TKR - Unable To Achieve Full Extension

[PhysioTOM]

Hi. I am a Physio student on placement in a rehabilitation ward for elderly patients. There is a patient who has had a knee replacement due to arthritis and is now unable to achieve full extension. In the four weeks i have worked with her she has remained around 38-40 degrees from full extension.

It is quite a significant amount and coupled with the pain from the other knee (due for replacement in future) struggles to walk with a ZWA with assistance of 2. 10 metres walking is a good day. Currently I am doing stretches, PNF, and some exercises. I am also attempting some gentle massage on the hamstring tendons as they are extremely tight compared with other leg.

The leg without the knee replacement also does not achieve full extension so this is likely something the patient has suffered from for many years however has worsened post operation. The non replaced knee is about 20-25 degrees from zero. Anyway I would love to hear some advice on techniques, exercises or other modalities that might be worth trying.

Thanks for any help offered

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[bauer5152]

Thank you so much for your post.

[Bona Raval]

hi...... i generally deal with such patients.....
the first thing you can try with the long AKBK knee braces at night and stretching the hamstrings by placing pillows under the heels.
secondly you can go for the quadriceps strengthening exercises such as the terminal knee extension exercise and the proprioceptive exercises to facilitate knee extension.
you can actually go for surged faradic current with low intensity so as to facilitate extension......

hope these all acan surely gain knee extension in her...... but make sure whether knee flexion contracture has not developed otherwise it would require an arthrolysis surgery....

[msk101]

Hi There,
After many many years seeing TKRs my thoughts are:

Be cruel to be kind... you will achieve nothing if you are too nice as you need to maximise gains asap or you'll be stuck with a knee that is no better than before the op. Therefore ensure your patient gets pain relief 20 minutes before you treat.
Basic exercises - straight leg raise should be achievable by now (or as straight as possible) - good endurance and quality as well as no quads lag.
active quad static contraction (pushing hard back down to the bed to try to straighten the knee and holding 10 seconds)
inner range quads (over fulcrum) within available ROM
prolonged stretching... sit patient on one chair, put foot up on another chair and put a weight of 3-4kg on the knee for 10-15 minutes.. i'ts horrible, it will hurt and it will make your patient sweat... and you won't be popular but you will achieve hamstring fibre lengthening (not just short term stretch) and do this 4-5 times per day.
walking is a start but lots and lots of little bits, by 4 weeks this should be well and truly independent. try a 2 wheel frame so the patient doesn't have to pick it up off the ground with each step and you can help guide it sliding forwards with each step maybe.
also, check the surgical op report and see what ROM the surgeons achieved with the knee whilst the patient was under anaesthetic.. that will tell you if the restriction now is contracture that's been long standing or there's new issues. if it's new issues please ensure no DVT in the leg which will be painful and restrict ROM and abilities and will require medical intervention.

And you may need to discuss with the surgical team about potentially doing a manipulation under anaesthetic (often this scares patients into action a bit more) but your patient should be doing exercises independently throughout the day even when you're not there.

Good luck with it