Neuromuscular electrical stimulation: this can be an adjunct to active exercise when quadriceps activation or strength is markedly limited, with screening for contraindications and a tolerable setup (Bove et al. 2026).
• Gait, balance and functional training: practice can include transfers, walking, turning, stairs, uneven surfaces and other meaningful tasks, with feedback or balance challenges matched to safety and goals (Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Physical activity and endurance: a gradual plan can build walking and low-impact aerobic activity around current capacity, interests and longer-term health goals (Bove et al. 2026).

Hands-on and symptom-relieving care

• Cold and positioning: cold and comfortable elevation can be used for short-term pain or swelling relief. Protect the skin, account for altered sensation or circulation, and follow wound and surgical guidance (Bove et al. 2026).
• Hands-on care: gentle soft-tissue or movement-based care can be used as an adjunct when it is consistent with wound healing and the surgical plan and helps a specific symptom or movement goal. Avoid deep pressure over the healing incision and do not use passive care in place of active rehabilitation (Bove et al. 2026).

Psychological, social and interdisciplinary support

• Confidence and distress: clear information, graded practice and problem-solving can address fear of falling or movement. Persistent distress, low mood, anxiety, cognitive change or pain-related concerns can be managed with the appropriate primary care, rehabilitation or mental-health provider.
• Care setting and supervision: self-directed, individual, group, virtual, home and outpatient options can be used. The level of supervision reflects safety, mobility, cognition, daily activity needs, goals, home support, transport, technology and access (NICE 2020; Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Interdisciplinary care: surgical and primary care, nursing, physiotherapy, occupational therapy, pharmacy, dietetics, home care and social services can be coordinated around medical stability, wound and medicine needs, mobility, self-care, nutrition, equipment and transitions (Rehabilitative Care Alliance 2026).

Medication coordination

• Analgesia and postoperative medicines: coordinate with an authorized prescriber or pharmacist when pain limits rehabilitation, adverse effects such as sedation, dizziness, nausea or constipation occur, or questions arise about anticoagulants, infection treatment or other postoperative medicines. Medication changes remain within the appropriate provider’s scope.

Return to activities

• Work, driving, recreation and sport: timing reflects the operated side, mobility, strength, reaction time, medicine effects, job or activity demands, transport and the surgeon’s advice. Low-impact activities are commonly used after recovery; higher-impact or contact activities require individual discussion with the surgical team (NICE 2020; Arthritis Society Canada n.d.).

Approaches not used routinely

• Continuous passive motion and early ROM bracing or splinting: these are not part of routine care solely to increase knee movement after uncomplicated primary total knee arthroplasty. A surgeon-directed plan for a specific complication takes precedence (Bove et al. 2026).
• Stand-alone passive care or prolonged restriction: passive modalities or hands-on care do not replace mobility, exercise and self-management, and prolonged bed rest or avoidable activity restriction can delay recovery.

Monitoring and reassessment

• Agree on a reassessment point based on the postoperative phase, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review pain, wound and swelling, relevant neurological and vascular findings, knee movement, strength, mobility, functioning, participation, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, surgical plan, differential diagnosis, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: after uncomplicated primary total knee arthroplasty, pain, mobility and daily activities often improve over the first weeks and months. Knee movement, strength, endurance, confidence and participation can continue to change for many months, and some people have ongoing pain, stiffness or activity limits (Bove et al. 2026; Arthritis Society Canada n.d.).
• Factors associated with a less favourable course: poorer mobility or strength before surgery, multimorbidity, surgical or medical complications, persistent pain or swelling, marked movement loss, quadriceps inhibition, fear of movement or falling, distress, limited support and barriers to rehabilitation may be associated with slower or incomplete recovery. These are group-level patterns, not certain individual predictions (Bove et al. 2026; Rehabilitative Care Alliance 2026).
• Potential supports for recovery: a clear surgical and rehabilitation plan, early safe mobility, appropriately progressed knee movement, strengthening and functional practice, suitable pain and swelling care, confidence, practical equipment, home support and access to review may support recovery (Bove et al. 2026; NICE 2020; Rehabilitative Care Alliance 2026).
• Discussing prognosis: explain what is known about the person’s procedure and current progress without promising a date, range-of-motion value or outcome. Compare change with baseline and goals, discuss uncertainty plainly, and update the outlook when symptoms, repeated outcomes, support or the surgical plan changes.